1
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Langdon J, Sharbidre K, Garner MS, Robbin M, Scoutt LM. Renal transplant ultrasound: assessment of complications and advanced applications. Abdom Radiol (NY) 2025; 50:2558-2585. [PMID: 39643733 DOI: 10.1007/s00261-024-04731-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2024] [Revised: 11/24/2024] [Accepted: 11/26/2024] [Indexed: 12/09/2024]
Abstract
Renal transplantation is the most commonly performed solid organ transplant procedure. Monitoring renal transplants with ultrasound is a critical component in the management of transplant patients both in the immediate aftermath of surgery and longitudinally. Many complications are detectable via ultrasound evaluation with relative prevalence dependent on the time since surgery. It is critical for the practicing radiologist to recognize these complications to help guide appropriate treatment. Fundamental understanding of the procedure, including various surgical techniques is of great importance. In this article, the sonographic findings of the most common postoperative and long-term complications of renal transplantation are reviewed. As complications are highly related to surgical technique, the most common surgical techniques are presented first. Comprehensive ultrasound evaluation of the allograft is discussed next, followed by extensive review of the ultrasound findings of common complications. Finally, select recent advances in ultrasound are presented with their current and potential applications to renal transplant evaluation.
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Affiliation(s)
- Jonathan Langdon
- Department of Radiology & Biomedical Imaging, Yale School of Medicine, New Haven, CT, USA.
| | - Kedar Sharbidre
- Department of Radiology, University of Alabama at Birmingham, Birmingham, USA
| | - Matthew S Garner
- Department of Surgery, SUNY Upstate Medical University, Syracuse, USA
| | - Michelle Robbin
- Department of Radiology, University of Alabama at Birmingham, Birmingham, USA
| | - Leslie M Scoutt
- Department of Radiology & Biomedical Imaging, Yale School of Medicine, New Haven, CT, USA
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2
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Expert Panel on Urological Imaging, Taffel MT, Khatri G, Purysko AS, Avery R, Caserta MP, Chang SD, De Leon AD, Ganeshan D, Gupta RT, Lew SQ, Lyshchik A, Nicola R, Piel C, Sener A, Smith AD, Nikolaidis P. ACR Appropriateness Criteria® Renal Transplant Dysfunction: 2024 Update. J Am Coll Radiol 2025; 22:S372-S395. [PMID: 40409889 DOI: 10.1016/j.jacr.2025.02.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2025] [Accepted: 02/24/2025] [Indexed: 05/25/2025]
Abstract
Renal transplantation remains the treatment of choice in patients with end-stage renal disease as the 5-year survival rates for the graft in renal transplant patients range from 72% to 99%. Despite improvements in graft survival related to increased efficacy of immunosuppression drugs and improvements in surgical technique, various complications do occur. Ultrasound is the first-line imaging modality for the evaluation of renal transplants in the immediate postoperative period and for longitudinal follow-up. Various other imaging techniques serve as complementary examinations in specific clinical settings. Angiography remains the reference standard for arterial complications and is used for nonsurgical intervention, but noninvasive CT or MR angiography could be considered prior to an invasive procedure. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
| | - Myles T Taffel
- New York University Langone Medical Center, New York, New York.
| | - Gaurav Khatri
- Panel Chair, UT Southwestern Medical Center, Dallas, Texas
| | | | - Ryan Avery
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois; Commission on Nuclear Medicine and Molecular Imaging
| | | | - Silvia D Chang
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | - Rajan T Gupta
- Duke University Medical Center, Durham, North Carolina
| | - Susie Q Lew
- George Washington University, Washington, District of Columbia; American Society of Nephrology
| | - Andrej Lyshchik
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Refky Nicola
- SUNY Upstate Medical University, Syracuse, New York
| | - Carl Piel
- UT Southwestern Medical Center, Dallas, Texas; American College of Emergency Physicians
| | - Alp Sener
- Western University, London, Ontario, Canada; American Urological Association
| | - Andrew D Smith
- University of Alabama at Birmingham, Birmingham, Alabama
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3
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Revzin MV, Srivastava B, Pellerito JS. Ultrasound of the Upper Urinary Tract. Radiol Clin North Am 2025; 63:57-82. [PMID: 39510663 DOI: 10.1016/j.rcl.2024.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2024]
Abstract
Ultrasound (US) plays a primary role in the assessment and diagnosis of renal and ureteral pathologies and their management. It is considered the first-line imaging modality for evaluation of urinary obstruction, nephrolithiasis, and urinary retention among other indications. US is also essential for evaluation of renal vasculature and assessment of renal transplantation. Contrast-enhanced US is an advanced application of US gaining its acceptance in evaluation of the renal masses.
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Affiliation(s)
- Margarita V Revzin
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, USA.
| | | | - John S Pellerito
- Department of Radiology, Division of US, CT and MRI, Peripheral Vascular Laboratory, North Shore - Long Island Jewish Health System
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4
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Fernández T, Sebastià C, Paño B, Corominas Muñoz D, Vas D, García-Roch C, Revuelta I, Musquera M, García F, Nicolau C. Contrast-enhanced US in Renal Transplant Complications: Overview and Imaging Features. Radiographics 2024; 44:e230182. [PMID: 38781089 DOI: 10.1148/rg.230182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
Renal transplant is the first-line treatment of end-stage renal disease. The increasing number of transplants performed every year has led to a larger population of transplant patients. Complications may arise during the perioperative and postoperative periods, and imaging plays a key role in this scenario. Contrast-enhanced US (CEUS) is a safe tool that adds additional value to US. Contrast agents are usually administered intravenously, but urinary tract anatomy and complications such as stenosis or leak can be studied using intracavitary administration of contrast agents. Assessment of the graft and iliac vessels with CEUS is particularly helpful in identifying vascular and parenchymal complications, such as arterial or venous thrombosis and stenosis, acute tubular injury, or cortical necrosis, which can lead to graft loss. Furthermore, infectious and malignant graft involvement can be accurately studied with CEUS, which can help in detection of renal abscesses and in the differentiation between benign and malignant disease. CEUS is also useful in interventional procedures, helping to guide percutaneous aspiration of collections with better delimitation of the graft boundaries and to guide renal graft biopsies by avoiding avascular areas. Potential postprocedural vascular complications, such as pseudoaneurysm, arteriovenous fistula, or active bleeding, are identified with CEUS. In addition, newer quantification tools such as CEUS perfusion are promising, but further studies are needed to approve its use for clinical purposes. ©RSNA, 2024 Supplemental material is available for this article.
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Affiliation(s)
- Tomás Fernández
- From the Departments of Radiology (T.F., C.S., B.P., D.C.M., D.V., C.N.), Nephrology (I.R.), and Urology (M.M.), Hospital Clínic de Barcelona, Villarroel 170, E3P1, 08036 Barcelona, Spain; Department of Radiology, Hospital Virgen de la Salud, Toledo, Spain (C.G.R.); and Department of Radiology, Fundación del Hospital Nacional de Parapléjicos, Toledo, Spain (F.G.)
| | - Carmen Sebastià
- From the Departments of Radiology (T.F., C.S., B.P., D.C.M., D.V., C.N.), Nephrology (I.R.), and Urology (M.M.), Hospital Clínic de Barcelona, Villarroel 170, E3P1, 08036 Barcelona, Spain; Department of Radiology, Hospital Virgen de la Salud, Toledo, Spain (C.G.R.); and Department of Radiology, Fundación del Hospital Nacional de Parapléjicos, Toledo, Spain (F.G.)
| | - Blanca Paño
- From the Departments of Radiology (T.F., C.S., B.P., D.C.M., D.V., C.N.), Nephrology (I.R.), and Urology (M.M.), Hospital Clínic de Barcelona, Villarroel 170, E3P1, 08036 Barcelona, Spain; Department of Radiology, Hospital Virgen de la Salud, Toledo, Spain (C.G.R.); and Department of Radiology, Fundación del Hospital Nacional de Parapléjicos, Toledo, Spain (F.G.)
| | - Daniel Corominas Muñoz
- From the Departments of Radiology (T.F., C.S., B.P., D.C.M., D.V., C.N.), Nephrology (I.R.), and Urology (M.M.), Hospital Clínic de Barcelona, Villarroel 170, E3P1, 08036 Barcelona, Spain; Department of Radiology, Hospital Virgen de la Salud, Toledo, Spain (C.G.R.); and Department of Radiology, Fundación del Hospital Nacional de Parapléjicos, Toledo, Spain (F.G.)
| | - Daniel Vas
- From the Departments of Radiology (T.F., C.S., B.P., D.C.M., D.V., C.N.), Nephrology (I.R.), and Urology (M.M.), Hospital Clínic de Barcelona, Villarroel 170, E3P1, 08036 Barcelona, Spain; Department of Radiology, Hospital Virgen de la Salud, Toledo, Spain (C.G.R.); and Department of Radiology, Fundación del Hospital Nacional de Parapléjicos, Toledo, Spain (F.G.)
| | - Carmen García-Roch
- From the Departments of Radiology (T.F., C.S., B.P., D.C.M., D.V., C.N.), Nephrology (I.R.), and Urology (M.M.), Hospital Clínic de Barcelona, Villarroel 170, E3P1, 08036 Barcelona, Spain; Department of Radiology, Hospital Virgen de la Salud, Toledo, Spain (C.G.R.); and Department of Radiology, Fundación del Hospital Nacional de Parapléjicos, Toledo, Spain (F.G.)
| | - Ignacio Revuelta
- From the Departments of Radiology (T.F., C.S., B.P., D.C.M., D.V., C.N.), Nephrology (I.R.), and Urology (M.M.), Hospital Clínic de Barcelona, Villarroel 170, E3P1, 08036 Barcelona, Spain; Department of Radiology, Hospital Virgen de la Salud, Toledo, Spain (C.G.R.); and Department of Radiology, Fundación del Hospital Nacional de Parapléjicos, Toledo, Spain (F.G.)
| | - Mireia Musquera
- From the Departments of Radiology (T.F., C.S., B.P., D.C.M., D.V., C.N.), Nephrology (I.R.), and Urology (M.M.), Hospital Clínic de Barcelona, Villarroel 170, E3P1, 08036 Barcelona, Spain; Department of Radiology, Hospital Virgen de la Salud, Toledo, Spain (C.G.R.); and Department of Radiology, Fundación del Hospital Nacional de Parapléjicos, Toledo, Spain (F.G.)
| | - Fernando García
- From the Departments of Radiology (T.F., C.S., B.P., D.C.M., D.V., C.N.), Nephrology (I.R.), and Urology (M.M.), Hospital Clínic de Barcelona, Villarroel 170, E3P1, 08036 Barcelona, Spain; Department of Radiology, Hospital Virgen de la Salud, Toledo, Spain (C.G.R.); and Department of Radiology, Fundación del Hospital Nacional de Parapléjicos, Toledo, Spain (F.G.)
| | - Carlos Nicolau
- From the Departments of Radiology (T.F., C.S., B.P., D.C.M., D.V., C.N.), Nephrology (I.R.), and Urology (M.M.), Hospital Clínic de Barcelona, Villarroel 170, E3P1, 08036 Barcelona, Spain; Department of Radiology, Hospital Virgen de la Salud, Toledo, Spain (C.G.R.); and Department of Radiology, Fundación del Hospital Nacional de Parapléjicos, Toledo, Spain (F.G.)
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5
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Fonseca de Jesus Silva C, Sosa Barrios RH, Burguera Vion V, Fernández Lucas M, Rivera Gorrín ME. Reversed diastolic intrarenal flow in page kidney following renal biopsy. J Ultrasound 2024:10.1007/s40477-023-00857-6. [PMID: 38413476 DOI: 10.1007/s40477-023-00857-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 12/03/2023] [Indexed: 02/29/2024] Open
Abstract
Page's kidney is a condition that occurs due to external renal compression, usually caused by a subcapsular haematoma, generating a renal compartmental syndrome with parenchymal damage and renal perfusion alteration. Classically associated with renal trauma, Page's kidney can also arise after invasive renal procedures, such as renal biopsies or percutaneous nephrostomies. Clinically, it can trigger hypertension due to activation of the renin-angiotensin system induced by hypoperfusion secondary to renal parenchymal compression and can also present with varying degrees of renal function impairment. Furthermore, severe acute renal failure may be found particularly in patients with solitary kidneys or renal transplants. We present two cases of Page's kidney after renal biopsy and their PoCUS ultrasound findings. We would like to highlight the reversed diastolic flow on Doppler ultrasound in this entity, a pattern we have found in all two cases.
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Affiliation(s)
| | - R Haridian Sosa Barrios
- Servicio de Nefrología, Hospital Universitario Ramón y Cajal, IRyCIS, Madrid, Spain.
- Sociedad Española de Nefrología: Pje. de Peña, 2, 39008 Santander, Cantabria, Madrid, Spain.
- , Ctra Colmenar Viejo km 9.1, 28034, Madrid, Spain.
| | - Víctor Burguera Vion
- Servicio de Nefrología, Hospital Universitario Ramón y Cajal, IRyCIS, Madrid, Spain
- Sociedad Española de Nefrología: Pje. de Peña, 2, 39008 Santander, Cantabria, Madrid, Spain
| | - Milagros Fernández Lucas
- Servicio de Nefrología, Hospital Universitario Ramón y Cajal, IRyCIS, Madrid, Spain
- Sociedad Española de Nefrología: Pje. de Peña, 2, 39008 Santander, Cantabria, Madrid, Spain
- Universidad de Alcalá de Henares, UAH, Madrid, Spain
| | - Maite E Rivera Gorrín
- Servicio de Nefrología, Hospital Universitario Ramón y Cajal, IRyCIS, Madrid, Spain
- Sociedad Española de Nefrología: Pje. de Peña, 2, 39008 Santander, Cantabria, Madrid, Spain
- Universidad de Alcalá de Henares, UAH, Madrid, Spain
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6
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Xia L, Ye Y, Luo Y, Miao B, Na N. Case report: Application of nonsurgical method in saving transplant renal vein thrombosis caused by acute diarrhea. Front Med (Lausanne) 2023; 10:1275188. [PMID: 38173940 PMCID: PMC10762308 DOI: 10.3389/fmed.2023.1275188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 11/27/2023] [Indexed: 01/05/2024] Open
Abstract
Transplant renal vein thrombosis is a rare complication after kidney transplantation, which can seriously threaten graft survival. Though the measures like thrombolytic therapy or operative intervention could be taken to deal with this complication, allograft loss is the most common outcome. Thus, early finding as well as decisive intervention is crucial to saving the graft. Here we present a 46-year-old male patient who underwent kidney transplantation from a cadaveric donor who developed a transplant renal venous thrombosis induced by acute diarrhea more than 1 year after renal transplantation with an initial symptom of sudden anuria and pain in the graft area. Subsequently, serum creatinine levels increased to 810.0 μmol/L. Pelvic CT showed increased vascular density of the transplanted kidney, and contrast-enhanced ultrasound confirmed venous thrombosis. The patient was treated with heparin sodium alone and diuresis gradually resumed. After more than 1 year of follow-up, serum creatinine returned to the baseline level prior to thrombosis. Our case indicates that quick ancillary examination and treatment without hesitation would be indispensable in rescuing allografts with renal vein thrombus. Unfractionated heparin can be recommended as an effective treatment for mid-long-term renal transplantation patients with renal vein thrombosis.
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Affiliation(s)
| | | | | | | | - Ning Na
- Department of Kidney Transplantation, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
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7
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Kim PY, Shoghi A, Fananapazir G. Renal Transplantation: Immediate and Late Complications. Radiol Clin North Am 2023; 61:809-820. [PMID: 37495289 DOI: 10.1016/j.rcl.2023.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
Kidney grafts are the most common transplanted solid organ. To optimize graft survival, radiologists should be familiar with the anatomy and potential complications unique to transplanted kidneys. In addition to being able to recognize the imaging characteristics to diagnose etiologies of kidney graft dysfunction, an understanding of the pathophysiology is a key to narrowing the differential diagnosis. This article provides a summary of the most common complications based on broad categories of type of complication and posttransplant timing.
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Affiliation(s)
- Patrick Yoon Kim
- Department of Radiology, University of California Davis Health, Sacramento, CA 95817, USA
| | - Azarin Shoghi
- University of California, Davis School of Medicine, Sacramento, CA 95817, USA
| | - Ghaneh Fananapazir
- Department of Radiology, University of California Davis Health, Sacramento, CA 95817, USA.
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8
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Patel A, Sener A, Lee SY. Reversed diastolic flow in a renal transplant due to ureteric obstruction from intraluminal blood clot. JOURNAL OF CLINICAL ULTRASOUND : JCU 2022; 50:521-524. [PMID: 34634838 DOI: 10.1002/jcu.23079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 09/16/2021] [Accepted: 10/05/2021] [Indexed: 06/13/2023]
Abstract
Reversal of arterial diastolic flow is commonly considered a sign of transplant renal vein thrombosis until proven otherwise, with the differential including acute rejection, acute tubular necrosis, and perirenal hematoma. We discuss a case of a patient who presented with decreased urine output on the second postoperative day following living unrelated kidney transplantation. Doppler ultrasound was performed and demonstrated reversal of diastolic flow in the transplant renal artery. Prompt surgical exploration revealed intraluminal blood clot obstructing the ureter. To our knowledge, this is the first reported case of reversed diastolic flow secondary to ureteral obstruction by an intraluminal blood clot.
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Affiliation(s)
- Arbaaz Patel
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Alp Sener
- Departments of Surgery and Microbiology and Immunology, Matthew Mailing Center for Translational Transplant Studies, Western University, London, Ontario, Canada
| | - Stefanie Y Lee
- Department of Radiology, McMaster University, Hamilton Health Sciences - Juravinski Hospital and Cancer Centre, Hamilton, Ontario, Canada
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9
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Chen FK, Sanyal R. Serial changes in renal allograft resistive index. J Bras Nefrol 2020; 42:391-392. [PMID: 33258466 PMCID: PMC7860657 DOI: 10.1590/2175-8239-jbn-2020-e003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 09/16/2020] [Indexed: 11/22/2022] Open
Affiliation(s)
- Frank K Chen
- Mayo Clinic, Department of Radiology, Jacksonville, FL, USA
| | - Rupan Sanyal
- Mayo Clinic, Department of Radiology, Jacksonville, FL, USA
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10
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Como G, Da Re J, Adani GL, Zuiani C, Girometti R. Role for contrast-enhanced ultrasound in assessing complications after kidney transplant. World J Radiol 2020; 12:156-171. [PMID: 32913562 PMCID: PMC7457161 DOI: 10.4329/wjr.v12.i8.156] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 04/30/2020] [Accepted: 07/18/2020] [Indexed: 02/06/2023] Open
Abstract
Kidney transplantation (KT) is an effective treatment for end-stage renal disease. Despite their rate has reduced over time, post-transplant complications still represent a major clinical problem because of the associated risk of graft failure and loss. Thus, post-KT complications should be diagnosed and treated promptly. Imaging plays a pivotal role in this setting. Grayscale ultrasound (US) with color Doppler analysis is the first-line imaging modality for assessing complications, although many findings lack specificity. When performed by experienced operators, contrast-enhanced US (CEUS) has been advocated as a safe and fast tool to improve the accuracy of US. Also, when performing CEUS there is potentially no need for further imaging, such as contrast-enhanced computed tomography or magnetic resonance imaging, which are often contraindicated in recipients with impaired renal function. This technique is also portable to patients' bedside, thus having the potential of maximizing the cost-effectiveness of the whole diagnostic process. Finally, the use of blood-pool contrast agents allows translating information on graft microvasculature into time-intensity curves, and in turn quantitative perfusion indexes. Quantitative analysis is under evaluation as a tool to diagnose rejection or other causes of graft dysfunction. In this paper, we review and illustrate the indications to CEUS in the post-KT setting, as well as the main CEUS findings that can help establishing the diagnosis and planning the most adequate treatment.
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Affiliation(s)
- Giuseppe Como
- Institute of Radiology, University Hospital S. Maria della Misericordia, Udine 33100, Italy
| | - Jacopo Da Re
- Institute of Radiology, Department of Medicine, University of Udine, University Hospital S. Maria della Misericordia, Udine 33100, Italy
| | - Gian Luigi Adani
- Department of Medicine, General Surgery and Transplantation, University Hospital S. Maria della Misericordia, Udine 33100, Italy
| | - Chiara Zuiani
- Institute of Radiology, Department of Medicine, University of Udine, University Hospital S. Maria della Misericordia, Udine 33100, Italy
| | - Rossano Girometti
- Institute of Radiology, Department of Medicine, University of Udine, University Hospital S. Maria della Misericordia, Udine 33100, Italy
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11
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Sugi MD, Joshi G, Maddu KK, Dahiya N, Menias CO. Imaging of Renal Transplant Complications throughout the Life of the Allograft: Comprehensive Multimodality Review. Radiographics 2020; 39:1327-1355. [PMID: 31498742 DOI: 10.1148/rg.2019190096] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The kidney is the most commonly transplanted solid organ. Advances in surgical techniques, immunosuppression regimens, surveillance imaging, and histopathologic diagnosis of rejection have allowed prolonged graft survival times. However, the demand for kidneys continues to outgrow the available supply, and there are efforts to increase use of donor kidneys with moderate- or high-risk profiles. This highlights the importance of evaluating the renal transplant patient in the context of both donor and recipient risk factors. Radiologists play an integral role within the multidisciplinary team in care of the transplant patient at every stage of the transplant process. In the immediate postoperative period, duplex US is the modality of choice for evaluating the renal allograft. It is useful for establishing a baseline examination for comparison at future surveillance imaging. In the setting of allograft dysfunction, advanced imaging techniques including MRI or contrast-enhanced US may be useful for providing a more specific diagnosis and excluding nonrejection causes of renal dysfunction. When a pathologic diagnosis is deemed necessary to guide therapy, US-guided biopsy is a relatively low-risk, safe procedure. The range of complications of renal transplantation can be organized temporally in relation to the time since surgery and/or according to disease categories, including immunologic (rejection), surgical or iatrogenic, vascular, urinary, infectious, and neoplastic complications. The unique heterotopic location of the renal allograft in the iliac fossa predisposes it to a specific set of complications. As imaging features of infection or malignancy may be nonspecific, awareness of the patient's risk profile and time since transplantation can be used to assign the probability of a certain diagnosis and thus guide more specific diagnostic workup. It is critical to understand variations in vascular anatomy, surgical technique, and independent donor and recipient risk factors to make an accurate diagnosis and initiate appropriate treatment.©RSNA, 2019.
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Affiliation(s)
- Mark D Sugi
- From the Department of Radiology, Mayo Clinic, Scottsdale, Ariz (M.D.S., N.D., C.O.M.); and Departments of Radiology and Imaging Sciences (G.J., K.K.M.) and Emergency Medicine (G.J., K.K.M.), Emory University School of Medicine, Atlanta, Ga
| | - Gayatri Joshi
- From the Department of Radiology, Mayo Clinic, Scottsdale, Ariz (M.D.S., N.D., C.O.M.); and Departments of Radiology and Imaging Sciences (G.J., K.K.M.) and Emergency Medicine (G.J., K.K.M.), Emory University School of Medicine, Atlanta, Ga
| | - Kiran K Maddu
- From the Department of Radiology, Mayo Clinic, Scottsdale, Ariz (M.D.S., N.D., C.O.M.); and Departments of Radiology and Imaging Sciences (G.J., K.K.M.) and Emergency Medicine (G.J., K.K.M.), Emory University School of Medicine, Atlanta, Ga
| | - Nirvikar Dahiya
- From the Department of Radiology, Mayo Clinic, Scottsdale, Ariz (M.D.S., N.D., C.O.M.); and Departments of Radiology and Imaging Sciences (G.J., K.K.M.) and Emergency Medicine (G.J., K.K.M.), Emory University School of Medicine, Atlanta, Ga
| | - Christine O Menias
- From the Department of Radiology, Mayo Clinic, Scottsdale, Ariz (M.D.S., N.D., C.O.M.); and Departments of Radiology and Imaging Sciences (G.J., K.K.M.) and Emergency Medicine (G.J., K.K.M.), Emory University School of Medicine, Atlanta, Ga
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12
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Abstract
Vascular complications are a significant source of morbidity and mortality among renal transplant recipients. Imaging using ultrasound, CT, and MRI plays a key role in diagnosing such complications. This review focuses on the major vascular complications of renal grafts, which include transplant renal arterial and venous stenoses, arterial and venous thromboses, arteriovenous fistulas, and pseudoaneurysms. Etiology, diagnostic modalities useful for diagnosis, and imaging appearance will be presented.
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Affiliation(s)
- Ghaneh Fananapazir
- Department of Radiology, University of California Davis Medical Center, 4860 Y Street Suite 3100, Sacramento, CA, 95817, USA.
| | - Christoph Troppmann
- Department of Surgery, University of California Davis Medical Center, 2315 Stockton Blvd # 1018, Sacramento, CA, 95817, USA
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13
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Taffel MT, Nikolaidis P, Beland MD, Blaufox MD, Dogra VS, Goldfarb S, Gore JL, Harvin HJ, Heilbrun ME, Heller MT, Khatri G, Preminger GM, Purysko AS, Smith AD, Wang ZJ, Weinfeld RM, Wong-You-Cheong JJ, Remer EM, Lockhart ME. ACR Appropriateness Criteria ® Renal Transplant Dysfunction. J Am Coll Radiol 2018; 14:S272-S281. [PMID: 28473084 DOI: 10.1016/j.jacr.2017.02.034] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 02/20/2017] [Accepted: 02/21/2017] [Indexed: 02/06/2023]
Abstract
Renal transplantation is the treatment of choice in patients with end-stage renal disease because the 5-year survival rates range from 72% to 99%. Although graft survival has improved secondary to the introduction of newer immunosuppression drugs and the advancements in surgical technique, various complications still occur. Ultrasound is the first-line imaging modality for the evaluation of renal transplants in the immediate postoperative period and for long-term follow-up. In addition to depicting many of the potential complications of renal transplantation, ultrasound can also guide therapeutic interventions. Nuclear medicine studies, CT, and MRI are often helpful as complementary examinations for specific indications. Angiography remains the reference standard for vascular complications and is utilized to guide nonsurgical intervention. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer-reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | - Myles T Taffel
- Principal Author, George Washington University Hospital, Washington, District of Columbia.
| | - Paul Nikolaidis
- Panel Vice-chair, Northwestern University, Chicago, Illinois
| | | | - M Donald Blaufox
- Albert Einstein College of Medicine, Bronx, New York; Society of Nuclear Medicine and Molecular Imaging
| | - Vikram S Dogra
- University of Rochester Medical Center, Rochester, New York
| | - Stanley Goldfarb
- University of Pennsylvania School of Medicine, Philadelphia; Pennsylvania, American Society of Nephrology
| | - John L Gore
- University of Washington, Seattle, Washington; American Urological Association
| | | | | | | | | | - Glenn M Preminger
- Duke University Medical Center, Durham, North Carolina; American Urological Association
| | | | - Andrew D Smith
- The University of Mississippi Medical Center, Jackson, Mississippi
| | - Zhen J Wang
- University of California San Francisco School of Medicine, San Francisco, California
| | - Robert M Weinfeld
- Oakland University William Beaumont School of Medicine, Troy, Michigan
| | | | | | - Mark E Lockhart
- Panel Chair, University of Alabama at Birmingham, Birmingham, Alabama
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Narasimhan E, Kennedy A, Campsen J. Transplant with a twist: A pitfall in sonographic diagnosis of renal transplant torsion. JOURNAL OF CLINICAL ULTRASOUND : JCU 2017; 45:528-530. [PMID: 28150312 DOI: 10.1002/jcu.22439] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Revised: 10/16/2016] [Accepted: 11/14/2016] [Indexed: 06/06/2023]
Abstract
Torsion is an uncommon cause of impaired function in a renal transplant. We present a case of intraperitoneal transplant torsion secondary to adhesions to the left fallopian tube and ovary. Inability to confirm renal venous flow with Doppler misled to the erroneous sonographic diagnosis of renal vein thrombosis, although end diastolic flow was absent rather than reversed. The correct diagnosis was made with CT. The combination of abnormal orientation of the graft on ultrasonography, acutely impaired renal function, and abnormal Doppler study should have led to a diagnosis of transplant torsion. The case is also unusual in that the lead point was adnexal pathology. © 2017 Wiley Periodicals, Inc. J Clin Ultrasound 45:528-530, 2017.
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Affiliation(s)
- Evan Narasimhan
- Swedish Medical Center, General Surgery Residency, Seattle, WA
| | - Anne Kennedy
- Department of Radiology and Imaging Sciences, University of Utah Medical Center, Salt Lake City, UT
| | - Jeffrey Campsen
- Transplant Surgery Division, Department of Surgery, University of Utah Medical Center, Salt Lake City, UT
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15
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Fananapazir G, Tse G, Corwin MT, Santhanakrishnan C, Perez RV, McGahan JP, Stewart S, Troppmann C. Pediatric En Bloc Kidney Transplants: Clinical and Immediate Postoperative US Factors Associated with Vascular Thrombosis. Radiology 2016; 279:935-42. [DOI: 10.1148/radiol.2015150430] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Late-onset renal vein thrombosis in renal allograft. INDIAN JOURNAL OF TRANSPLANTATION 2016. [DOI: 10.1016/j.ijt.2016.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Sonographic Evaluation of Clinically Significant Perigraft Hematomas in Kidney Transplant Recipients. AJR Am J Roentgenol 2015; 205:802-6. [PMID: 26397328 DOI: 10.2214/ajr.15.14426] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE The purpose of this study was to assess the sensitivity of ultrasound in evaluating peritransplant hematomas that require surgical evacuation in recipients of kidney transplants. MATERIALS AND METHODS Thirty-four patients who underwent 37 hematoma evacuations underwent ultrasound examinations in the 24 hours before surgical evacuation. The operative reports were evaluated for presence and size of collection, presence of active bleeding at operation, and composition of the hematoma. The clinical findings leading to the ultrasound examination were recorded. Ultrasound examinations were evaluated in consensus by two board-certified and fellowship-trained abdominal radiologists for the presence, size, and echogenicity of the collection; subjective perfusion visualized with color and power Doppler ultrasound; velocities of the renal arteries; and arcuate artery resistive indexes. RESULTS Ten of the 37 imaged hematomas (27%) had either no or small (< 50 mL) fluid collections on ultrasound examination. With sonographic volumetry, the reported intraoperative volumes were underestimated by 46%. The mean arcuate artery resistive index was 0.82 in the superior pole, 0.81 in the mid pole, and 0.78 in the inferior pole of the kidney. A decrease in hemoglobin level was the most sensitive clinical finding for determining the presence of perigraft hematomas. CONCLUSION Our results suggest that gray-scale sonography alone appears to have limited sensitivity in detecting clinically significant peritransplant hematomas and that its use may result in overall underestimates of hematomas.
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Abstract
One of the principal roles of a nephrologist is to closely monitor renal transplant allograft function and promptly evaluate any dysfunction. Renal transplant sonography has a major role in this assessment process given its ability to easily define renal transplant anatomy and surrounding structures. Abnormalities can be extrarenal or involve vascular, parenchymal and urological components of the graft and these can acutely or chronically influence graft function and survival. Procedural guidance as is required during allograft biopsy, as well as routine surveillance and screening for post transplant complications such as malignancy are also important applications of ultrasound in the management of renal transplant recipients. This article outlines key ultrasound findings and applications in renal transplantation from the clinician's perspective.
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Affiliation(s)
- Khai Gene Leong
- Department of Nephrology Monash Health Clayton Victoria Australia
| | - Peter Coombs
- Monash Imaging C/-Monash HealthClaytonVictoriaAustralia; Department of Medical ImagingRadiation Sciences Monash UniversityClaytonVictoriaAustralia
| | - John Kanellis
- Department of Nephrology Monash HealthClaytonVictoriaAustralia; Centre for Inflammatory DiseasesDepartment of Medicine Monash UniversityClaytonVictoriaAustralia
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Abstract
Ultrasonography is an excellent tool for evaluation of the renal transplant in the immediate postoperative period and for long-term follow-up. In this article, normal imaging findings and complications of renal transplantations are described. Disease processes are divided into vascular, perinephric, urologic and collecting system, and parenchymal abnormalities. Attention is paid to the time of occurrence of each complication, classic imaging findings, and potential pitfalls.
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Affiliation(s)
- Shuchi K Rodgers
- Department of Radiology, Sidney Kimmel Medical College at Thomas Jefferson University, Einstein Medical Center, 5501 Old York Road, Philadelphia, PA 19141, USA.
| | - Christopher P Sereni
- Department of Radiology, Sidney Kimmel Medical College at Thomas Jefferson University, Einstein Medical Center, 5501 Old York Road, Philadelphia, PA 19141, USA
| | - Mindy M Horrow
- Department of Radiology, Sidney Kimmel Medical College at Thomas Jefferson University, Einstein Medical Center, 5501 Old York Road, Philadelphia, PA 19141, USA
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Late onset of renal vein thrombosis after renal transplantation. Ultrasound Q 2014; 30:228-9. [PMID: 25148500 DOI: 10.1097/ruq.0000000000000105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Granata A, Di Nicolò P, Scarfia VR, Insalaco M, Lentini P, Veroux M, Fatuzzo P, Fiorini F. Renal transplantation parenchymal complications: what Doppler ultrasound can and cannot do. J Ultrasound 2014; 18:109-16. [PMID: 26191098 DOI: 10.1007/s40477-014-0118-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Accepted: 07/06/2014] [Indexed: 12/13/2022] Open
Abstract
Kidney transplantation is the treatment of choice in end-stage renal disease, given the better quality of life of transplanted patients when compared with patients on maintenance dialysis. In spite of surgical improvements and new immunosuppressive regimens, parts of transplanted grafts still develop chronic dysfunction. Ultrasonography, both in B-mode and with Doppler ultrasound, is an important diagnostic tool in case of clinical conditions which might impair kidney function. Even though ultrasonography is considered fundamental in the diagnosis of vascular and surgical complications of the transplanted kidney, its role is not fully understood in case of parenchymal complications of the graft. The specificity of Doppler is low both in case of acute complications, such as acute tubular necrosis, drugs toxicity and acute rejection, and in case of chronic conditions, such as chronic allograft nephropathy. Single determinations of resistance indices present low diagnostic accuracy, which is higher in case of successive measurements performed during the follow-up of the graft. Modern techniques such as tissue pulsatility index, maximal fractional area and contrast-enhanced ultrasound increase ultrasonography diagnostic power in case of parenchymal complications of the transplanted kidney.
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Affiliation(s)
- Antonio Granata
- Nephrology and Dialysis Unit, "San Giovanni di Dio" Hospital, Agrigento, Italy ; Via F. Paradiso n°78/a, 95024 Acireale, CT Italy
| | - Pierpaolo Di Nicolò
- Nephrology and Dialysis Unit, "Santa Maria della Scaletta" Hospital, Imola, Bo Italy
| | - Viviana R Scarfia
- Nephrology and Dialysis Unit, "San Giovanni di Dio" Hospital, Agrigento, Italy
| | - Monica Insalaco
- Nephrology and Dialysis Unit, "San Giovanni di Dio" Hospital, Agrigento, Italy
| | - Paolo Lentini
- Nephrology and Dialysis Unit, "San Bassiano" Hospital, Bassano del Grappa, Italy
| | - Massimiliano Veroux
- Vascular Surgery and Organ Transplant Unit, University Hospital of Catania, Catania, Italy
| | - Pasquale Fatuzzo
- Nephrology and Dialysis Unit, University Hospital of Catania, Catania, Italy
| | - Fulvio Fiorini
- Nephrology and Dialysis Unit, "Santa Maria della Consolazione" Hospital, Rovigo, Italy
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Lal H, Helavar RV, Gamanagatti S, Jain S, Kumar R. Imaging in renal transplant: Review. INDIAN JOURNAL OF TRANSPLANTATION 2014. [DOI: 10.1016/j.ijt.2014.01.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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Kolofousi C, Stefanidis K, Cokkinos DD, Karakitsos D, Antypa E, Piperopoulos P. Ultrasonographic features of kidney transplants and their complications: an imaging review. ISRN RADIOLOGY 2012; 2013:480862. [PMID: 24967275 PMCID: PMC4045518 DOI: 10.5402/2013/480862] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/20/2012] [Accepted: 11/05/2012] [Indexed: 12/13/2022]
Abstract
Renal transplantation is the treatment of choice for managing patients with end-stage kidney disease. Being submitted to a very serious surgical procedure, renal transplant recipients can only benefit from follow-up imaging and monitoring strategies. Ultrasound is considered as the principal imaging test in the evaluation of renal transplants. It is an easily applied bedside examination that can detect possible complications and guide further imaging or intervention. In this imaging review, we present essential information regarding the sonographic features of healthy renal transplants, detailing the surgical technique and how it affects the sonoanatomy. We focus on various complications that occur following renal transplantation and their sonographic features by reviewing pertinent literature sources and our own extensive imaging archives.
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Affiliation(s)
| | | | | | | | - Eleni Antypa
- Radiology Department, Evangelismos Hospital, 10676 Athens, Greece
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27
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McArthur TA, Lockhart ME, Robbin ML. High venous pressure in the main renal vein causing development of peritransplant venous collaterals in renal transplant patients: a rare finding. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2011; 30:1731-1737. [PMID: 22124009 DOI: 10.7863/jum.2011.30.12.1731] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
We will show the sonographic appearance of peritransplant venous collaterals in renal transplants with renal venous hypertension. Three cases of renal transplants with pericapsular vessels were identified at our institution. Two cases were related to renal vein thrombosis. The third case had pericapsular vessels secondary to venous hypertension from arterialization of the transplant renal vein by a preexisting right thigh arteriovenous graft. The development of high venous pressures in renal transplants leading to the collaterals' venous drainage has been rarely described. This finding should be recognized as a rare complication of renal transplants but does not necessarily lead to transplant failure.
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Affiliation(s)
- Tatum A McArthur
- Department of Diagnostic Radiology, University of Alabama, Birmingham, AL 35249-6830, USA.
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Sutherland T, Temple F, Chang S, Hennessy O, Lee WK. Sonographic evaluation of renal transplant complications. J Med Imaging Radiat Oncol 2010; 54:211-8. [DOI: 10.1111/j.1754-9485.2010.02161.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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Gufler H, Weimer W, Neu K, Wagner S, Rau WS. Contrast enhanced MR angiography with parallel imaging in the early period after renal transplantation. J Magn Reson Imaging 2009; 29:909-16. [PMID: 19306426 DOI: 10.1002/jmri.21726] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
PURPOSE To evaluate renal allograft vessels in the early period after kidney transplantation with three-dimensional (3D) contrast-enhanced MR angiography (3D CE MRA) using a parallel imaging technique. MATERIALS AND METHODS Sixty-three consecutive patients were examined with 3D CE MRA and integrated SENSE technique (Sensitivity Encoding) 2 to 21 days after renal transplantation. MR angiography studies were analyzed for the presence of arterial stenosis. The degree of renal transplant artery stenosis was graded qualitatively as <50% = mild, 50-70% = moderate, 70-99% = severe, and occlusion. Four patients (6.3%) with moderate (n = 1) or severe (n = 3) arterial stenoses on CE MRA underwent selective intra-arterial digital subtraction angiography. In two patients, selective intravenous digital subtraction angiography (DSA) was performed. RESULTS Twenty-seven (42.9%) of the 63 patients had normal CE MR angiograms, 29 (46%) showed mild, 3 patients (4.8%) moderate, and 4 patients (6.3%) severe stenoses of the donor artery. In three patients, the severe stenosis of the graft artery was confirmed by surgery or intra-arterial DSA. One patient with suspicion of severe arterial stenosis on MRA had moderate vessel narrowing on DSA. Twelve months after kidney transplantation, serum creatinine levels were not significantly different in patients with mild and moderate stenoses from those without (P > 0.19) but significantly different from those with severe stenoses (P < 0.05). CONCLUSION The incidence of mild and moderate vessel narrowing at the arterial anastomosis is unexpectedly high in the early period after kidney transplantation and is most likely due to surgery-related tissue edema.
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Affiliation(s)
- Hubert Gufler
- Department of Diagnostic and Interventional Radiology, University Clinic of Rostock, Rostock, Germany
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Reply. AJR Am J Roentgenol 2008. [DOI: 10.2214/ajr.08.1629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Reversed diastolic flow and acute tubular necrosis. AJR Am J Roentgenol 2008; 191:W323; author reply W324. [PMID: 19020228 DOI: 10.2214/ajr.08.1467] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Gerscovich EO, Bateni CP, Kazemaini MR, Gillen MA, Visis T. Reversal of diastolic blood flow in the testis of a patient with impending infarction due to epididymitis. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2008; 27:1643-1646. [PMID: 18946105 DOI: 10.7863/jum.2008.27.11.1643] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Affiliation(s)
- Eugenio O Gerscovich
- Department of Radiology, University of California, Davis Medical Center, Sacramento, CA 95817 USA.
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