Case Author(s): John R. Leahy, M.D. and Henry D. Royal, M.D. , 8/9/98 . Rating: #D2, #Q3

Diagnosis: Transplant infarction

Brief history:

49 year old woman with anuria soon after renal transplant.

Images:

Anterior flow images at 4 sec/frame after 8 sec delay.

View main image(rs) in a separate image viewer

View second image(rs). Anterior images at 4 min/frame after 3 min delay.

View third image(us). Renal ultrasound with color doppler.

Full history/Diagnosis is available below

Diagnosis: Transplant infarction

Full history:

49 year old woman with end stage renal disease underwent a living related donor transplant to the right iliac fossa. She developed anuria one week later.

Radiopharmaceutical:

8.2 mCi Tc-99m MAG3 i.v.

Findings:

The anterior pelvic radionuclide angiogram demonstrates no perfusion of the transplanted kidney in the right iliac fossa. On delayed images, there is no appreciable tracer uptake and no excretion from the transplant. Minimal activity is seen within the patient's native kidneys and bladder.

Renal ultrasound performed the same day shows normal kidney morphology and normal gray scale appearance. No flow was detected within the renal artery.

Discussion:

The likely causes of renal transplant dysfunction change depending on the length of time after surgery. In the immediate post-operative period, these causes include acute tubular necrosis (ATN), hyperacute or accelerated rejection, urine leak, hematoma, and infection. Vascular thrombosis can occur at any time, while arterial stenosis tends to occur after the first month. Clinically, ATN, rejection, cyclosporin toxicity and vascular thrombosis all result in decreased renal function. Treatment of renal dysfunction depends on its cause. Imaging can help determine the cause of the renal dysfunction.

Renal scintigraphy allows assessment of both perfusion and function in the transplanted kidney. Activity should be seen in the kidney 3-6 seconds after activity in the iliac artery. Peak activity in the graft should occur in less than 5 minutes, followed by prompt wash-out. In ATN, there is a slight reduction in perfusion, with significant parenchymal dysfunction. In rejection, there is decreased perfusion and relatively preserved function early, with reduction in both perfusion and function with more chronic rejection. In practice, it is usually not possible to definitively distinguish ATN from rejection based on the scintigraphic findings because there is considerable overlap of the findings for these two causes of renal dysfunction. In arterial thrombosis, there is severe or total reduction in perfusion and function.

References:

Sandler MP et al: Diagnostic Nuclear Medicine, 3rd ed. Baltimore, Williams and Wilkins 1996. 1223-29, 1331-39.

Dubovsky EV, Russell CD: Radionuclide evaluation of renal transplants. Semin in Nucl Med 1988; 18: 181-198

Dodd GD, Tublin ME, Shah A: Vascular complications associated with renal transplants. AJR 1991; 157:449-459

Major teaching point(s):

Renal scintigraphy and renal ultrasound are complimentary modalities for use in evaluating the transplanted patient. Ultrasound can confirm absence of renal arterial flow, and possibly show the location of the thrombus.

ACR Codes and Keywords:

References and General Discussion of Renal Scintigraphy (Anatomic field:Genitourinary System, Category:Effect of Trauma)

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Case number: rs018

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