Abstract
Background
Retroperitoneal bleeding as a consequence of non-traumatic kidney or allograft rupture is well known, but there are no reports on hemorrhagia from a native kidney after allogeneic renal transplantation. Therefore, we present the first such case to be published and highlight the possibility of this complication after renal transplantation.
Case Report
We report the case of a 28-year-old male patient who developed early post-transplant hemorrhagia from a ruptured native kidney. The patient underwent left-sided nephrectomy. Histopathological examination revealed ruptured hemangioma of the patient’s native left kidney. The further postoperative period was not complicated. The patient was discharged on the 18th postoperative day, with good transplant function.
Conclusions
Transplantologists should be aware of the fact that in patients with uncontrolled blood pressure, native kidney hemangioma may rupture in the early post-transplant period, and it can be a life-threating and difficult to diagnose complication.
MeSH Keywords: Kidney Neoplasms, Kidney Transplantation, Postoperative Complications
Background
Spontaneous and non-traumatic rupture of the kidney is a rare clinical entity usually associated with underlying benign renal pathology, such as an angiomyolipoma, hemangioma, or acquired cystic kidney disease [1]. It may also be related with rupture of kidney cancer, but there are few reports of this in the literature [2]. Spontaneous rupture may also affect an allograft, which is a well-known complication of transplantation, mostly related to post-transplant renal vein thrombosis or acute rejection of the kidney [3]. This urgent urological complication may manifest symptoms ranging from mild to life-threating, and requires immediate diagnosis to initiate proper surgical treatment without delay. Since patients usually present with hypotension and significant drop of hemoglobin level, treatment consists of intense fluid resuscitation and often requires an operation with urgent nephrectomy or graftectomy.
Although retroperitoneal bleeding as a consequence of non-traumatic kidney or allograft rupture is well known, there are no reports on acute, early post-transplant hemorrhagia from a ruptured native kidney after allogeneic renal transplantation. Therefore, we present the first such published case and highlight the possibility of this complication after renal transplantation.
Case Report
A 28-year-old male patient who had chronic interstitial nephritis with end-stage renal disease was admitted to the Department of General and Transplant Surgery in Lodz for well-matched, deceased donor renal transplant. The deceased donor nephrectomy revealed no additional arteries. The main renal artery was anastomosed end-to-side with the external iliac artery. Following of 16 h of cold ischemia time and 20 min of warm ischemia time, the renal graft was reperfused with its positive primary function. Total operative time was 95 min. The patient was on triple drug immunosuppression using mycophenolate mofetil, tacrolimus, and prednisolone. The patient was in the good condition immediately after transplantation, with adequate urine production. However, on the 1st postoperative day, the patient was non-compliant and refused anti-hypertensive medication, with a subsequent rapid increase in blood pressure. Soon after that, the patient complained of severe pain around the transplanted kidney, accompanied by a drop in hemoglobin level and urine output, as well as hypotension. The urgent ultrasound examination of the surgical area revealed a normal graft with proper intra-parenchymal flow and peri-graft blood collection, and no other abnormalities were noticed. The patient was immediately operated on and fresh blood and clots from the transplanted kidney area were removed. No signs of arterial or venous anastomosis leaks were confirmed. Postoperatively, no major recovery of the patient was observed, with a further drop in hemoglobin level and hypotension resuscitated intensely by transfusion of blood and fresh frozen plasma. Repeatedly, ultrasound revealed blood collection around the transplanted kidney. The patient was reoperated, but both venous and arterial anastomoses were patent, and no signs of anastomotic leak were confirmed. The patient was stable, but on the 5th postoperative day, hemorrhagic shock was observed. Abdominal and pelvic computed tomography scanning was performed and showed an enlarged left native kidney surrounded by a massive retroperitoneal hematoma (Figure 1). The patient was immediately operated on. Intraoperatively, there were fresh blood and clots around the left native kidney, with an extensive “star-shaped” rupture on the convex surface, which was actively bleeding. Left-sided nephrectomy was performed. Histopathological examination revealed a ruptured hemangioma of the native left kidney. The postoperative period was uncomplicated. The patient was discharged on the 18st postoperative day, with good transplant function, and his creatinine level was 1.4 mg%.
Figure 1.
Abdominal computed tomography scan showing a massive retroperitoneal hematoma around the left kidney (arrow).
Discussion
Spontaneous non-traumatic hemorrhagia associated with underlying renal pathology was originally reported in 1856 by Wünderlich [4]. The most common causes of Wünderlich syndrome (WS) is spontaneous rupture of a benign renal tumor, including angiomyolipoma, adenoma, hamartoma, lipoma, and renal cyst [1], as well as malignant lesions, nephritis, atherosclerosis, blood dyscrasias, or anticoagulant therapy [2,5,6]. Major clinical manifestations include acute flank pain, abdominal tenderness, and signs of internal hemorrhagia (Lenk’s triad). Ultrasound has a definite screening and first-line role in presurgical evaluation of most, but not all, suspected renal ruptures and post-transplant hemorrhages [7]. However, if the native kidney rupture occurs after transplantation, as in our case, computed tomography (even non-contrast enhanced, to avoid contrast-induced acute kidney injury) seems to be a valuable aid in establishing the diagnosis. The treatment applied in spontaneous rupture of the kidney depends on its causes and intensity. If the general condition of the patient is not stable, it is necessary to perform surgical intervention. In functioning kidneys, if the tumor is small and limited, it may be removed with enucleation or partial nephrectomy. Radical nephrectomy is recommended only in cases of massive hematomas with complete renal involvement. In contrast, in all cases of ruptured hemangiomas in non-functioning kidneys, renal excision seems to be the treatment of choice if surgical treatment is necessary.
The exact mechanism of spontaneous kidney rupture remains unclear and there are no published reports regarding this issue. The pressure increase in the renal venous system secondary to neoplastic embolus or tumor mass effect was proposed as a risk factor for kidney rupture in patients with angiomyolipoma [8]. However, there are no reports on renal hemangioma rupture and its etiopathology in the literature. Nevertheless, a previous study found that nephrogenic hypertension is closely associated with renal hemangioma in patients with end-stage renal disease [9]. Our case emphasizes the possibility that uncontrolled blood pressure can be a significant clinical risk factor for renal hemangioma rupture. Likewise, there are many reports on liver hemangioma rupture due to high blood pressure in preeclampsia syndrome during pregnancy [10].
Conclusions
The native kidneys, although no longer functioning, may suffer from various pathologies, including hemangiomas. Therefore, patients on maintenance dialysis as well as after transplantation should be monitored and further treated for this pathology. The spontaneous rupture of a kidney hemangioma is an exceptional event. However, transplantologists should be aware that in patients with uncontrolled blood pressure, native kidney hemangioma may rupture in the early post-transplant period, and it can be a life-threating and difficult to diagnose complication.
Footnotes
Source of support: Departmental sources
References
- 1.Borràs M, Valdivielso JM, Egido R, et al. Haemoperitoneum caused by bilateral renal cyst rupture in an ACKD peritoneal dialysis patient. Nephrol Dial Transplant. 2006;21:789–91. doi: 10.1093/ndt/gfi298. [DOI] [PubMed] [Google Scholar]
- 2.Goto T, Sengiku A, Sawada A, et al. Bilateral renal cell carcinoma of dialysis patient manifesting as spontaneous renal rupture. Hinyokika Kiyo. 2009;55:707–10. [PubMed] [Google Scholar]
- 3.Busi N, Capocasale E, Mazzoni MP, et al. Spontaneous renal allograft rupture without acute rejection. Acta Biomed. 2004;75(2):131–33. [PubMed] [Google Scholar]
- 4.Wünderlich CRA. Handbuch der Pathologie und Therapie. 2nd ed. Stuttgart: Ebner & Seuber; 1856. [in German] [Google Scholar]
- 5.Numasato S, Okamoto T, Matsuzaka J. [A case report of spontaneous renal rupture due to arteriosclerosis]. Hinyokika Kiyo. 1994;40(9):817–20. [in Japanese] [PubMed] [Google Scholar]
- 6.Oon SF, Murphy M, Connolly SS. Wunderlich syndrome as the first manifestation of renal cell carcinoma. Urol J. 2010;7(2):129–32. [PubMed] [Google Scholar]
- 7.Soler R, Pérez-Fontán FJ, Lago M, et al. Renal allograft rupture: diagnostic role of ultrasound. Nephrol Dial Transplant. 1992;7(8):871–74. [PubMed] [Google Scholar]
- 8.Chronopoulos PN, Kaisidis GN, Vaiopoulos CK, et al. Spontaneous rupture of a giant renal angiomyolipoma-Wunderlich’s syndrome: Report of a case. Int J Surg Case Rep. 2016;19:140–43. doi: 10.1016/j.ijscr.2015.12.017. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Memmedoğlu A, Musayev J. Spontaneous rupture of the kidney in the patients with synchronous renal hemangioma and nephrogenic hypertension. Turk J Urol. 2015;41(4):231–34. doi: 10.5152/tud.2015.48264. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Mascarenhas R, Mathias J, Varadarajan R, et al. Spontaneous hepatic rupture: A report of five cases. HPB (Oxford) 2002;4(4):167–70. doi: 10.1080/13651820260503819. [DOI] [PMC free article] [PubMed] [Google Scholar]