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Source publication
We report a rare case of allograft loss from acute Page kidney secondary to trauma that occurred 12 years after kidney transplantation. A 67-year-old Caucasian male with a past surgical history of kidney transplant presented to the emergency department at a local hospital with left lower abdominal tenderness. He recalled that his cat, which weighs...
Context in source publication
Context 1
... was because PK causes acute deterioration of graft function, which resembles rejection. Since then, 30 cases of post transplant PK have been reported in the literature (Table 1) [46,1031] . The most common causes are iatrogenic (kidney biopsy in 18 cases, renal artery stenting in 1 case, ureteral stenting in 1 case, and nephrostomy in 1 case); trauma (3 cases) [5,6] ; spontaneous (2 cases) [15,27] ; and postoperative bleeding (2 cases) [11,12] . ...
Citations
... Other rarer non-bleeding causes due to extrinsic compression include lymphoceles, cysts and retroperitoneal paragangliomas. [4][5][6][7][8] Page kidney can present insidiously or acutely as a new-onset hypertensive event. Workup usually includes an ultrasound of the kidneys and contrastenhanced CT to visualise perinephric fluid collections. ...
A male in his late 70s with a history of an uncomplicated kidney transplantation 20 years prior was brought to the Emergency Department after experiencing blunt abdominal trauma following a motor vehicle collision. Imaging revealed a large perinephric haematoma, a retroperitoneal haematoma and multiple fractures. He was admitted to the intensive care unit where a renal haematoma was found to be expanding with ultrasonography (US) and developed renal dysfunction including anuria and hyperkalemia. His creatinine rose to twice his baseline and Doppler US showed elevated resistive indices, confirming extrinsic compression and causing a Page phenomenon. An open surgical exploration through the upper aspect of his Gibson incisional scar was performed followed by evacuation of the haematoma. An intraoperative US was done demonstrating good flow in the renal vessels. His postoperative course was uncomplicated and was discharged home with renal function back to baseline. On follow-up, he continued to have a good renal function.
... Allograft dysfunction induced by PK can be reduced by appropriate management before irreversible damage occurs [16], although the optimal intervention is a matter of debate [5,12,16]. Some clinicians have advocated a cautious wait-and-see approach in SH patients because of the possibility of spontaneous resolution [10,11]. ...
... Allograft dysfunction induced by PK can be reduced by appropriate management before irreversible damage occurs [16], although the optimal intervention is a matter of debate [5,12,16]. Some clinicians have advocated a cautious wait-and-see approach in SH patients because of the possibility of spontaneous resolution [10,11]. ...
Background
Page kidney (PK) is the occurrence of kidney hypoperfusion and ischemia due to pressure on the kidney by a subcapsular hematoma (SH), a mass, or fluid collection. SH after renal transplantation may result in kidney ischemia and graft loss.
Case presentation
We present a rare case of early spontaneous SH in an allograft kidney that led to a decrease in renal function. A 56-year-old male patient underwent deceased donor kidney transplantation. After declamping, appropriate renal perfusion and immediate diuresis were observed, with no evidence of SH. However, his urinary output abruptly decreased 6 h postoperatively. Abdominal ultrasonography showed 28 mm deep SH on transplant and the resistive index (RI) increased to 0.98–1 and diastolic flow reversal was observed. Surgical interventions were performed 2 days after transplantation, following a further decrease in urinary output. Serum creatinine decreased to 2.2 mg/dL, urinary output increased to an average of 200 cc per hour and the RI value was decreased to 0.7 on POD 7.
Conclusion
In patients with abrupt decreased renal function after transplantation, SH should be suspected and the presence of PK should be determined using Doppler USG. In these cases, surgical intervention may avoid allograft dysfunction.
... Page kidney was first described as a "cellophane perinephritis" in 1939, 2 since then many causes have been attributed, namely subcapsular hematoma, trauma, spontaneous bleeding, hemorrhage, postbiopsy, lithotripsy or surgery, lymphocele, urinoma, and, tumor. 3,4,6 As discussed earlier, the presentation in solitary kidneys is different; hence, the occurrence in posttransplant kidneys may be actually be under-reported. In fact, till 2015, most authors 3,14 attributed posttransplant Page kidney to just three cases, two following lymphocele and one following a hematoma. ...
... The authors also noted that allograft loss due to this mechanism was reported in only three cases, including theirs. 6 The series illustrates that Page kidney in the first few days or weeks following transplant is uncommon, and during this time, it is particularly challenging to distinguishing it from other causes of oliguria, such as rejection and tacrolimus toxicity. [9][10][11][12][13] The series vindicates our belief that page kidney is an under-reported entity following transplant and reversible if aggressive treatment including surgery is initiated early. ...
... In fact, some have labeled it "pseudo rejection" in the past. 13 Many clues have been suggested in the identification of Page phenomenon; if empirical methylprednisolone therapy has been initiated for suspected rejection and there is no clinical or radiological improvement; 14 clear Doppler indices of absent diastolic flow, reversal of flow, high initial or subsequent RI (>0.7) of the transplant arteries with normal peak systolic velocity; 6 and, unexplained HTN preceding the delayed graft function. 8 Our third case developed transplant artery stenosis (TRAS) probably due to a combination of inadequate graft artery lumen and technical error, which was managed with percutaneous angiography and stenting. ...
Oliguria in the early postoperative phase after renal transplantation has many causes with overlapping presentations. Page kidney refers to external compression of the kidney by a hematoma, urinoma or tumor, leading to parenchymal hypoperfusion, unexplained hypertension (HTN), or frank acute renal failure. About 100 cases of Page kidney are reported; mostly after kidney biopsy. After the analysis of records, we identified four cases of acute Page kidney posttransplant, akin to a compartment syndrome. All biochemical, laboratory, and clinical parameters were recorded. Cases occurred within two to three weeks of transplant, with different causes. Clinical presentation was sudden, with HTN, raised serum creatinine and perigraft swelling in all. Rejection co-existed Page kidney in two cases, while tacrolimus had to be potentiated with diltiazem in one case. Serial parameters such as increased resistive index (>0.7), perigraft collection, and absent diastolic flow with normal peak systolic velocity were consistent with diagnosis. Two were caused by lymphoceles, more than 3 L. Both were managed by laparoscopic fenestration surgery; probably the first such instance for Page kidney. Two patients had postoperative hematoma; in one case, it followed early percutaneous angiographic stenting and "leakage" from the transplant artery, only the second such report. A high index of suspicion required for diagnosis; after excluding rejection and pre/postrenal causes, aggressive early management is the key for graft salvage.
... The elevated CRP or low-grade fever in the present case might reflect relatively active vascular inflammation. Although most cases of Page kidney show hypertension or mild renal damage, a few cases of severe kidney failure have been reported in patients with solitary kidney, such as patients who have undergone kidney transplantation (11). In this case, the right kidney was impaired by atrophy and hydronephrosis. ...
A 71-year-old Japanese man with progressive kidney failure was referred to our hospital. Laboratory tests showed elevated IgG4 levels. Contrast-enhanced computed tomography (CT) revealed soft tissue surrounding the left kidney and right atrophic kidney. A histopathological examination revealed inflammation and fibrosis with rich IgG4-positive cells in the thickened kidney capsule, but not in the kidney parenchyma. Poor enhancement in the left kidney on contrast-enhanced CT and wrinkling of glomerular capillaries in pathological tissues were also observed. These findings indicated IgG4-related perirenal lesions leading to low renal perfusion and kidney failure. The perirenal lesions and kidney failure were improved by corticosteroid therapy.
... Out of the SRH cases reported in the scientific literature, forty-four reports refer to kidney grafts (Table 1). It is still a matter of debate whether patients diagnosed with SRH should undergo interventional treatments (such as percutaneous drainage, surgical decortication, and nephrectomy) [2][3][4] or a cautious wait-and-see approach, due to the possible spontaneous resolution of this condition [5,6]. Therapy should rely on a multidisciplinary approach and should be tailored on the single patient. ...
Subcapsular renal hematoma (SRH) is a challenging condition, which may jeopardize kidney function or constitute a life-threatening event. This is particularly true in single-kidney patients, such as kidney-transplant recipients. SRH may exert an excessive pressure on the surrounding parenchyma, thus resulting in hypoperfusion and ischemia, with high risk of acute kidney failure and graft loss. Moreover, SRH may precede an overt renal rupture with subsequent hemorrhage and hemodynamic instability. The indication to an interventional management for this condition is still a matter of debate, with some authors advocating the high possibilities of spontaneous resolution and others advocating the high-risk of graft loss and even internal bleeding in case of overt renal rupture. Herein, we report the case of a 51-year-old simultaneous pancreas-kidney transplantation recipient who presented a SRH following a mild trauma. The therapeutic choices were carefully balanced on the specific case, and the conservative management proved successful.
... There have been 30 cases reported in the literature so far of Page kidney, with some related to trauma 40,41 and two cases of allograft losses. 42,43 In transplant recipients, a doppler scan of transplant kidney can show features of compromised renal perfusion such as absent or reversible arterial diastolic flow with significant increase in resistive index coupled with peri graft hematoma. 44 In cases of managing trauma in transplant recipients, it is recommended that the patient is transferred to a transplant unit for specialist care. ...
Management of Renal Allograft Trauma
... 39 There have been 30 cases reported in the literature so far of Page kidney, with some related to trauma 40,41 and two cases of allograft losses. 42,43 In transplant recipients, a doppler scan of transplant kidney can show features of compromised renal perfusion such as absent or reversible arterial diastolic flow with significant increase in resistive index coupled with peri graft hematoma. 44 In cases of managing trauma in transplant recipients, it is recommended that the patient is transferred to a transplant unit for specialist care. ...
... In the experiment, cellophane was wrapped around a native kidney leading to the constriction in renal parenchyma and hypertension [7]. In the context of kidney transplantation, Page kidney phenomenon can occur spontaneously after kidney transplantation [8,9], after percutaneous kidney graft biopsy [5,[10][11][12], or after trauma to the allograft [13]. It can also occur in a native kidney [14]. ...
... Although the occurrence of PK is rare in allograft, some recipients develop PK because of subcapsular hematomas after allograft biopsy, peritransplant lymphocele, or trauma. Doppler ultrasonography (US) is regarded as an important tool for the early diagnosis of PK and may reveal findings such as subcapsular hematomas and elevated resistive index (RI) [3][4][5][6]. In our case, these signs were undetected even with repeated examination by Doppler US. ...
... Reportedly, PK for allograft is caused mainly by allograft biopsy and trauma. Risk factors for the development of PK for allograft are not well established [5,8]. Takahashi et al. summarized previous reports, and the most common causes were iatrogenic, meaning allograft biopsy and three cases lost their allograft function [5]. ...
... Risk factors for the development of PK for allograft are not well established [5,8]. Takahashi et al. summarized previous reports, and the most common causes were iatrogenic, meaning allograft biopsy and three cases lost their allograft function [5]. Although the cause of subcapsular bleeding was unclear in this case, a small cyst of the allograft, which might rupture at donor nephrectomy, was located in the middle of hematoma, and oozing around the cyst was observed. ...
Background:
Page kidney phenomenon is caused by strong renal parenchymal compression and leads to renal hypoperfusion and microvascular ischemia, resulting in renal dysfunction and hypertension. Although the development of Page kidney phenomenon in allograft is rare, most of its cases are induced by allograft biopsy or trauma. We observed a case of Page kidney phenomenon that was induced by unusual causes immediately after kidney transplantation.
Case presentation:
A 66-year-old man, whose wife donated a kidney, underwent ABO-compatible living kidney transplantation. The allograft had three renal arteries that were trimmed and formed into one piece on the back table, and subsequently, it was anastomosed to the internal iliac artery. Intraoperative Doppler ultrasonography (US) revealed adequate blood flow of each renal artery. Urine output was also observed as soon as allograft blood flow was reperfused. After the surgery, the urine output decreased, and serum creatinine level increased to 6.0 mg/dL. Doppler US did not show evidence of acute rejection, ureteral obstruction, or anastomotic stenosis of the renal arteries. On postoperative day 7, surgical exploration was performed and revealed that the blood flow of each renal artery was adequate but subcapsular hematoma was detected at the upper pole of the allograft. Capsulotomy and hematoma evacuation were performed. Subsequently, urine output increased and serum creatinine level decreased up to 1.7 mg/dL. Allograft sample was obtained 1 h after the transplantation from the lower pole of the allograft. Although the cause of subcapsular bleeding was unclear in this case, a small cyst of the allograft, which might have ruptured during donor nephrectomy, was located in the middle of the hematoma, and oozing around the cyst was observed.
Conclusions:
Our case indicated that the small ruptured cyst of the allograft could be the cause of subcapsular hematoma and Page kidney phenomenon. Subcapsular hematoma caused by oozing over time could be difficult to diagnose using Doppler US, and thus, other imaging modalities, such as computed tomography, should be considered. Knowledge of the Page kidney phenomenon in the allograft can lead to early diagnosis and intervention, resulting in better outcomes for recipients with allograft dysfunction.
... In the experiment, cellophane was wrapped around a native kidney leading to the constriction in renal parenchyma and hypertension [6]. In the context of kidney transplantation, Page kidney phenomenon can occur spontaneously after kidney transplantation 7, after percutaneous kidney graft biopsy [4,[8][9][10], or after trauma to the allograft [11]. It can also occur in a native kidney. ...
... The page kidney phenomenon may develop almost immediately after percutaneous renal biopsy. However, it could have delay presentation sometimes such as 10 days following biopsy [11], as in our case 1. The late presentation could be due to the rupture of a pseudpaneurysm that was formed following percutaneous biopsy". ...
