British Journal of Radiology (2005) 78, 346-348
© 2005 British Institute of Radiology
doi: 10.1259/bjr/12933217
Papillary necrosis causing hydronephrosis in renal allograft treated by percutaneous retrieval of sloughed papilla
S Kamath, MD, MRCP1,
M P Moody, FRCS2,
J C Hammonds, FRCS2 and
I P Wells, MRCS, LRCP, FRCR1
Departments of 1 Radiology and 2 Urology, Derriford Hospital, Plymouth PL6 8DH, UK
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Abstract
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Obstructive uropathy is the second most common urological complication in a transplanted kidney. The usual causes of obstruction are ureteral stenosis and calculi. Papillary necrosis as a cause of obstruction in a transplant kidney is extremely rare with only one prior report published. Moreover, percutaneous removal of sloughed papilla in a transplant kidney has not previously been reported. We report an unusual case of a sloughed papilla causing hydronephrosis of a transplant kidney and its successful percutaneous removal. The recognition of renal papillary necrosis is important, not only because it can be a sign of acute rejection but also it because it can lead to obstruction, infection and potentially the loss of the transplant as exemplified by our case. Rapid diagnosis and meticulous retrieval technique are the crucial factors in minimizing the complications due to obstruction of a transplanted kidney by sloughed papilla.
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Introduction
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Obstruction to a transplant kidney can result from a variety of causes including ureteral anastomotic stenosis, urolithiasis, blood clot and fungal ball. However, a sloughed papilla resulting from papillary necrosis as a cause of obstruction in a transplant kidney is extremely rare and has only been reported once to date [1]. Moreover, the percutaneous removal of the sloughed papilla in a transplant kidney has not previously been reported. We report the successful percutaneous removal of a sloughed papilla, causing hydronephrosis of a transplant kidney.
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Case report
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A 57-year-old diabetic woman presented with a 1-week history of fever, dysuria and decreasing urine output leading to anuria for 2 days. She had received a cadaveric renal transplant 4 years previously for adult polycystic kidney disease.
Examination revealed pyrexia of 38.4°C, tachycardia of 98 beats per minute (bpm) and tenderness over the transplant in the right iliac fossa. Her biochemistry revealed a urea of 31.5 mmol l–1 and a creatinine of 559 µmol l–1. Blood cultures revealed proteus bacteraemia. The previous renal function tests performed 2 months before admission had revealed the following: urea 15 mmol l–1 and creatinine 210 µmol l–1.
Ultrasound demonstrated a moderate hydronephrosis of the transplant kidney with an obstructing lesion at the pelviureteric junction. A provisional diagnosis of pyonephrosis of the transplant kidney leading to bacteraemia was made. Percutaneous nephrostomy was performed, which drained cloudy urine. A nephrostogram confirmed a smooth filling defect in the renal pelvis, which extended into the proximal ureter (Figure 1
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Figure 1. Nephrostogram of the transplant kidney demonstrates a large filling defect (arrow) in the renal pelvis extending into the proximal ureter causing partial obstruction.
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The obstructing lesion was thought to be amenable to percutaneous removal, which was performed 2 weeks later. A nephrostogram immediately prior to the attempted removal demonstrated a large defect (papillary ulcer) in the lower pole calyces with extensive loss of papillary tissue (Figure 2). The obstructing lesion was therefore thought to be a sloughed renal papilla. The nephrostomy tract into the transplant kidney was dilated up to 30 Fr and using a nephroscope the soft white tissue obstructing the pelviureteric junction of the transplant ureter was removed in pieces. Subsequently, there was free flow of contrast down the ureter into the bladder (Figure 3) and the specimen was sent for histology. The histology revealed tissue consistent with necrotic sloughed papilla.
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Figure 2. A large sloughed papilla in the renal pelvis extending into the proximal ureter has resulted in complete obstruction to the kidney. A large papillary ulcer (arrow), which is the donor site for the sloughed papilla is demonstrated.
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The patient continued to improve on antibiotics. Following removal of her nephrostomy drainage catheter, the patient was discharged home 6 days later.
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Discussion
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The urological complications following renal transplantation vary from 2.9% to 13.4% [2–4]. These include obstructive uropathy, urinary leaks, distal ureteric fistulas (necrosis), vesicoureteral reflux and renal calculi.
Obstructive uropathy is second only to urinary leaks as the most frequent urological complication in a transplanted kidney [5] and usually occurs after 1 year following transplantation [6]. While the usual causes of obstruction are ureteral stenosis and calculi, unusual causes include granulomatous disease [7] and fungal bezoars [8]. In the past, a significant proportion of patients with renal transplant underwent open surgical procedures for the treatment of obstruction [9]. However with advances in technology these complications are now treated more often by percutaneous and/or endoscopic techniques.
Obstruction to a native kidney from a sloughed papilla resulting from renal papillary necrosis is a well-recognized entity [10]. Similarly, renal papillary necrosis in a transplant kidney is not unusual. However, hydronephrosis resulting from obstruction to a transplant kidney from a sloughed renal papilla is extremely unusual and only one such case has been reported to date [1].
Papillary necrosis in renal transplant patients is most commonly associated with acute or chronic rejection [11] causing ischaemia due to decreased perfusion of the renal medulla. However, it can also be found in acute tubular necrosis, diabetes, acute bacterial or fungal infection and analgesic usage [11–18]. Renal papillary necrosis, though thought to be a rather late complication in patients with a renal allograft, (an average of 28.1 months after transplantation) can occur as early as 2 months after transplantation [11].
The abnormality in transplant renal morphology following papillary necrosis varies from dilatation and clubbing of calyces in milder form to severe deformity with papillary ulcers and extensive loss of papillary tissue as in our case [11, 13]. Recognition of renal papillary necrosis is important not only because it can be a sign of acute rejection but also because it can lead to various complications such as obstruction, infection and potentially the loss of the transplant. In the only previously reported case of obstructed transplanted kidney due to sloughed papilla, the patient underwent nephrectomy. However, we demonstrate that percutaneous/endoscopic removal of the sloughed papilla is possible resulting in relief of obstruction and improvement in the renal function. To our knowledge, this is the first reported case of percutaneous retrieval of a sloughed papilla from a transplant renal pelvis with subsequent relief of obstruction.
Received for publication August 18, 2004.
Revision received October 27, 2004.
Accepted for publication November 25, 2004.
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References
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Abstract
Introduction
