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 Table of Contents     
CASE REPORT
Year : 2012  |  Volume : 27  |  Issue : 3  |  Page : 192-195  

Post re-anastomosis demonstration of regain in function in non-visualized upper half of kidney in a dual arterial allogenic renal graft on renal scintigraphy


Department of Nuclear Medicine and PET, Bombay Hospital and Medical Research Centre, Mumbai, India

Date of Web Publication31-May-2013

Correspondence Address:
Sunita Tarsarya Sonavane
Department of Nuclear Medicine and PET, Bombay Hospital and Medical Research Centre, 12, Marine Lines, Mumbai-400 020
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-3919.112734

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   Abstract 

A young male patient with end stage renal disease underwent renal allograft having dual arterial supply. Immediate post-operative urine output dropped, an urgent Technetium-99m-mercaptoacetyltriglycine ( 99m Tc-MAG3) renogram revealed non-visualized upper-half and the preserved perfusion and parenchymal function of the small transplant kidney. Patient was re-explored and re-anastomosis was performed.A renogram at 24h post re-anastomosis revealed increase in the size of renal allograft, with preserved perfusion to the upper-half of transplant. Transplant kidney biopsy of the Upper-half showed acute tubular necrosis. 99mTc-MAG3renogram at 10 days post re-vascularization remains unchanged with persistent improvement at 2 months follow-up. We conclude that early recognition of renal functional loss allows early management and the high probability of salvaging the renal function.

Keywords: Dual artery, dynamic renogram, perfusion, renal transplant, technetium-99m-mercaptoacetyltriglycine


How to cite this article:
Sonavane ST, Lahoti A, Jaiswar R. Post re-anastomosis demonstration of regain in function in non-visualized upper half of kidney in a dual arterial allogenic renal graft on renal scintigraphy. Indian J Nucl Med 2012;27:192-5

How to cite this URL:
Sonavane ST, Lahoti A, Jaiswar R. Post re-anastomosis demonstration of regain in function in non-visualized upper half of kidney in a dual arterial allogenic renal graft on renal scintigraphy. Indian J Nucl Med [serial online] 2012 [cited 2019 Nov 14];27:192-5. Available from: http://www.ijnm.in/text.asp?2012/27/3/192/112734


   Introduction Top


Renal scintigraphy has provided a clinically important functional evaluation of renal transplants since the beginning of the transplantation era. [1] Nuclear medicine scanning and flow studies remain the primary means for evaluating vascular supply to the transplant after surgery. [2] Although the sensitivity of renal scintigraphy for functional abnormality is rather high, the specificity reports have been variable. [3] Since three decades, non-invasive radionuclide procedures for the evaluation of renal disease, provide a valuable data on perfusion and function of individual kidneys and has become an invaluable asset to clinicians in the evaluation of renal parenchyma and urologic abnormalities. [4]


   Case Report Top


A young male with end stage renal disease on maintenance hemodialysis since 6 months was subjected to renal transplant. Pre-transplant human leucocyte antigen (HLA) cross match with donor mother was 5% i.e., negative donor(Mother) Computed tomography (CT) renal angiography revealed dual arterial supply in both kidneys and accessory artery supplying the upper poles. Donor glomerulation filtration rate (GFR) by 99m Tc Diethyene tetraamine pentaacetic acid (DTPA) was 94.8 ml/min. Patient underwent allograft renal transplant with dual arterial supply in right iliac fossa by end to side anastomosis. Post-operative urine output dropped significantly within 8h. Patient was urgently evaluated with 99m Tc-mercaptoacetyltriglycine ( 99m TcMAG3) renogram, which revealed small transplant kidney in the right iliac fossa, the upper-half of kidney was not visualized and only inferior half of the transplant was visualized with preserved perfusion, preserved parenchymal function and non-obstructed drainage pattern. 99m TcMAG3 clearance was 26.7ml/min [Figure 1]. Subsequent Doppler of transplant kidney revealed absent perfusion in upper-half of the transplant corroborating with the renogram finding. Patient was re-explored, there was discolouration of upper-half of the transplant kidney with no pulsation in the artery supplying superior pole, re-anastomosis was performed. At 24 h post re-anastomosis, patient was re-referred for renogram which revealed increase in the size of renal allograft compared to the previous scan. Upper-half of the transplant was visualized and revealed preserved perfusion, mild to moderately impaired parenchymal function and progressive tracer concentration with no definite drainage. The lower-half of the transplant remained similar. 99m TcMAG3 clearance was 49.2ml/min [Figure 2] and a and b. Upper-half of the transplant kidney on biopsy revealed acute tubular necrosis. 99m TcMAG3 renogram findings 10 days post re-anastomosis remained unchanged [Figure 3] and a and b. Two months post re-anastomosis a 99m TcMAG3 follow-up renogram revealed further improvement in drainage pattern of upper-half. 99m TcMAG3 clearance improved to 88.4ml/min [Figure 4] and a and b. We conclude that early recognition of renal functional loss allows early management and high probability of salvaging the renal function.
Figure 1: Eight hours post-Transplant Technetium-99m-mercaptoacetyltriglycine renogram revealed small transplant kidney in the right iliac fossa. The upper-half of kidney was not visualized and only inferior half of transplant was visualized with preserved perfusion, preserved parenchymal function and non-obstructed drainage pattern

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Figure 2:

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Figure 3:

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Figure 4:

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   Discussion Top


Mark Tulchinsky assessed 99m TcMAG3 for determination of renal transplant prognosis for recovery in patients with early post-operative dysfunction. [5] The postulate tested was that good tracer extraction may imply high likelihood of recovery, while poor extraction may confer a poor prognosis. [6] One of the most critical clinical questions in patients with dysfunctioning renal transplant during the early post-operative period is a likelihood of functional recovery. This is important because a patient who has no hope of transplant recovery could potentially benefit from early termination of immunosuppression and transplant removal. [3] Several reports have suggested that the absence of perfusion or tracer uptake on renal scintigraphy correlates with conditions that confer a grave prognosis for survival of the renal transplant, [4] uptake of OIH is proportional to the renal viability and is well-correlated to the kidney's ability to regain normal function after ischemic damage, as demonstrated in an animal model. [7] Importantly, it takes only a few minutes after initiation of renal scintigraphy to obtain this critical information, allowing a prompt decision regarding further patient management. [8] Recent evidence indicates that transplant function in those patients can be saved by prompt restoration of blood flow. [9] In today's era, where there is scarcity of donor organs, early recognition of deterioration of renal perfusion/function, allows early management of complication, thereby aid in prompt measures for salvaging the renal graft function.

 
   References Top

1.Pouteil-Noble C, Yatim A, Najem R, Colon S, Peyrin JO, Touraine JL. Diagnostic value of 99m Tc MAG-3 imaging in the oligoanuria of the renal transplant patient in the first month after transplantation. Transplant Proc 1994;26:303-4.  Back to cited text no. 1
    
2.Aktaþ A, Aras M, Colak T, Gençoðlu A, Moray G. Indicators of acute rejection on Tc-99m DTPA renal scintigraphy. Transplant Proc 2006;38:443-8.  Back to cited text no. 2
    
3.Sayman HB, Sönmezoglu K, Ayaz M, Kahraman N, Kapicioglu T, Urgancioglu I. Functional evaluation of renal transplants with scintigraphy. J Nucl Biol Med 1993;37:115-8.  Back to cited text no. 3
    
4.He W, Fischman AJ. Nuclear imaging in the genitourinary tract: Recent advances and future directions. Radiol Clin North Am 2008;46:25-43, v.  Back to cited text no. 4
    
5.Tulchinsky M, Dietrich TJ, Eggli DF, Yang HC. Technetium-99m-MAG3 scintigraphy in acute renal failure after transplantation: Amarker of viability and prognosis. J Nucl Med 1997;38:475-8.  Back to cited text no. 5
    
6.Lin EC, Gellens ME, Goodgold HM. Prognostic value of renal scintigraphy with 99m Tc-MAG3 in patients with acute renal failure [Abstract]. J Nucl Med 1995;36:232P-3.  Back to cited text no. 6
    
7.Dahlager JI, Bilde T. The 125I-Hippuran renogram in rabbit kidneys after graded warm ischaemia. Scand J Urol Nephrol 1980;14:85-90.  Back to cited text no. 7
    
8.Duckett T, Bretan PN Jr, Cochran ST, Rajfer J, Rosenthal JT. Noninvasive radiological diagnosis of renal vein thrombosis in renal transplantation. J Urol 1991;146:403-6.  Back to cited text no. 8
    
9.Borowicz MR, Hanevold CD, Cofer JB, Bromberg JS, Orak JK, Rajagopalan PR. Extrinsic compression in the iliac fossa can cause renal vein occlusion in pediatric kidney recipients but graft loss can be prevented. Transplant Proc 1994;26:119-20.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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