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Complications of Renal Transplantation: Evaluation with US and Radionuclide Imaging¹

¹ From the Department of Radiology, Wake Forest University School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157-1088. Presented as a scientific exhibit at the 1998 RSNA scientific assembly. Received March 30, 1999; revision requested May 12 and received June 7; accepted June 9. Address reprint requests to M.Y.M.C. (e-mail: mchen@wfubmc.edu).

View larger version (25K): [in a new window]   Figure 1.   Drawing shows the typical end-to-side anastomosis used in renal transplantation: renal artery (RA) and vein (RV) to the external iliac artery (EIA) and vein (EIV). Ao  = aorta, IVC  = inferior vena cava, K  = renal transplant.

View larger version (157K): [in a new window]   Figure 2.   Hematoma in a patient who presented with pain over the graft after falling against a bed rail. Longitudinal US image shows an echogenic mass (arrowheads) surrounding the renal transplant.

View larger version (149K): [in a new window]   Figure 3.   Color Doppler US image obtained immediately after transplantation shows a small fluid collection (arrow). This is an expected finding in the early posttransplantation period.

View larger version (161K): [in a new window]   Figure 4.   Abscess in a patient who presented with fever and elevated white blood cell count. Longitudinal US image shows a complex fluid collection (arrows) superficial to the renal transplant.

View larger version (122K): [in a new window]   Figure 5a.   Urinoma. Anterior (a) and right lateral (b) views from a technetium-99m mercaptoacetyltriglycine (MAG3) study show abnormal radionuclide activity around the transplant (arrows).

View larger version (120K): [in a new window]   Figure 5b.   Urinoma. Anterior (a) and right lateral (b) views from a technetium-99m mercaptoacetyltriglycine (MAG3) study show abnormal radionuclide activity around the transplant (arrows).

View larger version (104K): [in a new window]   Figure 6.   (6) Lymphocele. Longitudinal US image demonstrates a large hypoechoic fluid collection adjacent to the renal transplant (arrow). The lymphocele was repaired surgically.

View larger version (156K): [in a new window]   Figure 7.   Hydronephrosis secondary to a lymphocele. Color Doppler US image shows the hydronephrotic kidney adjacent to a large fluid collection, seen inferior to the kidney and superior to the bladder (arrow).

View larger version (157K): [in a new window]   Figure 8a.   Lymphocele. (a) Transverse US image of the midpole region of a renal transplant shows a large anechoic fluid collection adjacent to the renal hilum. (b) Longitudinal color Doppler image shows hydronephrosis resulting from extrinsic compression of the collecting system. (c) Transverse US image obtained after repair of the lymphocele shows that the hydronephrosis has decreased and the fluid collection is absent.

View larger version (159K): [in a new window]   Figure 8b.   Lymphocele. (a) Transverse US image of the midpole region of a renal transplant shows a large anechoic fluid collection adjacent to the renal hilum. (b) Longitudinal color Doppler image shows hydronephrosis resulting from extrinsic compression of the collecting system. (c) Transverse US image obtained after repair of the lymphocele shows that the hydronephrosis has decreased and the fluid collection is absent.

View larger version (149K): [in a new window]   Figure 8c.   Lymphocele. (a) Transverse US image of the midpole region of a renal transplant shows a large anechoic fluid collection adjacent to the renal hilum. (b) Longitudinal color Doppler image shows hydronephrosis resulting from extrinsic compression of the collecting system. (c) Transverse US image obtained after repair of the lymphocele shows that the hydronephrosis has decreased and the fluid collection is absent.

View larger version (106K): [in a new window]   Figure 9a.   Lymphocele. (a) Views from a Tc-99m MAG3 study demonstrate the appearance of the normal transplant in the right lower quadrant. (b) Views from a repeat study performed 2 months later show that the upper pole of the transplant is compressed by a large photopenic defect (arrows).

View larger version (112K): [in a new window]   Figure 9b.   Lymphocele. (a) Views from a Tc-99m MAG3 study demonstrate the appearance of the normal transplant in the right lower quadrant. (b) Views from a repeat study performed 2 months later show that the upper pole of the transplant is compressed by a large photopenic defect (arrows).

View larger version (110K): [in a new window]   Figure 10a.   Percutaneous drainage of a lymphocele. (a) Longitudinal US image obtained during needle placement shows the echogenic needle within the fluid collection (arrow). (b) On a US image obtained after placement of the pigtail catheter, the catheter can be seen as a larger echogenic structure coursing into the collection (arrow).

View larger version (111K): [in a new window]   Figure 10b.   Percutaneous drainage of a lymphocele. (a) Longitudinal US image obtained during needle placement shows the echogenic needle within the fluid collection (arrow). (b) On a US image obtained after placement of the pigtail catheter, the catheter can be seen as a larger echogenic structure coursing into the collection (arrow).

View larger version (109K): [in a new window]   Figure 11a.   Acute tubular necrosis following transplantation with a cadaveric graft. (a, b) Views from a Tc-99m MAG3 study obtained at 16 minutes (a) and at 65 minutes (b) show the increasing parenchymal activity in the graft. (c) Time/activity curve shows the delayed time to peak activity.

View larger version (114K): [in a new window]   Figure 11b.   Acute tubular necrosis following transplantation with a cadaveric graft. (a, b) Views from a Tc-99m MAG3 study obtained at 16 minutes (a) and at 65 minutes (b) show the increasing parenchymal activity in the graft. (c) Time/activity curve shows the delayed time to peak activity.

View larger version (20K): [in a new window]   Figure 11c.   Acute tubular necrosis following transplantation with a cadaveric graft. (a, b) Views from a Tc-99m MAG3 study obtained at 16 minutes (a) and at 65 minutes (b) show the increasing parenchymal activity in the graft. (c) Time/activity curve shows the delayed time to peak activity.

View larger version (75K): [in a new window]   Figure 12a.   Focal acute tubular necrosis of the upper pole following transplantation with a cadaveric graft. (a) View from a Tc-99m MAG3 study obtained at 10 minutes shows the delay of tracer activity in the upper pole of the graft (arrow). (b) Delayed view from the Tc-99m MAG3 study shows increasing parenchymal activity in the same region (arrow). (c) Time/activity curve of the upper pole region of interest demonstrates the delayed time to peak activity, with progressively increasing activity over 15 minutes.

View larger version (105K): [in a new window]   Figure 12b.   Focal acute tubular necrosis of the upper pole following transplantation with a cadaveric graft. (a) View from a Tc-99m MAG3 study obtained at 10 minutes shows the delay of tracer activity in the upper pole of the graft (arrow). (b) Delayed view from the Tc-99m MAG3 study shows increasing parenchymal activity in the same region (arrow). (c) Time/activity curve of the upper pole region of interest demonstrates the delayed time to peak activity, with progressively increasing activity over 15 minutes.

View larger version (21K): [in a new window]   Figure 12c.   Focal acute tubular necrosis of the upper pole following transplantation with a cadaveric graft. (a) View from a Tc-99m MAG3 study obtained at 10 minutes shows the delay of tracer activity in the upper pole of the graft (arrow). (b) Delayed view from the Tc-99m MAG3 study shows increasing parenchymal activity in the same region (arrow). (c) Time/activity curve of the upper pole region of interest demonstrates the delayed time to peak activity, with progressively increasing activity over 15 minutes.

View larger version (142K): [in a new window]   Figure 13.   Chronic rejection. Longitudinal US image demonstrates the complete loss of corticomedullary differentiation.

View larger version (148K): [in a new window]   Figure 14.   Acute tubular necrosis following transplantation with a cadaveric graft. Longitudinal US image obtained 2 days after transplantation shows large, hypoechoic pyramids.

View larger version (145K): [in a new window]   Figure 15.   Normal transplant. On a duplex color Doppler US image of a normal transplant, the spectral waveform shows a brisk systolic upstroke and high diastolic flow. Resistive index is normal.

View larger version (143K): [in a new window]   Figure 16.    Acute tubular necrosis following transplantation with a cadaveric graft. Duplex color Doppler US image obtained 2 days after transplantation shows a spectral waveform with a brisk systolic upstroke and low end-diastolic flow, an appearance typical for acute tubular necrosis. Resistive index is elevated.

View larger version (149K): [in a new window]   Figure 17.    Acute transplant rejection. Pulsed-wave color Doppler US image shows that end-diastolic flow in the renal graft is absent. Resistive index is elevated.

View larger version (146K): [in a new window]   Figure 18a.   Severe transplant rejection. (a) Duplex color Doppler US image shows a spectral waveform in which the arterial flow in diastole is reversed. Differential diagnosis for this finding includes acute tubular necrosis and renal vein thrombosis. (b) On another duplex image, the spectral waveform shows that the renal vein is patent, thus the diagnosis of renal vein thrombosis is excluded. Findings from biopsy confirmed transplant rejection.

View larger version (152K): [in a new window]   Figure 18b.   Severe transplant rejection. (a) Duplex color Doppler US image shows a spectral waveform in which the arterial flow in diastole is reversed. Differential diagnosis for this finding includes acute tubular necrosis and renal vein thrombosis. (b) On another duplex image, the spectral waveform shows that the renal vein is patent, thus the diagnosis of renal vein thrombosis is excluded. Findings from biopsy confirmed transplant rejection.

View larger version (61K): [in a new window]   Figure 19a.   Renal artery stenosis. (a) Color Doppler US image shows the renal artery in the region of the anastomosis. Note aliasing in the region of the stenosis (arrow). (b) Pulsed-wave color Doppler US image shows a peaked systolic waveform with short acceleration time in the stenotic segment (arrow). Velocity at the prestenotic region is 1.0 m/sec, and velocity at the stenotic segment is 2.2 m/sec.

View larger version (68K): [in a new window]   Figure 19b.   Renal artery stenosis. (a) Color Doppler US image shows the renal artery in the region of the anastomosis. Note aliasing in the region of the stenosis (arrow). (b) Pulsed-wave color Doppler US image shows a peaked systolic waveform with short acceleration time in the stenotic segment (arrow). Velocity at the prestenotic region is 1.0 m/sec, and velocity at the stenotic segment is 2.2 m/sec.

View larger version (98K): [in a new window]   Figure 20a.   Renal artery stenosis. (a) Duplex Doppler US image shows a tardus parvus waveform distal to the stenosis. (b) Angiogram obtained with a right common iliac artery injection before angioplasty shows the stenotic segment at the anastomosis (arrow). (c) Angiogram obtained after angioplasty shows resolution of the stenosis (arrow).

View larger version (123K): [in a new window]   Figure 20b.   Renal artery stenosis. (a) Duplex Doppler US image shows a tardus parvus waveform distal to the stenosis. (b) Angiogram obtained with a right common iliac artery injection before angioplasty shows the stenotic segment at the anastomosis (arrow). (c) Angiogram obtained after angioplasty shows resolution of the stenosis (arrow).

View larger version (122K): [in a new window]   Figure 20c.   Renal artery stenosis. (a) Duplex Doppler US image shows a tardus parvus waveform distal to the stenosis. (b) Angiogram obtained with a right common iliac artery injection before angioplasty shows the stenotic segment at the anastomosis (arrow). (c) Angiogram obtained after angioplasty shows resolution of the stenosis (arrow).

View larger version (131K): [in a new window]   Figure 21.   Renal vein thrombosis. Duplex Doppler US image shows a spectral waveform in which the diastolic flow in the renal artery is reversed and plateauing. No venous signal could be obtained.

View larger version (156K): [in a new window]   Figure 22a.   Intrarenal arteriovenous fistula following biopsy. (a) Color Doppler image shows an abnormal focus of increased flow in the midpole (arrow). (b) Duplex color Doppler US image of this same area shows marked turbulence in the waveform. (c) Angiogram obtained with an aortic injection shows early filling of the right external iliac vein (arrow). (d) Angiogram obtained with subselective injection of the main renal artery shows early filling of the transplant renal vein (arrow). (e) On an angiogram obtained after repair, early draining veins are not visualized.

View larger version (133K): [in a new window]   Figure 22b.   Intrarenal arteriovenous fistula following biopsy. (a) Color Doppler image shows an abnormal focus of increased flow in the midpole (arrow). (b) Duplex color Doppler US image of this same area shows marked turbulence in the waveform. (c) Angiogram obtained with an aortic injection shows early filling of the right external iliac vein (arrow). (d) Angiogram obtained with subselective injection of the main renal artery shows early filling of the transplant renal vein (arrow). (e) On an angiogram obtained after repair, early draining veins are not visualized.

View larger version (140K): [in a new window]   Figure 22c.   Intrarenal arteriovenous fistula following biopsy. (a) Color Doppler image shows an abnormal focus of increased flow in the midpole (arrow). (b) Duplex color Doppler US image of this same area shows marked turbulence in the waveform. (c) Angiogram obtained with an aortic injection shows early filling of the right external iliac vein (arrow). (d) Angiogram obtained with subselective injection of the main renal artery shows early filling of the transplant renal vein (arrow). (e) On an angiogram obtained after repair, early draining veins are not visualized.

View larger version (173K): [in a new window]   Figure 22d.   Intrarenal arteriovenous fistula following biopsy. (a) Color Doppler image shows an abnormal focus of increased flow in the midpole (arrow). (b) Duplex color Doppler US image of this same area shows marked turbulence in the waveform. (c) Angiogram obtained with an aortic injection shows early filling of the right external iliac vein (arrow). (d) Angiogram obtained with subselective injection of the main renal artery shows early filling of the transplant renal vein (arrow). (e) On an angiogram obtained after repair, early draining veins are not visualized.

View larger version (164K): [in a new window]   Figure 22e.   Intrarenal arteriovenous fistula following biopsy. (a) Color Doppler image shows an abnormal focus of increased flow in the midpole (arrow). (b) Duplex color Doppler US image of this same area shows marked turbulence in the waveform. (c) Angiogram obtained with an aortic injection shows early filling of the right external iliac vein (arrow). (d) Angiogram obtained with subselective injection of the main renal artery shows early filling of the transplant renal vein (arrow). (e) On an angiogram obtained after repair, early draining veins are not visualized.

View larger version (159K): [in a new window]   Figure 23a.   Extrarenal pseudoaneurysm. (a) Duplex color Doppler US image shows turbulent forward and reverse flow in the main renal artery. (b) Angiogram obtained with renal artery injection shows a pseudoaneurysm of the renal artery at the anastomosis (arrow). The pseudoaneurysm was repaired surgically.

View larger version (148K): [in a new window]   Figure 23b.   Extrarenal pseudoaneurysm. (a) Duplex color Doppler US image shows turbulent forward and reverse flow in the main renal artery. (b) Angiogram obtained with renal artery injection shows a pseudoaneurysm of the renal artery at the anastomosis (arrow). The pseudoaneurysm was repaired surgically.

View larger version (149K): [in a new window]   Figure 24a.   Cortical infarct. (a) On a gray-scale US image, the region of cortical infarct is hypoechoic (arrowhead). (b) Power color Doppler image shows a paucity of blood flow in the region of the infarct (arrowhead).

View larger version (138K): [in a new window]   Figure 24b.   Cortical infarct. (a) On a gray-scale US image, the region of cortical infarct is hypoechoic (arrowhead). (b) Power color Doppler image shows a paucity of blood flow in the region of the infarct (arrowhead).

View larger version (120K): [in a new window]   Figure 25a.   PTLD involving a renal transplant. (a) US image shows a hypoechoic mass (arrowhead) in the midpole of the graft. (b) On a CT image, the mass has low attenuation (arrowhead).

View larger version (110K): [in a new window]   Figure 25b.   PTLD involving a renal transplant. (a) US image shows a hypoechoic mass (arrowhead) in the midpole of the graft. (b) On a CT image, the mass has low attenuation (arrowhead).

View larger version (86K): [in a new window]   Figure 26.    Scarring from recurrent pyelonephritis in a child with vesicostomy and a renal transplant for posterior urethral valves. View from a Tc-99m MAG3 study shows multiple photopenic defects (arrows). The recurrent infections were attributed to the vesicostomy bag and decreased in frequency after discontinuation of its use.