1 Department of Nephrology and Rheumatology, 2 Department of Vascular Surgery and Renal Transplantation, Heinrich-Heine-University, Düsseldorf, Germany
Keywords: Duplex-sonography; renal transplant vein thrombosis; renal vein kinking; renal vein obstruction
A 33-year-old male ESRD patient received a cadaveric left kidney allograft in May 2001. The vascular anatomy of the kidney was normal but the renal vein was quite long. On the first postoperative day, Duplex-ultrasound showed a well perfused graft, but the patient required further dialysis. On the fourth postoperative day the patient complained about tenderness and pain over the graft. Routine Duplex-sonography showed again normal flow spectra (Figure 1). Three hours later the patient developed severe pain over the graft region. Immediately repeated B-mode-ultrasound and Doppler-sonography could not detect bleeding, urinary leakage or other local changes but surprisingly the Doppler waveform showed oscillating flow resulting in a zero forward net flow (Figure 2).
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Postoperative Duplex-sonography revealed unrestricted renal perfusion with normal arterial and venous spectra (Figure 3). Diuresis started 2 weeks later and no further haemodialysis was necessary. Serum creatinine at dismission was 2.0 mg/dl. During follow-up over 12 months kidney function has remained stable.
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In the case presented here typical Duplex-sonographic findings of complete obstruction of the graft vein were present. Early recognition and immediate surgical intervention without the application of other time consuming diagnostic steps as angiography or CT scan was essential for the outcome of graft function in this patient. The intraoperative finding was surprising as no thrombosis was found. Instead, mechanical obstruction due to acute venous kinking was responsible for the clinical symptoms and the Duplex-sonographic findings. Probably migration of the graft after postoperative mobilization was one possible cause for kinking of the transplant vein. Fortunately we did not decide on thrombolysis, because this would not have solved the mechanical cause of venous outflow obstruction.
This case emphasizes the importance of Duplex-sonography in the diagnosis of renal vein obstruction in kidney transplantation. As the method cannot differentiate between thrombosis and other causes of venous obstruction, surgical revision seems more effective, quicker and less risky.
Notes
Correspondence and offprint requests to: A. Voiculescu, MD, Department of Nephrology and Rheumatology, Heinrich-Heine-University, Moorenstrasse 5, D-40225 Düsseldorf, Germany. Email: voicules{at}uni-duesseldorf.de
References