Nephrol Dial Transplant (1999) 14: 2022-2024
© 1999 European Renal Association-European Dialysis and Transplant Association
Case Reports
An unusual cause of post-biopsy oliguria in an allograft
Josep M. Cruzado,
Joan Torras,
Joan Domínguez1,
Concha Sancho1,
Jeroni Alsina and
Josep M. Grinyó
1 Departments of Nephrology and Radiology, Hospital de Bellvitge, CSUB, L'Hospitalet, Barcelona, Spain
Correspondence and offprint requests to:
Josep M. Cruzado, Nephrology Department, Hospital de Bellvitge, Feixa Llarga s/n, 08907 L'Hospitalet, Barcelona, Spain.
Keywords: acute renal failure; embolization; renal arteriovenous fistula; renal artery stenosis; renal biopsy; renal transplantation
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Introduction
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Renal biopsy of the transplanted kidney is an essential diagnostic
tool of acute and chronic rejection as well as recurrent and
de novo nephropathies in renal allograft recipients [
1]. The
application of molecular biology techniques to renal tissue
samples obtained by this procedure may also contribute to increasing
the understanding of the pathophysiology of the kidney [
2].
In comparison with the classical manual Tru-Cuth technique,
the introduction of percutaneous renal biopsy with sonographic
assistance using thin automatic biopsy needle has significantly
reduced complications related to kidney puncture [
3]. Thus,
renal bleeding or arteriovenous fistulas are seldom encountered
after this procedure [
4]. This fact allows protocol biopsy studies
to be conducted in renal transplant recipients that provide
useful information in order accurately to predict graft outcome
[
5]. Although this procedure is usually safe [
4], in some instances
it can be associated with complications. We report a case of
acute renal failure in a renal allograft recipient caused by
a post-biopsy renal arteriovenous fistula superimposed on pre-existing
renal artery stenosis.
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Case
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A 63-year-old man was hospitalized because of oliguric acute
renal failure, which appeared 3 days after a renal allograft
biopsy was performed. Eighteen months earlier he had started
haemodialysis treatment for end-stage renal disease due to IgA
nephropathy. Four months earlier he had received a cadaveric
renal allograft under a cyclosporin-based immunosuppressive
treatment. The post-transplant course was uncomplicated and
he was discharged on post-operative day 14 with a serum creatinine
of 176 µmol/l. Three months earlier he had begun taking
20 mg of nifedipine once a day and 2 mg of doxazosine twice
a day, prescribed because of arterial hypertension. Three days
earlier and after giving informed consent, he was admitted to
our department for renal allograft biopsy. Allograft sonography
was normal and percutaneous renal biopsy was done using a biopsy
needle (Monopty 18G, Bard). Histology revealed mild features
of chronic allograft nephropathy, and the patient was discharged
24 h post-biopsy.
On admission, the patient's complaint was oligura (300 ml/24 h in the day before admission). Physical examination showed bilateral pedal oedema and right femoral bruit, which irradiated to the graft implanted in the right iliac fossa. Further relevant clinical and analytical data are shown in Table 1
. Because of acute renal failure, an allograft ultrasound was indicated, which disclosed a suspicious image of an arteriovenous fistula in the upper renal pole, confirmed by colour-coded Doppler sonography. A right iliac arteriography showed a large arteriovenous fistula and a severe renal artery stenosis (Figure 1). Using a superselective catheterization technique, the fistula was occluded completely by means of delivery of several helical platinum microcoils [6]. Also, a transluminal renal angioplasty was carried out, but only a partial dilation was obtained due to technical difficulties (Figure 2). Thereafter, the patient had polyuria (200 ml/h in the next 24 h after embolization), and renal function improved rapidly; fractional excretion of sodium increase to more than its basal value (Table 1). Arterial hypertension was controlled with 20 mg of nifedipine once a day, and on the seventh day after arteriography, the patient was discharged. Four years later, the patient is well, arterial hypertension is treated with 2 mg of doxazosine twice a day and serum creatinine is 185 µmol/l.
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Fig. 1. Right iliac arteriography showing that the renal artery of the donor was anastomosed end-to-side to the external iliac artery of the recipient. The renal artery shows a severe stenosis (medium-sized arrow). The arteriovenous fistula (wide arrow) is supplied by a branch of the renal artery (thin arrows) and, as this early arterial phase shows, the fistula immediately drains into the renal vein (**).
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Fig. 2. Arteriography immediately after delivery of platinum microcoils (wide arrowheads) showing the completely occluded arteriovenous fistula and the lumen dilatation of the renal artery stenosis after angioplasty (thin arrowhead). Note the hypoperfusion of the renal upper pole. This fact was due to vasospasm, since 3 days after embolization, 99mTc-pertechnectate angiogammagraphy demonstrated complete perfusion of the whole kidney.
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Discussion
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Arteriovenous fistulas after percutaneous renal biopsy may remain
asymptomatic or lead to haematuria [
7], hypertension and renal
insufficiency [
8]. What is noteworthy from our case is that
it illustrates the renal haemodynamic mechanisms involved in
maintaining the glomerular filtration rate when renal plasma
flow is reduced. In the presence of renal artery stenosis, the
renin–angiotensin system is activated. Thus, angiotensin
II increases blood pressure and produces vasoconstriction of
the efferent glomerular arterioles, both mechanisms leading
to preserve glomerular filtration pressure distal to the renal
artery stenosis. Accordingly, before renal biopsy, our patient
had arterial hypertension and showed a trend to low urinary
sodium and fractional excretion of sodium. This fragile equilibrium
was broken by arteriovenous fistula-induced blood loss, which
abruptly reduced the effective renal plasma flow. In order to
restore the intrarenal haemodynamics, this demanded further
activation of the renin–angiotensin system [
8]. This disastrous
combination caused acute renal hypoperfusion, and indeed oliguria
and pre-renal azotaemia, which was associated with a dramatic
reduction of urinary sodium and fractional excretion of sodium.
After embolization of the arteriovenous fistula and angioplasty
of the renal artery stenosis, renal function parameters returned
to basal levels, urinary sodium and fractional excretion of
sodium increased over pre-renal biopsy values, but antihypertensive
treatment was required, suggesting that probably the renal angioplasty
was incomplete.
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References
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Cruzado JM, Gil-Vernet S, Ercilla G et al. Hepatitis C virus-associated membranoproliferative glomerulonephritis in renal allografts. J Am Soc Nephrol 1996; 7: 2469–2475[Abstract]
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Schena FP, Gesualdo L. Renal biopsy—beyond histology and immunofluorescence. Nephrol Dial Transplant 1994; 9: 1541–1544[Free Full Text]
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Riehl J, Maigatter S, Kierdorf H, Schmitt H, Maurin N, Sieberth HG. Percutaneous renal biopsy: comparison of manual and automated puncture techniques with native and transplanted kidneys. Nephrol Dial Transplant 1994; 9: 1568–1574[Abstract/Free Full Text]
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Hergesell O, Felten H, Andrassy K, Kuhn K, Ritz E. Safety of ultrasound-guided percutaneous renal biopsy—retrospective analysis of 1090 consecutive cases. Nephrol Dial Transplant 1998; 13: 975–977[Abstract/Free Full Text]
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Beaujeux R, Boudjema K, Ellero B et al. Endovascular treatment of renal allograft postbiopsy arteriovenous fistula with platinum microcoils. Transplantation 1994; 57: 311–314[Medline]
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Received for publication: 5. 3.99
Accepted in revised form: 31. 3.99
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