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Core > Urinary: Transplant > Flashcards

Urinary: Transplant Flashcards

1
Q

Where is a kidney transplant usually placed?

A

Extraperitoneal iliac fossa (so it can be anastomosed with the external iliac vessels and urinary bladder)

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2
Q

What is the most important indication of a healthy renal transplant on ultrasound?

A

Resistive index below 0.7

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3
Q

Common urologic complications of renal transplant

A
  • Obstruction
  • Hematoma
  • Urinoma
  • Lymphocele
  • Rejection
  • Acute tubular necrosis
  • Cyclosporin toxicity
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4
Q

Kidney transplant with mild hydronephrosis…

A

Normal finding

Note: Don’t call obstruction unless you see an obstruction, almost all kidney transplants have some mild hydronephrosis.

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5
Q

Where is the most common location for urologic obstruction in a renal transplant?

A

At the ureter-bladder dome anastomosis

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6
Q

Common causes of urologic obstruction in kidney transplants

A
  • Post operative edema
  • Scarring
  • Technical errors leading to kinking
  • Stones (less common, but still more common than in the general population)
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7
Q

When do urinomas tend to occur s/p renal transplant?

A

Within the first 2 weeks post op (usually at the ureter-bladder dome anastomosis)

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8
Q

Imaging test for post operative urinoma s/p renal transplant

A
  • MAG3 renal scintigraphy
  • CT with excretory images
  • Ultrasound (cheaper)
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9
Q

When do lymphocytes tend to occur s/p renal transplant?

A

1-2 months after transplant

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10
Q

What is the most common fluid collection to cause transplant hydronephrosis after renal transplant?

A

Lymphocele

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11
Q

What causes a post renal transplant lymphocele

A

Leakage of lymph from lymphatic vessels (either due to surgical disruption or leakage in the setting of inflammation)

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12
Q

Fluid collection medial to a renal transplant with ipsilateral lower extremity edema…

A

Lymphocele

Note: Lower extremity edema due to femoral vein compression.

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13
Q

Treatment for post operative lymphocele s/p renal transplant

A

Usually nothing (they just come back)

Note: If treated, usually its done using a sclerosing agent.

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14
Q

What is the order of timing for the following complications s/p renal transplant: Abscess, Urinoma, Lymphocele, Hematoma

A
  • Hematoma (within 1 week)
  • Urinoma (~2 weeks)
  • Abscess (weeks-months)
  • Lymphocele (2 weeks-6 months)
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15
Q

How can you differentiate a postoperative urinoma from a lymphocele?

A
  • Excretory phase CT
  • Renal scintigraphy with MAG3 or DTPA

Note: Only a urinoma will show leakage of contrast/radiotracer outside the bladder.

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16
Q

How can you differentiate a post renal transplant hematoma from a urinoma/lymphocele?

A

Post operative hematomas happen earlier (within 1 week) and tend to be more complex (heterogeneous, septa, etc.)

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17
Q

Hyperacute renal transplant rejection

A

Immediate failure of the graft (rarely imaged)

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18
Q

When does acute rejection of a renal transplant usually occur?

A

Weeks 1-3

Note: Acute rejection is rare in the first 3 days.

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19
Q

Imaging findings of acute renal transplant rejection

A
  • Edematous swelling of the graft
  • Increasing resistive indices on Doppler ultrasound
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20
Q

How can you differentiate acute renal transplant rejection from acute tubular necrosis on imaging?

A

MAG3 renal scintigraphy can help:

In acute rejection, the whole study will be crap

In acute tubular necrosis, the flow and uptake portions of the study will be relatively normal, but there will be slow excretion

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21
Q

“Delayed graft function” in a renal transplant

A

Basically means the pt will need dialysis for the first week or so after transplant, but the graft will probably recover now that its getting blood again

Note: This is due to acute tubular necrosis that occurs between organ harvest and transplantation.

22
Q

What is the most common time for cyclosporin toxicity to occur in a renal transplant?

A

Usually around 1 month post op (later than acute rejection 1-3 weeks post op and later than acute tubular necrosis)

23
Q

MAG3 renal scintigraphy findings of cyclosporin toxicity

A

Relatively normal flow and uptake portions of the study, but delayed excretion

Note: This is the same as for acute tubular necrosis, but cyclosporin toxicity occurs later (not within a few weeks of transplant).

24
Q

When does chronic renal transplant rejection occur?

A

Months to years after transplant

25
Q

Imaging findings of chronic renal transplant rejection

A

Elevated resistive indices (months to years after transplant)

26
Q

What is the mechanism of acute rejection of a renal transplant?

A

Antibody/cell-mediated

27
Q

What is the mechanism of acute tubular necrosis in a renal tranplant?

A

Ischemis during organ harvesting/transportation

28
Q

What is the mechanism of chronic rejection of a renal transplant?

A

Cellular (T/cell) mediated

29
Q

When is renal artery thombosis most common after a renal transplant?

A

Within the first month post transplant (usually within minutes to hours post transplant)

30
Q

What is the most common vascular complication of renal transplant?

A

Renal artery stenosis

31
Q

Refractory hypertension in a pt with a renal transplant…

A

Think renal artery stenosis in the transplant

32
Q

When is renal artery stenosis most most common after a renal transplant?

A

Within the first year (usually weeks-months after transplant)

Note: This is usually occurs at the anastomosis (especially end-to-end types).

33
Q

Criteria for renal artery stenosis in a kidney transplant

A
  • PSV > 200-300 cm/s
  • PSV ratio > 1.8-2.5x (stenotic vs non-stenotic)
  • Tardus parvus at the main renal artery hilum
  • Anastomotic jetting
34
Q

When is renal vein thrombosis most common after renal transplant?

A

Within the first week (peak at 48 hours)

35
Q

Renal artery Doppler on POD 5 s/p renal transplant…

A

Think renal vein thrombosis

Note: Reversed diastolic flow in the renal artery (“reversed M sign” below the x axis). They probably won’t show you absent flow in the renal vein (too easy).

36
Q

Common vascular complications s/p renal tranplant

A
  • Renal artery thrombosis
  • Renal artery stenosis
  • Renal vein thrombosis
  • Arteriovenous fistula
  • Pseudoaneurysm
37
Q

Renal transplant Doppler on the day after a percutaneous biopsy (same view with two different parameters)…

A

Arteriovenous fistula

Note: Tissue vibration artifact (non anatomic mosaic color Doppler due to tissue vibration adjacent to the fistula). After adjusting parameters to how high velocity flow, there is an infrarenal, hypervascular lesion (arrow), which is the AV fistula.

38
Q

Renal transplant ultrasound on the day after a percutaneous biopsy…

A

Pseudoaneurysm

Note: “yin-yang” sign on color Doppler.

39
Q

Renal tranplant ultrasound on the day after a percutaneous biopsy…

A

Pseudoaneurysm

Note: Biphasic waveform at the neck of the pseudoaneurysm.

40
Q

Renal allograft compartment syndrome (RACS)

A

An immediate postoperative complication of renal transplant (usually within 2 hours of transplant) where the donor kidney is too large for the recipients body, squeezing the kidney tranplant and resulting in absent or almost absent blood flow in the renal cortex.

41
Q

Absent renal transplant cortex flow on color Doppler 1 hour post transplantation, despite flow in the renal artery…

A

Consider renal allograft compartment syndrome (was the donor kidney too large for the recipient)

42
Q

Treatment for renal artery stenosis in a kidney transplant

A

Most try angioplasty first, but some go straight to surgery

43
Q

Treatment for renal transplant AV fistula

A

Usually none (most of these are asymptomatic and not hemodynamically significant)

44
Q

Treatment for renal transplant pseudoaneurysm

A

Unlike AV fistulas, pseudo aneurysms usually need to be treated (endovascular or surgery)

45
Q

Are renal transplants usually more or less protected from traumatic injury?

A

Renal transplants are less protected (no ribs and more superficial location)

46
Q

Are renal transplant pts at an increased risk for cancer?

A

Yes, pts with a renal transplant are at a ~100x increased risk of developing cancer (specifically nonmelanomatous skin cancer, lymphoma, and colon cancer)

Note: This is mostly due to long term immunosuppression therapy.

47
Q

Are renal tranplant pts at an increased risk for renal cell carcinoma?

A

Yes, but most cases actually occur in the pts native kidney (90%), not the transplant

Note: Immunosuppressive therapy and prior dialysis play a role.

48
Q

What is the most common RCC subtype in renal transplants?

A

Papillary type

49
Q

Renal transplant pt on rituximab…

A

Think post transplant lymphoproliferative disorder (PTLD)

Note: Rituximab is used to treat CMV in renal transplant pts (CMV is a risk factor for PTLD).

50
Q

Treatment for post transplant lymphoproliferative disorder (PTLD)

A

Reduce immunosuppression therapy

51
Q

BK virus infection in a renal transplant pt…

A

Think urothelial malignancy

52
Q

What is a common musculoskeletal complication of renal transplant?

A

Avascular necrosis of the femoral head

Note: This is not as common as it used to be due to lower steroid doses, but still affects 4-5% of renal transplant pts.

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