DOI: 10.1148/rg.255045133
Complications of Renal Transplantation1
Syed A. Akbar, MD,
S. Zafar H. Jafri, MD,
Marco A. Amendola, MD,
Beatrice L. Madrazo, MD,
Riad Salem, MD, MBA and
Kostaki G. Bis, MD
1 From the Division of Abdominal Imaging and Intervention, Brigham and Women’s Hospital, Boston, Mass (S.A.A.); Department of Radiology, William Beaumont Hospital, Royal Oak, Mich (S.Z.H.J., K.G.B.); Department of Radiology, University of Miami, Jackson Memorial Hospital, Miami, Fla (M.A.A., B.L.M.); and Department of Radiology, Northwestern Memorial Hospital, Chicago, Ill (R.S.). Recipient of a Certificate of Merit award for an education exhibit at the 2001 RSNA Annual Meeting. Received June 14, 2004; revision requested August 9 and received March 24, 2005; accepted March 28. All authors have no financial relationships to disclose.
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Figure 1a. Urinoma from ruptured ureterovesical junction stenosis. (a) Gray-scale sonogram reveals a renal transplant that is obstructed because of a ruptured ureterovesical anastomosis and an urinoma. (b) Postvoid sonogram demonstrates a fluid collection that represents extravasated urine (arrow) and a small bladder BL). (c) Cystogram demonstrates extravasation (arrow). (Reprinted, with permission, from reference 5.)
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Figure 1b. Urinoma from ruptured ureterovesical junction stenosis. (a) Gray-scale sonogram reveals a renal transplant that is obstructed because of a ruptured ureterovesical anastomosis and an urinoma. (b) Postvoid sonogram demonstrates a fluid collection that represents extravasated urine (arrow) and a small bladder (BL). (c) Cystogram demonstrates extravasation (arrow). (Reprinted, with permission, from reference 5.)
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Figure 1c. Urinoma from ruptured ureterovesical junction stenosis. (a) Gray-scale sonogram reveals a renal transplant that is obstructed because of a ruptured ureterovesical anastomosis and an urinoma. (b) Postvoid sonogram demonstrates a fluid collection that represents extravasated urine (arrow) and a small bladder (BL). (c) Cystogram demonstrates extravasation (arrow). (Reprinted, with permission, from reference 5.)
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Figure 2a. Hydronephrosis secondary to ureteral stricture. (a) Gray-scale sonogram demonstrates mild hydronephrosis secondary to ureteral stricture. (b) Retrograde pyelogram shows the area of narrowing at the site of ureteral implantation into the bladder (arrow). (Fig 2a and 2b reprinted, with permission, from reference 5.)
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Figure 2b. Hydronephrosis secondary to ureteral stricture. (a) Gray-scale sonogram demonstrates mild hydronephrosis secondary to ureteral stricture. (b) Retrograde pyelogram shows the area of narrowing at the site of ureteral implantation into the bladder (arrow). (Fig 2a and 2b reprinted, with permission, from reference 5.)
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Figure 3a. Hydronephrosis relieved by stent placement. (a) Gray-scale sonogram reveals severe hydronephrosis resulting from narrowing at the ureterovesical anastomosis. Obstruction was relieved by stent placement. (b) Sonogram obtained after placement of a retrograde stent (arrow) demonstrates complete resolution of the hydronephrosis.
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Figure 3b. Hydronephrosis relieved by stent placement. (a) Gray-scale sonogram reveals severe hydronephrosis resulting from narrowing at the ureterovesical anastomosis. Obstruction was relieved by stent placement. (b) Sonogram obtained after placement of a retrograde stent (arrow) demonstrates complete resolution of the hydronephrosis.
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Figure 4a. Dilation of a ureteral stenosis. Sequence of fluoroscopic images (a–c) demonstrates placement of a JJ stent across a midureteral stricture.
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Figure 4b. Dilation of a ureteral stenosis. Sequence of fluoroscopic images (a–c) demonstrates placement of a JJ stent across a midureteral stricture.
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Figure 4c. Dilation of a ureteral stenosis. Sequence of fluoroscopic images (a–c) demonstrates placement of a JJ stent across a midureteral stricture.
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Figure 5a. Subcapsular hematoma in a patient who sustained blunt trauma to the abdomen while playing a sport. (a) US image demonstrates an isoechoic subcapsular fluid collection (arrows). (b) CT scan shows a heterogeneous crescentic subcapsular collection in the transplanted kidney secondary to hematoma (arrows).
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Figure 5b. Subcapsular hematoma in a patient who sustained blunt trauma to the abdomen while playing a sport. (a) US image demonstrates an isoechoic subcapsular fluid collection (arrows). (b) CT scan shows a heterogeneous crescentic subcapsular collection in the transplanted kidney secondary to hematoma (arrows).
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Figure 6. Lymphocele. US image demonstrates mild hydronephrosis of the transplanted kidney. The anechoic area represents a lymphocele (L) adjacent to the kidney.
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Figure 7. Lymphocele. Sonogram of another patient shows a multilocular fluid collection (arrows) that surrounds the renal transplant. The collection proved to be a lymphocele.
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Figure 8. Infected lymphoceles. US image demonstrates a complex echogenic fluid collection (arrows) adjacent to the transplanted kidney.
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Figure 9. Perinephric abscess. US image demonstrates a loculated perinephric fluid collection with complex sonographic features (arrow). The collection proved to be an infected urinoma.
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Figure 10a. Fungus ball of the transplanted kidney. (a) US image demonstrates a soft-tissue echogenic mass (m) in the renal pelvis of a transplanted kidney. (b) Retrograde pyelogram shows filling defects (arrows) within the renal pelvis. These findings proved to be a fungus ball. (Fig 10a and 10b reprinted, with permission, from reference 5.)
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Figure 10b. Fungus ball of the transplanted kidney. (a) US image demonstrates a soft-tissue echogenic mass (m) in the renal pelvis of a transplanted kidney. (b) Retrograde pyelogram shows filling defects (arrows) within the renal pelvis. These findings proved to be a fungus ball. (Fig 10a and 10b reprinted, with permission, from reference 5.)
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Figure 11. Hydronephrosis secondary to a fungus ball. Color Doppler US image demonstrates an echogenic mass (m) in the transplanted kidney that is causing hydronephrosis. The mass proved to be a fungus ball.
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Figure 12. Renal transplant tuberculosis. Retrograde pyelogram demonstrates a renal transplant with irregular margins from renal tuberculosis. (Reprinted, with permission, from reference 5.)
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Figure 13. Renal artery stenosis. Maximum intensity projection (MIP) image of a 35-year-old patient with recurrent severe hypertension who underwent a second renal transplantation shows severe proximal stenosis (arrow) in the renal artery of the first transplant. Notice the severe decrease in the perfusion of the first transplant.
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Figure 14a. Percutaneous transluminal angioplasty of a renal artery stenosis. (a) Angiogram shows narrowing of the proximal renal artery (arrow). (b) Another angiogram shows a catheter placed across the area of stenosis. (c) Angiogram obtained after angioplasty was performed shows restoration of a near normal arterial lumen.
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Figure 14b. Percutaneous transluminal angioplasty of a renal artery stenosis. (a) Angiogram shows narrowing of the proximal renal artery (arrow). (b) Another angiogram shows a catheter placed across the area of stenosis. (c) Angiogram obtained after angioplasty was performed shows restoration of a near normal arterial lumen.
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Figure 14c. Percutaneous transluminal angioplasty of a renal artery stenosis. (a) Angiogram shows narrowing of the proximal renal artery (arrow). (b) Another angiogram shows a catheter placed across the area of stenosis. (c) Angiogram obtained after angioplasty was performed shows restoration of a near normal arterial lumen.
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Figure 15. Infarct of a renal graft. Power Doppler US image demonstrates segmental loss of perfusion in the transplanted kidney (arrows), a finding compatible with infarct.
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Figure 16. Infarct of a renal graft. CT scan demonstrates segmental hypoattenuation (arrow) in the transplanted kidney, a finding that proved to represent an infarct.
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Figure 17a. Occlusion of a graft renal artery with lower pole infarction in a 38-year-old patient. (a) Nontargeted MIP image reveals one graft renal artery that is normal. However, a total of three graft renal arteries were anastomosed to the external iliac artery, and nonvisualization of two of the three arteries indicates perioperative thrombosis. This vascular anatomy could not be ascertained with Doppler US. (b) Another MIP image demonstrates the venous anatomy. (c) Contrast material–enhanced three-dimensional MIP image demonstrates perfusion to the upper renal pole with lack of perfusion to the lower pole, a finding that indicates lower pole infarction from arterial thrombosis.
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Figure 17b. Occlusion of a graft renal artery with lower pole infarction in a 38-year-old patient. (a) Nontargeted MIP image reveals one graft renal artery that is normal. However, a total of three graft renal arteries were anastomosed to the external iliac artery, and nonvisualization of two of the three arteries indicates perioperative thrombosis. This vascular anatomy could not be ascertained with Doppler US. (b) Another MIP image demonstrates the venous anatomy. (c) Contrast material–enhanced three-dimensional MIP image demonstrates perfusion to the upper renal pole with lack of perfusion to the lower pole, a finding that indicates lower pole infarction from arterial thrombosis.
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Figure 17c. Occlusion of a graft renal artery with lower pole infarction in a 38-year-old patient. (a) Nontargeted MIP image reveals one graft renal artery that is normal. However, a total of three graft renal arteries were anastomosed to the external iliac artery, and nonvisualization of two of the three arteries indicates perioperative thrombosis. This vascular anatomy could not be ascertained with Doppler US. (b) Another MIP image demonstrates the venous anatomy. (c) Contrast material–enhanced three-dimensional MIP image demonstrates perfusion to the upper renal pole with lack of perfusion to the lower pole, a finding that indicates lower pole infarction from arterial thrombosis.
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Figure 18a. Complete occlusion of a graft renal artery with allograft infarction in a 47-year-old patient with elevated serum creatinine levels. (a) Axial T1-weighted breath-hold gradient-echo image reveals peripheral high signal intensity involving the renal cortex (arrow), a finding compatible with hemorrhage. The patient had cortical necrosis proved at surgery. (b) Axial T2-weighted breath-hold short inversion time inversion recovery image demonstrates peripheral low signal intensity (arrow). (c) MIP image, obtained during the arterial phase of three-dimensional contrast-enhanced MR angiography, demonstrates complete occlusion of the graft renal artery beyond its origin (arrow). (d) Contrast-enhanced three-dimensional MIP image demonstrates lack of a cortical nephrogram with a peripheral rim sign (arrow), an appearance that indicates total infarction of the kidney.
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Figure 18b. Complete occlusion of a graft renal artery with allograft infarction in a 47-year-old patient with elevated serum creatinine levels. (a) Axial T1-weighted breath-hold gradient-echo image reveals peripheral high signal intensity involving the renal cortex (arrow), a finding compatible with hemorrhage. The patient had cortical necrosis proved at surgery. (b) Axial T2-weighted breath-hold short inversion time inversion recovery image demonstrates peripheral low signal intensity (arrow). (c) MIP image, obtained during the arterial phase of three-dimensional contrast-enhanced MR angiography, demonstrates complete occlusion of the graft renal artery beyond its origin (arrow). (d) Contrast-enhanced three-dimensional MIP image demonstrates lack of a cortical nephrogram with a peripheral rim sign (arrow), an appearance that indicates total infarction of the kidney.
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Figure 18c. Complete occlusion of a graft renal artery with allograft infarction in a 47-year-old patient with elevated serum creatinine levels. (a) Axial T1-weighted breath-hold gradient-echo image reveals peripheral high signal intensity involving the renal cortex (arrow), a finding compatible with hemorrhage. The patient had cortical necrosis proved at surgery. (b) Axial T2-weighted breath-hold short inversion time inversion recovery image demonstrates peripheral low signal intensity (arrow). (c) MIP image, obtained during the arterial phase of three-dimensional contrast-enhanced MR angiography, demonstrates complete occlusion of the graft renal artery beyond its origin (arrow). (d) Contrast-enhanced three-dimensional MIP image demonstrates lack of a cortical nephrogram with a peripheral rim sign (arrow), an appearance that indicates total infarction of the kidney.
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Figure 18d. Complete occlusion of a graft renal artery with allograft infarction in a 47-year-old patient with elevated serum creatinine levels. (a) Axial T1-weighted breath-hold gradient-echo image reveals peripheral high signal intensity involving the renal cortex (arrow), a finding compatible with hemorrhage. The patient had cortical necrosis proved at surgery. (b) Axial T2-weighted breath-hold short inversion time inversion recovery image demonstrates peripheral low signal intensity (arrow). (c) MIP image, obtained during the arterial phase of three-dimensional contrast-enhanced MR angiography, demonstrates complete occlusion of the graft renal artery beyond its origin (arrow). (d) Contrast-enhanced three-dimensional MIP image demonstrates lack of a cortical nephrogram with a peripheral rim sign (arrow), an appearance that indicates total infarction of the kidney.
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Figure 19. Multiple cortical infarctions from drug-induced vasculitis in a 42-year-old patient. Early contrast-enhanced three-dimensional MIP image reveals a large upper pole infarction with multiple smaller focal cortical areas of signal loss, findings compatible with small infarctions.
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Figure 20a. Arteriovenous fistula. (a) Color Doppler US image demonstrates a highly vascular lesion. (b) Color duplex Doppler image shows the classic waveform of an arteriovenous fistula, with high velocities and low impedance.
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Figure 20b. Arteriovenous fistula. (a) Color Doppler US image demonstrates a highly vascular lesion. (b) Color duplex Doppler image shows the classic waveform of an arteriovenous fistula, with high velocities and low impedance.
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Figure 21a. Arteriovenous fistula. (a) Duplex Doppler US image of the lower pole segmental artery shows increased velocity and decreased resistive index. (b) Duplex Doppler US image of the adjacent vein shows arterialization of flow, a finding consistent with arteriovenous fistula.
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Figure 21b. Arteriovenous fistula. (a) Duplex Doppler US image of the lower pole segmental artery shows increased velocity and decreased resistive index. (b) Duplex Doppler US image of the adjacent vein shows arterialization of flow, a finding consistent with arteriovenous fistula.
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Figure 22. Arteriovenous fistula following transplant biopsy. A color Doppler study in a 41-year-old hypertensive patient with a bruit audited over the renal allograft revealed tissue vibration. Because of marked tissue vibration, it was difficult to interrogate the transplant vasculature. Non-targeted MIP images during the arterial phase of contrast-enhanced three-dimensional MR angiography reveal a focal severe stenosis of the graft renal artery beyond its origin (arrow). The transplanted renal venous system is enhancing during the early arterial phase along with the iliac vasculature and inferior vena cava. The cortical nephrogram is very faint due to the marked arteriovenous shunting.
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Figure 23. Arteriovenous fistula. Contrast-enhanced three-dimensional MR angiogram demonstrates the renal artery and veins simultaneously, an appearance suggestive of fistula formation. The diagnosis was confirmed at angiography (not shown).
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Figure 24. Renal vein thrombosis. Duplex Doppler image demonstrates reversal of flow in diastole (arrows) in the transplanted kidney due to renal vein thrombosis secondary to deep venous thrombosis.
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Figure 25a. Iliac venous compression from a lymphocele in a 39-year-old patient with right lower extremity edema. (a) MIP image produced from subtracting the arterial phase data from the equilibrium phase data demonstrates a normal renal vein and poor visualization of the external iliac vein due to compression. (b) Axial source image (from a two-dimensional time-of-flight MR venographic study) helps confirm that the external iliac vein (solid arrow) is compressed by the underlying lymphocele (open arrow).
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Figure 25b. Iliac venous compression from a lymphocele in a 39-year-old patient with right lower extremity edema. (a) MIP image produced from subtracting the arterial phase data from the equilibrium phase data demonstrates a normal renal vein and poor visualization of the external iliac vein due to compression. (b) Axial source image (from a two-dimensional time-of-flight MR venographic study) helps confirm that the external iliac vein (solid arrow) is compressed by the underlying lymphocele (open arrow).
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Figure 26a. Renal transplant calculus in a 34-year-old patient with hematuria. (a) US image demonstrates hydronephrosis with a shadowing echogenic focus seen in the upper middle renal pole (arrow). (b) US image of the distal ureter shows an echogenic focus with shadowing (arrow) a finding consistent with an obstructing calculus.
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Figure 26b. Renal transplant calculus in a 34-year-old patient with hematuria. (a) US image demonstrates hydronephrosis with a shadowing echogenic focus seen in the upper middle renal pole (arrow). (b) US image of the distal ureter shows an echogenic focus with shadowing (arrow) a finding consistent with an obstructing calculus.
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Figure 27. Renal transplant adenocarcinoma. CT scan shows a cystic mass (arrow) arising from the renal transplant that proved to be renal cell carcinoma.
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Figure 28. Renal transplant herniation. CT scan demonstrates multiple distended small bowel loops around the transplanted kidney, findings compatible with obstruction. Small bowel had herniated through the peritoneal defect related to the renal graft, a diagnosis that was surgically proved.
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Figure 29a. Posttransplantation lymphoproliferative disease in a 25-year-old renal allograft recipient who presented with abdominal pain. (a) Contrast-enhanced CT scan demonstrates circumferential thickening of the jejunum (arrows). (b) Contrast-enhanced CT scan obtained at a lower level shows encasement of the superior mesenteric artery by lymphadenopathy (arrowheads), in addition to the jejunal thickening (arrow).
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Figure 29b. Posttransplantation lymphoproliferative disease in a 25-year-old renal allograft recipient who presented with abdominal pain. (a) Contrast-enhanced CT scan demonstrates circumferential thickening of the jejunum (arrows). (b) Contrast-enhanced CT scan obtained at a lower level shows encasement of the superior mesenteric artery by lymphadenopathy (arrowheads), in addition to the jejunal thickening (arrow).
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Figure 30. Posttransplantation lymphoproliferative disease in a kidney transplant recipient who presented with fever. Contrast-enhanced CT scan demonstrates a necrotic mass in the pelvis posterior to the transplanted kidney (arrows).
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Copyright © 2005 by the Radiological Society of North America.
