Presentation
Renal transplant 7 days earlier. Raised inflammatory markers. Background of sickle cell disease and chronic kidney disease.
Patient Data
Renal transplant in the left iliac fossa, with a stent in the transplant ureter. A femoral-femoral vascular bypass graft runs across the lower abdomen/pelvis, deep to the anterior abdominal wall. Small volume of fluid is superior to this, tracking within an extra-peritoneal space. Small hematoma in left lower quadrant anterior abdominal wall. Transplant kidney enhancement is suboptimal, but uniform, and there is no filling defect of the supplying and draining vessels.
The native kidneys are atrophic. Heterogeneous high density is present throughout the normal-sized spleen. Heterogeneous bone density throughout the imaged skeleton, particularly the vertebral bodies. Sclerosis and irregular contour of the femoral heads is consistent with avascular necrosis, as well as abnormal irregular high density in femoral necks due to infarcts.
Further acquisition after a delay (no additional contrast administered) shows increased density of the extraperitoneal free fluid (axial, coronal, sagittal) appearing to emanate from the junction between the transplant ureter and urinary bladder, consistent with a urine leak.
A conservative path was followed. A cystogram study 4 weeks after the CT shows a persistent urine leak close to the junction between the transplant ureter and the urinary bladder. The changes of avascular necrosis of the left femoral head are also well seen.
No leak was seen on this study acquired at 8 weeks.
Surgical clips seen at site of transplant.
The extensive bone changes of avascular necrosis and infarcts involving the femoral heads and necks are also seen, as well as vascular calcification.
Case Discussion
There are a number of important learning points to be gleaned from the imaging findings in this study:
by bringing the patient back after a delay (having already administered intravenous contrast for the initial portal venous phase contrast CT), the leak from the ureteric anastomosis is readily visible
-
multiple features of chronic sickle cell disease and it's complications are noted
avascular necrosis of the femoral heads
infarcts of the femoral necks
irregular sclerosis of the vertebral bodies
chronic kidney disease necessitating a renal transplant
calcific sclerosis of arterial vessels in the pelvis, associated with chronic kidney disease
Case uploaded with the assistance of Dr Vikas Shah
Unable to process the form. Check for errors and try again.