Primary Nonfunction of Renal Allograft?
The patient is a live donor renal allograft recipient (underlying disease is chronic glomerulonephritis). After vascularization the kidney was well perfused, but there was no urine formation. One day postoperatively the patient had 400 mL urine output, but thereafter urine output was < 100 mL/day. The ultrasound was normal. A DTPA scan shows delayed uptake, poor concentration, and no excretion. Allograft biopsy shows normal epithelium and glomeruli, mild tubulitis, multiple intratubular casts, and no vasculitis. What are the potential causes of renal dysfunction?

Ashish Sharma, MS

Acute tubular necrosis, though uncommon in recipients of kidneys from living donors, is a potential cause of posttransplant acute renal failure. However, the presence of tubulitis suggests that this patient has an early cellular rejection. The DTPA scan is consistent with tubular dysfunction, whether from acute tubular necrosis or rejection. It is important in early biopsies to perform C4d staining to rule out humoral rejection. This patient should be treated with a depleting antilymphocyte agent and should be rebiopsied if renal function does not improve in 7-10 days.