Double J-related hemoperitoneum in a living-related renal transplantation recipien

Dear editor, Renal transplantation (RTX) is the first choice for end-stage renal disease (ESRD). Double-J catheter is inserted in the ureter after anastomosis of ureter to urinary bladder (UB) in most hospitals. We report a case of double-J penetration-related complication, which caused hemoperitoneum initially, and then urinoma-related sepsis after removal of Foley catheter. The 40-year-old man with ESRD had received hemodialysis for 15 years. Living-related RTX from his wife will performed. Complement-dependent lymphocytotoxicity (CDC) cross-match was negative but Luminex test was positive (A33, DR11,14). Anti-CD20 (375 mg/m2), intravenous immunoglobulin (IVIG) 2g/kg and double filtration plasmapheresis were administered before operation. After performing anastomosis of ureter and insertion of double-J catheter, very low capacity of UB with presence of pus was discovered. Graft sonography just after operation disclosed fluid accumulation over upper pole, 1cm in diameter. Urine volume (UV)/hour was decreasing: 300c.c, 200c.c., but 30 c.c. in the third hour. Fluid accumulation progressed to 2 cm in diameter from upper pole to lower pole, extending to peri-umbilicus, with taut abdominal skin and right upper limb skin. Heart rate increased to 120/min with systolic blood pressure of 140mmHg. Hemoglobin dropped from 15g/dL to 7 g/dL. Foley catheter flow was adequate but irrigation with 30 c.c. normal saline caused lower abdominal pain. Sonography-guided needle aspiration suggested hematoma: 89300/cumm of red blood cells (RBC). Five hours later, right flank and upper limb ecchymosis were found. Non-contrast computed tomography (NCCT) showed perihepaitc, perigraft (especially upper pole) and subcutaneous hematoma (Figure 1B), without active bleeding. Before NCCT, plain film was taken due to abdominal fullness (1A). Two days later, the CDC cross-match was still negative, so hyperacute or accelerated acute rejection could be excluded. Daily UV was only 100 to 200 c.c. Daily sonography showed fair perfusion. Seven days later, graft biopsy showed acute tubular injury. Methylprednisolone 500mg for three days were given owing to suspected acute rejection from post-operation day 7 to day 9. UV increased gradually to over 1000 c.c. per day without diuretics. Due to very low capacity of UB after removal of Foley catheter, he needed to urinate once every hour with volume of 70-100 c.c. He was discharged 16 days after operation with serum creatinine (SCr) of 1.7mg/dL and complete reabsorption of hematoma according to follow-up NCCT (Figure 1D). Prior to discharge, prolonged drainage tube was inserted due to persistent serosanguinous fluid formation, which was confirmed as lymphocele due to presence of …