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Subcapsular hematoma of transplant kidney is rare and cases are associated with kidney biopsy. Early diagnosis and surgical intervention are essential to preserve kidney function. We are presenting a case series of kidney transplant recipients with subcapsular hematoma.
We retrospectively review electronic medical records to identify adult patients with transplant kidney subcapsular hematoma in the last 5 years. Cases of early subcapsular hematoma within a week of transplantation were excluded. Data collection include patient demographics, comorbidities, medications, clinical data and outcomes.
All patients were recipients of deceased donor kidney transplant. Three patients underwent kidney biopsy post transplant. Subcapsular hematoma occurred immediately after kidney biopsy in case 1, 3 days after kidney biopsy in case 2 whereas case 3 developed subcapsular hematoma 2 months after the biopsy. All patients who underwent kidney biopsy were not on anticoagulants or antiplatelets at the time of the biopsy. Case 4 developed subcapsular hematoma following endovascular procedure through access of the ipsilateral femoral vein in a patient with liver cirrhosis and on anticoagulation. In terms of outcomes, case 1 had complete recovery of kidney function and did not require renal replacement therapy. The subcapsular hematoma developed after inpatient kidney biopsy which led to immediate evaluation and surgical intervention. In the other cases, delayed patient presentation and subsequent surgical intervention led to permanent loss of kidney function.
Case 2 did not have any complications with 2 prior kidney biopsies at 3 and 6 months post-transplant. He continued to have kidney dysfunction despite evacuation of subcapsular hematoma. In case 3, transplant kidney angiogram was done and showed large pseudoaneurysm originating from the right external iliac artery at the level of the transplant renal artery. Sequential balloon angioplasty was performed with exclusion stent placement. Repeat kidney transplant US showed no flow to the transplant kidney so the decision was to proceed with surgical evacuation of subcapsular hematoma and graft nephrectomy.
Case 4 had kidney biopsy which showed that the majority of the renal tissue is necrotic and single focus of cortical tubules appear possibly viable and he remained on dialysis
Summary of cases are detailed in table 1
Table 1. Summary of subcapsular hematoma cases.
Case 1
Case 2
Case 3
Case 4
Age (years)
61
60
56
Race
Hispanic
African American
Caucasian
Gender
Female
Male
Primary kidney disease
HTN, DM
DM
CNI toxicity
IgA nephropathy
Comorbidities
HTN, DM, CAD
HTN, DM, stage 3 liver fibrosis
HTN, DM, CAD, AF, liver cirrhosis
Type of transplant
DDKT
Time since transplant
2 years
1 year
3 months
Anticoagulation
No
Rivaroxaban
Antiplatelets
Yes
INR at the time of event
1.1
0.9
1.3
1.4
Platelet (k/ul)
154
99
149
73
Cr on admission (mg/dl)
2.3
1.5
3.5
Clinical Presentation
HTN, headache, anuria and RLQ pain
HTN, oliguria and RLQ pain
HTN, oliguria, anemia and RLQ pain
HTN, anuria and RLQ pain
Clinical events before presentation
Biopsy 1 day ago
Biopsy 3 days ago
Biopsy 2 months ago
RF ablation 30 hours ago
Hematoma thickness on CT scan (cm)
3.8
3
3.1
Vascular doppler on US
Poor diastolic flow throughout the kidney
Poor flow within the main renal artery and no significant flow within the renal vein.
Flow is not detected in the interlobar artery arteries. pseudoaneurysm versus AV fistula of the transplant kidney vasculature
Decreased renal artery velocities with elevated resistive index at the midpole measuring 0.92
Intervention
Surgical evacuation
Surgical evacuation and graft nephrectomy
Outcome
Recovery of renal function
Dialysis dependent
Abbreviations: HTN: hypertension; DM: diabetes; CAD: coronary artery disease; RLQ: right lower quadrant, RF: radiofrequency, Cr: creatinine, US: Ultrasound
Subcapsular hematoma occurs rarely and causes of acute graft dysfunction in kidney transplant recipients. Hypertension, graft pain and decreasing urine output were the presenting symptoms in all cases. delayed diagnosis and intervention are associated with poor outcomes.