Kidney Transplantation

  • Ghaneh Fananapazir
  • Christoph Troppmann


Worldwide, there were almost 80,000 kidney transplants performed in 2014, comprising the majority of solid organs transplanted. Most kidney grafts are from deceased donors, but living donor kidneys still constitute a significant percentage. For recipients of kidneys from deceased and live donors, graft survival is 94% and 98% at 1 year and 73% and 84% at 5 years, respectively [1]. Recipients require close follow-up, which includes regular urinalysis, serum creatinine measurements, monitoring of the immunosuppressive therapy, ultrasounds, and biopsies. The clinical features of graft dysfunction are often nonspecific, and imaging plays an important role not only in evaluating the kidney transplant but also in guiding graft biopsies as necessary. Before undertaking an evaluation of the transplanted kidney, it is important to be familiar with the surgical-anatomical placement of the kidney transplant, the type of donor kidney, the arterial and venous anastomoses, and the ureteral attachments.


Kidney Renal Transplant Graft Recipient Complications 


  1. 1.
    Matas A, Smith J, Skeans M, Thompson B, Gustafson S, Schnitzler M, et al. OPTN/SRTR 2012 annual data report: kidney. Am J Transplant. 2014;14(S1):11–44.CrossRefPubMedGoogle Scholar
  2. 2.
    Nemati E, Einollahi B, Pezeshki ML, Porfarziani V, Fattahi MR. Does kidney transplantation with deceased or living donor affect graft survival? Nephrourol Mon. 2014;6(4):e12182.CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Gill J, Cho YW, Danovitch GM, Wilkinson A, Lipshutz G, Pham P-T, et al. Outcomes of dual adult kidney transplants in the United States: an analysis of the OPTN/UNOS database. Transplantation. 2008;85(1):62–8.CrossRefPubMedGoogle Scholar
  4. 4.
    Fananapazir G, Tse G, Corwin MT, Santhanakrishnan C, Perez RV, McGahan JP, et al. Pediatric en bloc kidney transplants: clinical and immediate postoperative US factors associated with vascular thrombosis. Radiology. 2015;279(3):935–42.CrossRefPubMedGoogle Scholar
  5. 5.
    Kay D, Mazonakis M, Geddes C, Baxter G. Ultrasonic microbubble contrast agents and the transplant kidney. Clin Radiol. 2009;64(11):1081–7.CrossRefPubMedGoogle Scholar
  6. 6.
    Schwenger V, Hankel V, Seckinger J, Macher-Göppinger S, Morath C, Zeisbrich M, et al., editors. Contrast-enhanced ultrasonography in the early period after kidney transplantation predicts long-term allograft function. Transplant Proc. 2014;46(10):3352–7. Elsevier.Google Scholar
  7. 7.
    Harvey CJ, Alsafi A, Kuzmich S, Ngo A, Papadopoulou I, Lakhani A, et al. Role of US contrast agents in the assessment of indeterminate solid and cystic lesions in native and transplant kidneys. Radiographics. 2015;35(5):1419–30.CrossRefPubMedGoogle Scholar
  8. 8.
    Mafeld S, Stenberg B, Elliott S. Intrarenal arteriovenous shunts in kidney transplants demonstrated by contrast-enhanced ultrasound. Clin Imaging. 2015;39(1):144–51.CrossRefPubMedGoogle Scholar
  9. 9.
    Zeisbrich M, Kihm LP, Drüschler F, Zeier M, Schwenger V. When is contrast-enhanced sonography preferable over conventional ultrasound combined with Doppler imaging in renal transplantation? Clin Kidney J. 2015;8(5):606–14. Scholar
  10. 10.
    Fananapazir G, Troppmann C, Corwin MT, Bent CK, Vu CT, Lamba R. Incidence of contrast-induced nephropathy after renal graft catheter arteriography using iodine-based contrast medium. Am J Roentgenol. 2016;206(4):783–6.CrossRefGoogle Scholar
  11. 11.
    Fananapazir G, Troppmann C, Corwin MT, Nikpour AM, Naderi S, Lamba R. Incidences of acute kidney injury, dialysis, and graft loss following intravenous administration of low-osmolality iodinated contrast in patients with kidney transplants. Abdom Radiol. 2016;41(11):2182–6.Google Scholar
  12. 12.
    Bley T, François C, Schiebler M, Wieben O, Takei N, Brittain J, et al. Non-contrast-enhanced MRA of renal artery stenosis: validation against DSA in a porcine model. Eur Radiol. 2016;26(2):547–55.CrossRefPubMedGoogle Scholar
  13. 13.
    Corwin MT, Fananapazir G, Chaudhari AJ. MR angiography of renal transplant vasculature with ferumoxytol:: comparison of high-resolution steady-state and first-pass acquisitions. Acad Radiol. 2016;23(3):368–73.CrossRefPubMedGoogle Scholar
  14. 14.
    Fananapazir G, Bashir MR, Corwin MT, Lamba R, Vu CT, Troppmann C. Comparison of ferumoxytol-enhanced MRA with conventional angiography for assessment of severity of transplant renal artery stenosis. J Magn Reson Imaging. 2017;45(3):779–85.CrossRefPubMedGoogle Scholar
  15. 15.
    Bashir MR, Jaffe TA, Brennan TV, Patel UD, Ellis MJ. Renal transplant imaging using magnetic resonance angiography with a nonnephrotoxic contrast agent. Transplantation. 2013;96(1):91–6.CrossRefPubMedGoogle Scholar
  16. 16.
    Vasanawala SS, Nguyen KL, Hope MD, Bridges MD, Hope TA, Reeder SB, et al. Safety and technique of ferumoxytol administration for MRI. Magn Reson Med. 2016;75:2107–11.CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Garcia SRM, Fischer T, Dürr M, Gültekin E, Braun J, Sack I, et al. Multifrequency magnetic resonance elastography for the assessment of renal allograft function. Invest Radiol. 2016;51(9):591–5.CrossRefGoogle Scholar
  18. 18.
    Lee CU, Glockner JF, Glaser KJ, Yin M, Chen J, Kawashima A, et al. MR elastography in renal transplant patients and correlation with renal allograft biopsy: a feasibility study. Acad Radiol. 2012;19(7):834–41.CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Han F, Xiao W, Xu Y, Wu J, Wang Q, Wang H, et al. The significance of BOLD MRI in differentiation between renal transplant rejection and acute tubular necrosis. Nephrol Dial Transplant. 2008;23(8):2666–72.CrossRefPubMedGoogle Scholar
  20. 20.
    Hueper K, Gutberlet M, Rodt T, Gwinner W, Lehner F, Wacker F, et al. Diffusion tensor imaging and tractography for assessment of renal allograft dysfunction—initial results. Eur Radiol. 2011;21(11):2427–33.CrossRefPubMedGoogle Scholar
  21. 21.
    Lanzman RS, Ljimani A, Pentang G, Zgoura P, Zenginli H, Kröpil P, et al. Kidney transplant: functional assessment with diffusion-tensor MR imaging at 3T. Radiology. 2013;266(1):218–25.CrossRefPubMedGoogle Scholar
  22. 22.
    Lanzman RS, Wittsack H-J, Martirosian P, Zgoura P, Bilk P, Kröpil P, et al. Quantification of renal allograft perfusion using arterial spin labeling MRI: initial results. Eur Radiol. 2010;20(6):1485–91.CrossRefPubMedGoogle Scholar
  23. 23.
    Silver TM, Campbell D, Wicks JD, Lorber MI, Surace P, Turcotte J. Peritransplant fluid collections. Ultrasound evaluation and clinical significance. Radiology. 1981;138(1):145–51.CrossRefPubMedGoogle Scholar
  24. 24.
    Fananapazir G, Rao R, Corwin MT, Naderi S, Santhanakrishnan C, Troppmann C. Sonographic evaluation of clinically significant perigraft hematomas in kidney transplant recipients. Am J Roentgenol. 2015;205(4):802–6.CrossRefGoogle Scholar
  25. 25.
    Allen R. Chapter 26: Vascular complications after kidney transplantation. In: Morris PJ, Knechtle SJ, editors. Kidney transplantation: principles and practice. 6th ed. Philadelphia: Saunders; 2008.Google Scholar
  26. 26.
    Khauli RB, Stoff JS, Lovewell T, Ghavamian R, Baker S. Post-transplant lymphoceles: a critical look into the risk factors, pathophysiology and management. J Urol. 1993;150(1):22–6.CrossRefPubMedGoogle Scholar
  27. 27.
    Imankulov S, Doskali M, Oskenbaeva K, Ibadildina A, Baigenzhin A, Doskaliyev Z. Evaluation of kidney allograft in the early posttransplant period using ultrasonography. Exp Clin Transplant. 2015;13:62–5.PubMedGoogle Scholar
  28. 28.
    Zhao J, Wang K, Gao Z. The transplantation operation and its surgical complications. INTECH Open Access Publisher; 2011.Google Scholar
  29. 29.
    Ulrich F, Niedzwiecki S, Fikatas P, Nebrig M, Schmidt SC, Kohler S, et al. Symptomatic lymphoceles after kidney transplantation–multivariate analysis of risk factors and outcome after laparoscopic fenestration. Clin Transplant. 2010;24(2):273–80.CrossRefPubMedGoogle Scholar
  30. 30.
    Tiong HY, Flechner SM, Zhou L, Wee A, Mastroianni B, Savas K, et al. A systematic approach to minimizing wound problems for de novo sirolimus-treated kidney transplant recipients. Transplantation. 2009;87(2):296–302.CrossRefPubMedGoogle Scholar
  31. 31.
    Lundin C, Bersztel A, Wahlberg J, Wadström J. Low molecular weight heparin prophylaxis increases the incidence of lymphocele after kidney transplantation. Ups J Med Sci. 2002;107(1):9–15.CrossRefPubMedGoogle Scholar
  32. 32.
    Szwed AJ, Maxwell DR, Kleit SA, Hamburger RJ. Angiotensin II, diuretics, and thoracic duct lymph flow in the dog. Am J Physiol—Legacy Content. 1973;224(3):705–8.CrossRefGoogle Scholar
  33. 33.
    Troppmann C, Pierce JL, Gandhi MM, Gallay BJ, McVicar JP, Perez RV. Higher surgical wound complication rates with sirolimus immunosuppression after kidney transplantation: a matched-pair pilot study. Transplantation. 2003;76(2):426–9.CrossRefPubMedGoogle Scholar
  34. 34.
    Pollak R, Veremis S, Maddux M, Mozes M. The natural history of and therapy for perirenal fluid collections following renal transplantation. J Urol. 1988;140(4):716–20.CrossRefPubMedGoogle Scholar
  35. 35.
    Sansalone CV, Aseni P, Minetti E, Di Benedetto F, Rossetti O, Manoochehri F, et al. Is lymphocele in renal transplantation an avoidable complication? Am J Surg. 2000;179(3):182–5.CrossRefPubMedGoogle Scholar
  36. 36.
    Shoskes DA, Hanbury D, Cranston D, Morris PJ. Urological complications in 1,000 consecutive renal transplant recipients. J Urol. 1995;153(1):18–21.CrossRefPubMedGoogle Scholar
  37. 37.
    Brown ED, Chen MY, Wolfman NT, Ott DJ, Watson NE Jr. Complications of renal transplantation: evaluation with US and radionuclide imaging. Radiographics. 2000;20(3):607–22.CrossRefPubMedGoogle Scholar
  38. 38.
    Akbar SA, Jafri SZH, Amendola MA, Madrazo BL, Salem R, Bis KG. Complications of renal transplantation. Radiographics. 2005;25(5):1335–56.CrossRefPubMedGoogle Scholar
  39. 39.
    Keller AK, Jorgensen TM, Jespersen B. Identification of risk factors for vascular thrombosis may reduce early renal graft loss: a review of recent literature. J Transplant. 2012;2012:793461.CrossRefPubMedPubMedCentralGoogle Scholar
  40. 40.
    Bakir N, Sluiter W, Ploeg R, Van Son W, Tegzess A. Primary renal graft thrombosis. Nephrol Dial Transplant. 1996;11(1):140–7.CrossRefPubMedGoogle Scholar
  41. 41.
    Fananapazir G, Tse G, Corwin MT, Santhanakrishnan C, Perez RV, McGahan JP, et al. Pediatric en bloc kidney transplants: clinical and immediate postoperative US factors associated with vascular thrombosis. Radiology. 2015:150430.Google Scholar
  42. 42.
    Lockhart ME, Wells CG, Morgan DE, Fineberg NS, Robbin ML. Reversed diastolic flow in the renal transplant: perioperative implications versus transplants older than 1 month. Am J Roentgenol. 2008;190(3):650–5.CrossRefGoogle Scholar
  43. 43.
    Rouvière O, Berger P, Béziat C, Garnier J-L, Lefrançois N, Martin X, et al. Acute thrombosis of renal transplant artery: graft salvage by means of intra-arterial fibrinolysis. Transplantation. 2002;73(3):403–9.CrossRefPubMedGoogle Scholar
  44. 44.
    Voiculescu A, Schmitz M, Hollenbeck M, Braasch S, Luther B, Sandmann W, et al. Management of arterial stenosis affecting kidney graft perfusion: a single-centre study in 53 patients. Am J Transplant. 2005;5(7):1731–8.CrossRefPubMedGoogle Scholar
  45. 45.
    Willicombe M, Sandhu B, Brookes P, Gedroyc W, Hakim N, Hamady M, et al. Postanastomotic transplant renal artery stenosis: association with de novo class II donor-specific antibodies. Am J Transplant. 2014;14(1):133–43.CrossRefPubMedGoogle Scholar
  46. 46.
    Patel NH, Jindal RM, Wilkin T, Rose S, Johnson MS, Shah H, et al. Renal arterial stenosis in renal allografts: retrospective study of predisposing factors and outcome after percutaneous transluminal angioplasty. Radiology. 2001;219(3):663–7.CrossRefPubMedGoogle Scholar
  47. 47.
    Bent C, Fananapazir G, Tse G, Corwin MT, Vu C, Santhanakrishnan C, et al. Graft arterial stenosis in kidney en bloc grafts from very small pediatric donors: incidence, timing, and role of ultrasound in screening. Am J Transplant. 2015;15(11):2940–6.CrossRefPubMedGoogle Scholar
  48. 48.
    Chen W, Kayler LK, Zand MS, Muttana R, Chernyak V, DeBoccardo GO. Transplant renal artery stenosis: clinical manifestations, diagnosis and therapy. Clin Kidney J. 2015;8(1):71–8. Scholar
  49. 49.
    Ngo A, Markar S, De Lijster M, Duncan N, Taube D, Hamady M. A systematic review of outcomes following percutaneous transluminal angioplasty and stenting in the treatment of transplant renal artery stenosis. Cardiovasc Intervent Radiol. 2015;38(6):1573–88.CrossRefPubMedGoogle Scholar
  50. 50.
    de Morais RH, Muglia VF, Mamere AE, Pisi TG, Saber LT, Muglia VA, et al. Duplex Doppler sonography of transplant renal artery stenosis. J Clin Ultrasound. 2003;31(3):135–41.CrossRefPubMedGoogle Scholar
  51. 51.
    Obed A, Uihlein D, Zorger N, Farkas S, Scherer M, Krüger B, et al. Severe renal vein stenosis of a kidney transplant with beneficial clinical course after successful percutaneous stenting. Am J Transplant. 2008;8(10):2173–6.CrossRefPubMedGoogle Scholar
  52. 52.
    Mei Q, He X, Lu W, Li Y. Renal vein stenosis after renal transplantation: treatment with stent placement. J Vasc Interv Radiol. 2010;21(5):756–8.CrossRefPubMedGoogle Scholar
  53. 53.
    Fananapazir G, Hannsun G, Wright LA, Corwin MT, Troppmann C. Diagnosis and management of transplanted kidney extrarenal pseudoaneurysms: a series of four cases and a review of the literature. Cardiovasc Intervent Radiol. 2016;39(11):1649–53.Google Scholar
  54. 54.
    Perini S, Gordon RL, LaBerge JM, Kerlan RK, Wilson MW, Feng S, et al. Transcatheter embolization of biopsy-related vascular injury in the transplant kidney: immediate and long-term outcome. J Vasc Interv Radiol. 1998;9(6):1011–9.CrossRefPubMedGoogle Scholar
  55. 55.
    Schwarz A, Hiss M, Gwinner W, Becker T, Haller H, Keberle M. Course and relevance of arteriovenous fistulas after renal transplant biopsies. Am J Transplant. 2008;8(4):826–31.CrossRefPubMedGoogle Scholar
  56. 56.
    Kumar S, Ameli-Renani S, Hakim A, Jeon J, Shrivastava S, Patel U. Ureteral obstruction following renal transplantation: causes, diagnosis and management. Br J Radiol. 2014;87(1044):20140169.CrossRefPubMedPubMedCentralGoogle Scholar
  57. 57.
    Duty BD, Conlin MJ, Fuchs EF, Barry JM. The current role of endourologic management of renal transplantation complications. Adv Urol. 2013;2013:1.CrossRefGoogle Scholar
  58. 58.
    Challacombe B, Dasgupta P, Tiptaft R, Glass J, Koffman G, Goldsmith D, et al. Multimodal management of urolithiasis in renal transplantation. BJU Int. 2005;96(3):385–9.CrossRefPubMedGoogle Scholar
  59. 59.
    Hess B, Metzger RM, Ackermann D, Montandon A, Jaeger P. Infection-induced stone formation in a renal allograft. Am J Kidney Dis. 1994;24(5):868–72.CrossRefPubMedGoogle Scholar
  60. 60.
    Mallon DH, Summers DM, Bradley JA, Pettigrew GJ. Defining delayed graft function after renal transplantation: simplest is best. Transplantation. 2013;96(10):885–9.CrossRefPubMedGoogle Scholar
  61. 61.
    Lechevallier E, Dussol B, Luccioni A, Thirion X, Vacher-Copomat H, Jaber K, et al. Posttransplantation acute tubular necrosis: risk factors and implications for graft survival. Am J Kidney Dis. 1998;32(6):984–91.CrossRefPubMedGoogle Scholar
  62. 62.
    Hoque MT, Mitra P, Samdani TS, Hossain G, Abedin Z, Mansur MA. Tacrolimus induced early graft dysfunction secondary to acute tubular necrosis in renal transplant recipient-a case report. BIRDEM Med J. 2012;2(1):63–5.CrossRefGoogle Scholar
  63. 63.
    Jushinskis J, Trushkov S, Bicans J, Suhorukov V, Shevelev V, Ziedina I, et al., editors. Risk factors for the development of delayed graft function in deceased donor renal transplants. Transplant Proc. 2009;41(2):746–8. Elsevier.Google Scholar
  64. 64.
    Rifkin MD, Needleman L, Pasto ME, Kurtz AB, Foy PM, McGlynn E, et al. Evaluation of renal transplant rejection by duplex Doppler examination: value of the resistive index. Am J Roentgenol. 1987;148(4):759–62.CrossRefGoogle Scholar
  65. 65.
    Ragab AR, Al-Mazroua MK, Al-Dakrory SA-E. Cyclosporine toxicity and toxicokinetics profiles in renal transplant recipients. J Clin Toxicol. 2013;2013.Google Scholar
  66. 66.
    Buckley AR, Cooperberg P, Reeve CE, Magil A. The distinction between acute renal transplant rejection and cyclosporine nephrotoxicity: value of duplex sonography. Am J Roentgenol. 1987;149(3):521–5.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of RadiologyUniversity of California Davis Medical CenterSacramentoUSA
  2. 2.Department of SurgeryUniversity of California Davis Medical CenterSacramentoUSA

Personalised recommendations