The patient is a 54-year-old female with alcoholic liver cirrhosis and chronic kidney failure, listed for liver and sequential renal transplantation. The patient underwent a percutaneous ethanol injection therapy for a solitary hepatocellular carcinoma in 2009. At the timepoint of transplantation the MELD score was 37.
The preoperatively conducted abdominal computed tomographic (CT) scan showed severe portal-systemic collateral vessels of the abdomen, including a splenorenal shunt ().
Preoperative CT imaging showing the splenorenal shunt (arrow) and a splenomegaly (left renal vein = star).
The patient underwent an orthotopic liver transplantation using a full-size organ. Donor age was 56 years, and the organ quality was rated as “acceptable” by the explant surgeon. Histopathological rating of steatosis was 25–30%. The center standardised transplant procedure was performed with replacement of the retrohepatic inferior vena cava and without any bypass procedure. Anastomosis time was 43
min, incision to suture time was 3 hours 09
min, and cold ischemic time was 8 hours 47
After reperfusion, Doppler ultrasonography showed total diversion of the portal flow into the existing splenorenal shunt, but because of severe coagulopathy and diffuse bleeding, ligation of the shunt was not attempted. A programmed relaparotomy was performed on the first postoperative day, and the left renal vein was ligated at its confluence to the inferior vena cava ().
Postoperative CT imaging (day 5) after the ligation of the left renal vein. The arrow shows the point of ligation.
Portal flows subsequently increased to 37
cm/sec. The postoperative graft function was excellent and substitution of plasma or coagulation factors was not necessary. The postoperative Doppler ultrasound examination showed normal flows for both the hepatic artery and portal vein. The further postoperative course was uncomplicated.
About two months after the liver transplantation, another CT scan of the abdomen was performed, and progredient thrombosis of the left renal vein was observed (Figures and ). Due to the preexisting chronic renal failure, this fact was without any consequence for our patient, but it demonstrates that the procedure of renal vein ligation bears the potential risk of renal impairment. The patient currently enjoys good allograft function with normal liver function tests.
Postoperative CT imaging (day 47) showing the thrombosis of the left renal vein at the point of ligation (arrow).
Postoperative CT imaging (day 47) showing in axial form the thrombosis of the left renal vein (arrow).