Transplant renal artery stenosis: Narrow and prone to closure

Complete anuria is an uncommon clinical presentation that is usually due to an obstructive (postrenal) cause. Less frequent aetiologies include catastrophic vascular compromise (prerenal), massive rhabdomyolysis or antiglomerular basement membrane disease (intrinsic renal). Two-dimensional ultrasonography is the initial imaging investigation of choice in these patients, as it is non-invasive, can identify the presence of obstruction (manifesting as hydronephrosis) and when combined with colour Doppler can provide information on renal perfusion. We present a case of severe transplant renal artery stenosis causing acute renal failure with complete anuria, where a premature closure in diagnostic reasoning caused a delay in diagnosis. We discuss the approach to formulating the differential diagnosis in patients presenting with anuria, the potential limitations of ultrasonography and the value of multidisciplinary team meetings in preventing diagnostic errors.