An unusual cause of post-biopsy oliguria in an allograft

Josep M. Cruzado, Joan Torras, Joan Domínguez1, Concha Sancho1, Jeroni Alsina and Josep M. Grinyó

1 Departments of Nephrology and Radiology, Hospital de Bellvitge, CSUB, L'Hospitalet, Barcelona, Spain

Correspondence and offprint requests to: Josep M. Cruzado, Nephrology Department, Hospital de Bellvitge, Feixa Llarga s/n, 08907 L'Hospitalet, Barcelona, Spain.

Keywords: acute renal failure; embolization; renal arteriovenous fistula; renal artery stenosis; renal biopsy; renal transplantation



   Introduction
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 Introduction
 Case
 Discussion
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Renal biopsy of the transplanted kidney is an essential diagnostic tool of acute and chronic rejection as well as recurrent and de novo nephropathies in renal allograft recipients [1]. The application of molecular biology techniques to renal tissue samples obtained by this procedure may also contribute to increasing the understanding of the pathophysiology of the kidney [2]. In comparison with the classical manual Tru-Cuth technique, the introduction of percutaneous renal biopsy with sonographic assistance using thin automatic biopsy needle has significantly reduced complications related to kidney puncture [3]. Thus, renal bleeding or arteriovenous fistulas are seldom encountered after this procedure [4]. This fact allows protocol biopsy studies to be conducted in renal transplant recipients that provide useful information in order accurately to predict graft outcome [5]. Although this procedure is usually safe [4], in some instances it can be associated with complications. We report a case of acute renal failure in a renal allograft recipient caused by a post-biopsy renal arteriovenous fistula superimposed on pre-existing renal artery stenosis.



   Case
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 Introduction
 Case
 Discussion
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A 63-year-old man was hospitalized because of oliguric acute renal failure, which appeared 3 days after a renal allograft biopsy was performed. Eighteen months earlier he had started haemodialysis treatment for end-stage renal disease due to IgA nephropathy. Four months earlier he had received a cadaveric renal allograft under a cyclosporin-based immunosuppressive treatment. The post-transplant course was uncomplicated and he was discharged on post-operative day 14 with a serum creatinine of 176 µmol/l. Three months earlier he had begun taking 20 mg of nifedipine once a day and 2 mg of doxazosine twice a day, prescribed because of arterial hypertension. Three days earlier and after giving informed consent, he was admitted to our department for renal allograft biopsy. Allograft sonography was normal and percutaneous renal biopsy was done using a biopsy needle (Monopty 18G, Bard). Histology revealed mild features of chronic allograft nephropathy, and the patient was discharged 24 h post-biopsy.

On admission, the patient's complaint was oligura (300 ml/24 h in the day before admission). Physical examination showed bilateral pedal oedema and right femoral bruit, which irradiated to the graft implanted in the right iliac fossa. Further relevant clinical and analytical data are shown in Table 1Go. Because of acute renal failure, an allograft ultrasound was indicated, which disclosed a suspicious image of an arteriovenous fistula in the upper renal pole, confirmed by colour-coded Doppler sonography. A right iliac arteriography showed a large arteriovenous fistula and a severe renal artery stenosis (Figure 1Go). Using a superselective catheterization technique, the fistula was occluded completely by means of delivery of several helical platinum microcoils [6]. Also, a transluminal renal angioplasty was carried out, but only a partial dilation was obtained due to technical difficulties (Figure 2Go). Thereafter, the patient had polyuria (200 ml/h in the next 24 h after embolization), and renal function improved rapidly; fractional excretion of sodium increase to more than its basal value (Table 1Go). Arterial hypertension was controlled with 20 mg of nifedipine once a day, and on the seventh day after arteriography, the patient was discharged. Four years later, the patient is well, arterial hypertension is treated with 2 mg of doxazosine twice a day and serum creatinine is 185 µmol/l.


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Table 1. Relevant clinical and analytical parameters
 


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Fig. 1. Right iliac arteriography showing that the renal artery of the donor was anastomosed end-to-side to the external iliac artery of the recipient. The renal artery shows a severe stenosis (medium-sized arrow). The arteriovenous fistula (wide arrow) is supplied by a branch of the renal artery (thin arrows) and, as this early arterial phase shows, the fistula immediately drains into the renal vein (**).

 


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Fig. 2. Arteriography immediately after delivery of platinum microcoils (wide arrowheads) showing the completely occluded arteriovenous fistula and the lumen dilatation of the renal artery stenosis after angioplasty (thin arrowhead). Note the hypoperfusion of the renal upper pole. This fact was due to vasospasm, since 3 days after embolization, 99mTc-pertechnectate angiogammagraphy demonstrated complete perfusion of the whole kidney.

 


   Discussion
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 Introduction
 Case
 Discussion
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Arteriovenous fistulas after percutaneous renal biopsy may remain asymptomatic or lead to haematuria [7], hypertension and renal insufficiency [8]. What is noteworthy from our case is that it illustrates the renal haemodynamic mechanisms involved in maintaining the glomerular filtration rate when renal plasma flow is reduced. In the presence of renal artery stenosis, the renin–angiotensin system is activated. Thus, angiotensin II increases blood pressure and produces vasoconstriction of the efferent glomerular arterioles, both mechanisms leading to preserve glomerular filtration pressure distal to the renal artery stenosis. Accordingly, before renal biopsy, our patient had arterial hypertension and showed a trend to low urinary sodium and fractional excretion of sodium. This fragile equilibrium was broken by arteriovenous fistula-induced blood loss, which abruptly reduced the effective renal plasma flow. In order to restore the intrarenal haemodynamics, this demanded further activation of the renin–angiotensin system [8]. This disastrous combination caused acute renal hypoperfusion, and indeed oliguria and pre-renal azotaemia, which was associated with a dramatic reduction of urinary sodium and fractional excretion of sodium. After embolization of the arteriovenous fistula and angioplasty of the renal artery stenosis, renal function parameters returned to basal levels, urinary sodium and fractional excretion of sodium increased over pre-renal biopsy values, but antihypertensive treatment was required, suggesting that probably the renal angioplasty was incomplete.



   References
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 Introduction
 Case
 Discussion
 References
 

  1. Cruzado JM, Gil-Vernet S, Ercilla G et al. Hepatitis C virus-associated membranoproliferative glomerulonephritis in renal allografts. J Am Soc Nephrol 1996; 7: 2469–2475[Abstract]
  2. Schena FP, Gesualdo L. Renal biopsy—beyond histology and immunofluorescence. Nephrol Dial Transplant 1994; 9: 1541–1544[ISI][Medline]
  3. Riehl J, Maigatter S, Kierdorf H, Schmitt H, Maurin N, Sieberth HG. Percutaneous renal biopsy: comparison of manual and automated puncture techniques with native and transplanted kidneys. Nephrol Dial Transplant 1994; 9: 1568–1574[Abstract]
  4. 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 Transplant 1998; 13: 975–977[Abstract]
  5. Seron D, Moreso F, Bover J et al. Early protocol renal allograft biopsies and graft outcome. Kidney Int 1997; 51: 310–316[ISI][Medline]
  6. Beaujeux R, Boudjema K, Ellero B et al. Endovascular treatment of renal allograft postbiopsy arteriovenous fistula with platinum microcoils. Transplantation 1994; 57: 311–314[ISI][Medline]
  7. Harrison KL, Nghiem HV, Coldwell DM, Davis CL. Renal dysfunction due to an arteriovenous fistula in a transplant recipient. J Am Soc Nephrol 1994; 5: 1300–1306[Abstract]
  8. Nishikimi T, Frohlich ED. Glomerular hemodynamics in aortocaval fistula rats: role of renin–angiotensin system. Am J Physiol 1993; 264: R681–R686[Abstract/Free Full Text]
Received for publication: 5. 3.99
Accepted in revised form: 31. 3.99





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