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Kidney Week

Abstract: PO2574

Delayed Diagnosis of Renal Allograft Uroenteric Fistula in a Pediatric Transplant Patient

Session Information

Category: Trainee Case Report

  • 1902 Transplantation: Clinical

Authors

  • Al Barbandi, Malek, University of Miami School of Medicine, Miami, Florida, United States
  • Arroyo Parejo Drayer, Patricia Alejandra, University of Miami School of Medicine, Miami, Florida, United States
  • Infante, Juan Carlos, University of Miami School of Medicine, Miami, Florida, United States
  • Burke, George William, University of Miami School of Medicine, Miami, Florida, United States
  • Chandar, Jayanthi, University of Miami School of Medicine, Miami, Florida, United States
  • Defreitas, Marissa J., University of Miami School of Medicine, Miami, Florida, United States
  • Katsoufis, Chryso P., University of Miami School of Medicine, Miami, Florida, United States
  • Seeherunvong, Wacharee, University of Miami School of Medicine, Miami, Florida, United States
  • Abitbol, Carolyn L., University of Miami School of Medicine, Miami, Florida, United States
Introduction

The diagnosis of uroenteric fistulae can be challenging and is often delayed for several months after symptoms begin. Here, we describe a rare case of a pediatric patient post en bloc kidney transplant who developed a urinoma post biopsy with a ureteral fistula into the small bowel resulting in profound acidosis and deceptive watery diarrhea.

Case Description

The patient is an 8 year old girl with end stage kidney disease secondary to steroid resistant nephrotic syndrome and focal segmental glomerulosclerosis (FSGS). She underwent a right native nephrectomy and a deceased donor “en bloc" kidney transplant with two separate ureters. She had a renal allograft biopsy for suspected rejection. A few days after the biopsy, she began experiencing watery diarrhea and metabolic acidosis. A comprehensive screening for diarrhea produced inconclusive findings. She was maintained on parenteral nutrition with no oral intake to try to slow the diarrhea. However, the watery diarrhea increased while urine output decreased. Throughout this period, the patient maintained normal kidney function. The watery stool and bladder urine were analyzed for solutes, pH and creatinine. An MRI with contrast was performed which demonstrated fistulization of the distal transplanted ureters into the small bowel. She underwent corrective surgery which identified the fistulous tract which was resected and the ureters were re-implanted. The surgery went well without complications. The diarrhea resolved and she was discharged 2 weeks later with normal renal function.

Discussion

This is a perplexing case of the development of a uroenteric fistula in a pediatric transplant patient that went undiagnosed for almost 3 weeks due to the deceptive nature of the watery diarrhea which was actually urine. An important aspect of the uroenteric fistula is the severe acidosis that results when urine is diverted in to the intestinal tract. This occurs in some cases of bladder augmentations that use the intestine. Another important diagnostic tool is the solute excretion in the diarrhea. Despite the watery nature of the diarrhea, the stool was not hyperosmolar and did not contain reducing substances. This made osmotic diarrhea unlikely and a fistula more likely.