Subcapsular haematoma: a cause of post biopsy oliguria in renal allografts

R. Rea1, K. Anderson1, D. Mitchell2, S. Harper1 and T. Williams3

1 Richard Bright Renal Unit 2 Department of Surgery, Southmead Hospital, Bristol 3 Department of Medicine, Gloucestershire Royal Hospital, UK

Sir,

Renal allograft biopsy is an important procedure in the investigation of worsening excretory renal function following transplantation in both the acute and chronic setting. Allograft biopsy has become safer with the introduction of sonographic guidance and narrow gauge percutaneous biopsy needle, resulting in reduced complications of bleeding and arterio-venous fistula formation. Yet unusual complications do occur which necessitate immediate action to prevent the loss of the allograft. We report the case of a 34-year-old man who developed a large subcapsular haematoma resulting in oliguria and marked impairment of renal function following an allograft biopsy.

A 34-year-old gentleman was admitted 3 years after receiving a live related transplant from his 61-year-old mother. He was admitted for a transplant biopsy to be performed to investigate a progressive rise in his serum creatinine from 154 to 245 mmol/l over the preceding 5 months. He had received the transplant 6 months after developing end-stage renal failure secondary to diabetic nephropathy, having had insulin dependent diabetes mellitus from 7 years of age.

The immediate post-transplant period had been complicated by a number of factors. Within the first 2 weeks he had two moderately severe episodes of rejection which responded to pulsed methylprednisolone. At 3 weeks post-transplant he was readmitted with a wound dehiscence and methicillin sensitive Staphylococcus aureus wound infection. He subsequently had a further severe episode of rejection which was treated with rabbit anti-thymocyte globulin. His maintenance immunosuppression was changed from prednisolone and cyclosporin A to prednisolone and FK 506. Six months after transplantation his nadir serum creatinine was 140 mmol/l.

On the day of admission he underwent a sonographically guided percutaneous renal allograft biopsy performed by an experienced operator using a 16G Biopty needle and gun. The capsule was extremely tough and tissue was only obtained at the third pass. Three hours later he complained of pain over the biopsy site, which was acutely tender and swollen. An ultrasound scan showed a large haematoma over the lateral aspect of the upper pole of the allograft. Diastolic flow was poor and in some areas reversed. The patient became oliguric, passing 200 ml of urine in the next 24 h with a marked rise in serum creatinine from 245 to 447 mmol/l. A helical computerized tomogram of the abdomen and pelvis with contrast was performed and a large intracapsular haematoma compressing the allograft was identified. The kidney enhanced normally but there was no evidence of excretion of contrast medium into the pelvicalyceal system. He underwent emergency surgical evacuation of the haematoma and regained excellent urine output. The serum creatinine fell to 248 mmol/l.

The biopsy showed changes consistent with transplant glomerulopathy and FK 506 toxicity. An attempt was made to switch his FK 506 to mycophenolate mofetil however this precipitated diarrhoea and was replaced by azathioprine, in addition to prednisolone. His creatinine has since stabilized.

Bleeding following renal allograft biopsy is well recognized but uncommon [1]. Attempts have been made to reduce bleeding complications using sonographic guidance and smaller automated core biopsy needles, although with no proven benefit [2,3]. The development of subcapsular haematomas with resulting deterioration in renal function has been described in native kidneys following trauma and percutaneous biopsy. However, only one case of anuria following biopsy of a transplant kidney is recorded [4]. In the case we describe the diagnosis was made with imaging using helical computerized tomography and surgical relief of the haematoma resulted in rapid diuresis and a return of the renal function to baseline.

In 1939 Page described the development of hypertension and impaired renal function due to compression of renal parenchyma [5]. Difficulty piercing the thickened capsules of ‘old’ renal allografts is not uncommon for renal biopsy operators. We suggest that in this case the capsule may have been particularly difficult to penetrate because of the post transplant wound infection and dehiscence that the patient had experienced. As a result, the post-biopsy bleeding was contained within the thickened perinephric capsule leading to compressed parenchyma and rapidly impaired renal function.

Renal biopsy is an integral part of the investigation of worsening allograft function. However it is not without its dangers. A subcapsular haematoma should be suspected if oliguria and rapid deterioration in renal function occur following the procedure. We believe that prompt surgical intervention should be undertaken to ensure maximum preservation of renal function.

References

  1. Hergesell O, Felten H, Andrassy K, Kuhn K, Ritz E. Safety of ultrasound-guided percutaneous renal biopsy-retrospective analysis of 1090 consecutive cases. Nephrol Dial Transplant1998; 13: 975–977[Abstract]
  2. Kovalik EC, Schwab SJ, Gunnells JC, Bowie D, Smith SR. No change in complication rate using spring-loaded gun compared to traditional percutaneous renal allograft biopsy techniques. Clin Nephrol1996; 45: 383–385[ISI][Medline]
  3. Kolb LG, Velosa JA, Berfstralh EJ, Offord KP. Percutaneous renal allograft biopsy. A comparison of two needle types and analysis of risk factors. Transplantation1994; 57: 1742–1746[ISI][Medline]
  4. Figueroa TE, Frentz GD. Anuria secondary to percutaneous needle biopsy of a transplant kidney: a case report. J Urol1988; 140: 355–356[ISI][Medline]
  5. Page IH. The production of persistent arterial hypertension by cellophane perinephritis. J Am Med Assoc1939; 113: 2046–2048




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