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http://www.kidney-international.org & 2012 International Society of Nephrology
Kidney International (2012) 81, 420; doi:10.1038/ki.2011.361
Ruptured pseudoaneurysm in a renal allograft after percutaneous biopsy Karel W.J. Klop1, Oguzhan Karatepe1, Jan J. Weening2, Madelon van Agteren3 and Frank J.M.F. Dor1 1
Erasmus MC University Medical Center, Division of Transplant Surgery, Department of Surgery, Rotterdam, The Netherlands; 2Erasmus MC University Medical Center, Department of Pathology, Rotterdam, The Netherlands and 3Erasmus MC University Medical Center, Division of Nephrology, Department of Internal Medicine, Rotterdam, The Netherlands Correspondence: Frank J.M.F. Dor, Erasmus MC University Medical Center, Division of Transplant Surgery, Department of Surgery, Room H-811, Postbus 2040, Rotterdam, CA 3000, The Netherlands. E-mail:
[email protected]
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Figure 1 | Macroscopic image of explanted kidney graft. A hemorrhage (a) is seen directly next to the pyelum wall and adjacent papilla (b).
Figure 2 | Microscopic image through the biopsy tract demonstrating necrosis, destruction of the arterial wall, and hemorrhage.
A 38-year-old female patient received her second deceased donor kidney transplant in January 2011. Two weeks after implantation she was re-admitted for a rise in creatinine. A percutaneous biopsy was taken for a suspected rejection, for which treatment (methylprednisolone and antithymocyte globulin) had already been initiated. Two days after the biopsy the patient had a hemoglobin level of 4.3 mmol/l (compared with 6.1 mmol/l before the biopsy), for which she received a blood transfusion with one unit of blood. An ultrasonography was performed; this demonstrated a hypoechogenic lesion in the lower pole of the kidney (30 20 mm), a small fluid collection around the lower pole, and adequate vascular signals. Pathological examination of the biopsy showed a type 1 cellular rejection. The anti-rejection treatment failed, the patient was discharged and sent for hemodialysis. Three weeks after the biopsy the patient presented at our emergency department with hemodynamic instability and sudden massive hematuria. Blood testing
showed a hemoglobin level of 3.2 mmol/l, for which she received three units of blood. Computed tomography–angiography was performed; a hemorrhage was seen in the lower pole of the transplanted kidney (42 33 mm) with a blush in the arterial phase. As she was progressively hemodynamically unstable and she had unsuccessfully been treated for biopsyproven rejection, it was decided to perform an emergency transplantectomy. Macroscopic examination of the removed kidney demonstrated a contained hemorrhage directly next to the pyelum and part of the medulla, as well as surrounding necrosis (Figure 1). Pathological examination of the graft showed vascular rejection; C4d staining was negative. Additional slides through the biopsy tract were made for microscopic evaluation. Besides necrosis and hemorrhage, these slides also demonstrated destruction and vanishing of the arterial wall (Figure 2). Development of a (contained) pseudoaneurysm after percutaneous biopsy should be considered a potentially dangerous complication.
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Kidney International (2012) 81, 420
