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, MRCP
1
M P Moody, FRCS
2
J C Hammonds, FRCS
2 and
I P Wells, MRCS, LRCP, FRCR
1
Departments of 1 Radiology and 2 Urology, Derriford Hospital, Plymouth PL6 8DH, UK
 |
Abstract
|
|---|
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.
|
Introduction
|
|---|
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.
|
Case report
|
|---|
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
).
View larger version (169K):
[in this window]
[in a new window]
|
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.
|
|
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.
View larger version (150K):
[in this window]
[in a new window]
|
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.
|
|
The patient continued to improve on antibiotics. Following removal of her nephrostomy drainage catheter, the patient was discharged home 6 days later.
|
Discussion
|
|---|
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.
|
References
|
|---|
- Shapeero LG, Vordermark JS. Papillary necrosis causing hydronephrosis in the renal allograft. Sonographic findings. J Ultrasound Med 1989;8:579–81.[Medline]
- Sert S, Gulay H, Hamaloglu E, Haberal M. Urological complications in 350 consecutive renal transplants. Br J Urol 1990;66:568–71.[Medline]
- Shoskes DA, Hanbury D, Cranston D, Morris PJ. Urological complications in 1,000 consecutive renal transplant recipients. J Urol 1995;153:18–21.[CrossRef][Medline]
- Mehta SN, Kennedy JA, Loughridge WG, Douglas JF, Donaldson RA, McGeown MG. Urological complications in 119 consecutive renal transplants. Br J Urol 1979;51:184–7.[Medline]
- Pappas P, Giannopoulos A, Stravodimos KG, Zavos G, Alexopoulos T, Boletis J, et al. Obstructive uropathy in the transplanted kidney: definitive management with percutaneous nephrostomy and prolonged ureteral stenting. J Endourol 2001;15:719–23.[CrossRef][Medline]
- Benoit G, Thiounn N, Opsal C, Hiesse C, Moukarzel M, Neyrat N, et al. Urologic complications in kidney transplantations. Indication for endo-urologic techniques. Presse Med 1991;20:2050–1.
- Rich LM, Piering WF. Ureteral stenosis due to recurrent Wegener's granulomatosis after kidney transplantation. J Am Soc Nephrol 1994;4:1516–21.[Abstract]
- Kamel G, Stephan A, Barbari A, Kilani H, Karam A, Zeineh S, et al. Obstructive anuria due to fungal bezoars in a renal graft recipient. Transplant Proc 2003;35:2692–3.[CrossRef][Medline]
- Oosterhof GO, Hoitsma AJ, Witjes JA, Debruyne FM. Diagnosis and treatment of urological complications in kidney transplantation. Urol Int 1992;49:99–103.[Medline]
- Vijayaraghavan SB, Kandasamy SV, Mylsamy A, Prabhakar M. Sonographic features of necrosed renal papillae causing hydronephrosis. J Ultrasound Med 2003;22:951–6.[Abstract/Free Full Text]
- Kaude JV, Stone M, Fuller TJ, Cade R, Tarrant DG, Juncos LI. Papillary necrosis in kidney transplant patients. Radiology 1976;120:69–74.[Abstract]
- Edmondson RP, Fawcett IW, Jones NF, Thompson AE, Wing AJ. Papillary necrosis in a transplanted kidney. Br Med J 1972;1:547.
- Knepshield JH, Feller HA, Leb DE. Papillary necrosis due to Candida albicans in a renal allograft. Arch Intern Med 1968;122:441–4.[Abstract/Free Full Text]
- Whitworth JA, Leroux-Robert C, Meyrier A, Morel-Maroger L, Scetbon V, Sraer JD. Papillary necrosis in renal allografts-report of 2 cases. Aust N Z J Med 1975;5:69–71.[Medline]
- Tuma S, Chaimowitz C, Erlik D, Gellei B, Rosenberger A, Better OS. Fatal papillary necrosis in a kidney graft. JAMA 1976;235:754–5.[Abstract/Free Full Text]
- Hoffman JC, Schnur MJ, Koenigsberg M. Demonstration of renal papillary necrosis by sonography. Radiology 1982;145:785–7.[Free Full Text]
- Kincaid-Smith P. Histological diagnosis of rejection of renal homografts in man. Lancet 1967;2:849–52.[Medline]
- Eknoyan G, Qunibi WY, Grissom RT, Tuma SN, Ayus JC. Renal papillary necrosis: an update. Medicine 1982;61:55–73.[Medline]
Top
Abstract
Introduction
