Abstract: TH-PO571
Unusual Bilateral Renal Parenchymal Urine Leak After Pediatric En Bloc Kidney Transplantation
Session Information
- Trainee Case Reports - II
October 25, 2018 | Location: Exhibit Hall, San Diego Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Trainee Case Reports
- 1600 Pediatric Nephrology
Authors
- Nayak, Rahul, Virginia Commonwealth University, School of Medicine, Richmond, Virginia, United States
- Sharma, Amit, Virginia Commonwealth University, School of Medicine, Richmond, Virginia, United States
Introduction
Use of en bloc kidney transplantation (EBKT) has not been universally accepted due to risk of technical difficulties and concerns related to inadequate nephron mass. We report an unusual case of renal parenchymal urine leak after EBKT that ultimately led to removal of both renal moieties.
Case Description
We transplanted pediatric en bloc deceased donor kidneys to a 49 year male with ESRD. Caudal ends of donor inferior vena cava and aorta were anastomosed to recipient’s external iliac vein & artery.
On POD 6, there was increased output of clear fluid in wound drain. CT-cystogram performed at this time showed mild caliectases of both transplant kidneys but no anastomotic bladder leak. Surgical re-exploration on POD 8 revealed necrotic area on infero-lateral pole of lateral kidney leaking urine. Parenchymal leakage was repaired, but drain output remained high.
On POD 31, patient was readmitted for abdominal pain. Renal scan revealed tracer accumulation originating from lower pole of lateral kidney confirming persistence of urine leak. Exploration confirmed recurrent lateral kidney urine leak at site of previous repair but other kidney showed a necrotic area at lower pole. Both kidneys were removed. Patient was relisted for transplantation.
Discussion
Early onset of urine leak from a necrotic area points towards vascular injury. Interestingly, pediatric recipient of liver from same donor as en bloc kidneys developed portal vein thrombosis. Another possible mechanism of urine leak could be thermal injury if Argon beam coagulation is used for superficial hemostasis on the thin cortex of pediatric kidneys after reperfusion.
It could be speculated that prolonged surgical drainage along with bladder decompression could have salvaged en bloc kidneys. However, this patient continued to have abdominal pain despite presence of surgical drain. The second kidney were removed due to concern for impending infection at vascular anastomosis.
Strategies to prevent complications after EBKT
| Avoid very small pediatric donors with history of severe hypotension |
| Ensure good flushing of pediatric kidneys in donor |
| Preserve perinephric and periureteric fat |
| Avoid vascular injuries during backbench preparation |
| Use pediatric ureteric stents |
| Avoid recipients with uncontrolled hypertension |
| Consider perioperative anti-coagulation |