Renal Vein Thrombosis and Vascular Occlusion by Sickled Erythrocytes with Diffuse Renal Allograft Necrosis
The University of Chicago Medical Center
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A 58 year old female developed end stage renal disease due to hypertensive nephrosclerosis and
received chronic peritoneal dialysis for 4 years. Her past medical history was notable for hypertension,
left cerebrovascular accident, asthma, avascular necrosis of the left hip treated by total hip
replacement and superior vena cava syndrome related to a central line. She underwent cadaveric renal
transplantation in May 2008. The transplant kidney was from a previously well 28 year old donor after
cardiac death. The cause of donor death was blunt head trauma from a motorcycle accident. This was the
recipient's first kidney transplant, with a six HLA antigen mismatch. Standard and flow cytometric
pre-transplant cross matches were negative. Donor warm ischemia time was 13 minutes. Pulsatile cold
(4°C) perfusion with University of Wisconsin perfusate was used for 17 hours and 17 minutes. Total
cold ischemia time was 24 hours and 29 minutes. Subsequent warm ischemia time at implantation was 56
minutes. At reperfusion the kidney became immediately homogenously pink. Within minutes a mottled blue
discoloration developed. At this time the renal artery had a regular strong pulse and the renal vein was
soft. The discoloration persisted and a needle biopsy was obtained at approximately 45 minutes and
sections are submitted (Slide 1, H&E). Indirect immunofluorescence for
C4d on a frozen core was negative. Over the next 24 hours the patient developed oliguria and then
anuria. Ultrasound revealed no flow in the renal vein and systolic flow in the renal artery. At this
time, the white cell count was 7.1 K/ µl (3.5-11), red cell count 4.2 M/ µl (3.9-5.3),
hemoglobin 11.4 g/dl (11.5-15.5), MCV 81.2 fL (81-99), MCHC 33.8 g/dl (32-35), hematocrit 33.8% (36-47),
RDW 16.5% (<15% in females) and platelets were 288 K/µl (150-450). The serum creatinine was 12.1
mg/dl (0.5-1.4). The patient had commenced Thymoglobulin induction. On re-exploration the allograft was
dark purple and had a palpable thrombus in the renal vein. Allograft nephrectomy was performed. On
gross examination the kidney was 290 gm and had firm thrombus filling the arcuate, interlobar and renal
vein branches. The cut surface was mottled red-purple. A representative section of the parenchyma is
submitted (Slide 2, H&E).
1. Renal transplant biopsy (˜45 minute)
LM: 17 glomeruli with diffuse segmental capillary obliteration by fibrin-platelet thrombi and with
focal marked glomerular capillary congestion. Focal glomerular capillary pyknotic nuclei, occasional
neutrophils and rare eosinophils. No thrombi apparent in arteries, arterioles or peritubular
capillaries. Tubules with acute tubular injury.
IF: Focal segmental glomerular capillary fibrinogen. C4d negative in peritubular capillaries.
Immunoperoxidase: CD61+ platelet aggregates in glomerular and peritubular capillaries, and
arterioles. Loss of capillary and arteriolar endothelial CD34 expression.
EM: Glomerular endothelial disruption and loss, with fibrin tactoids, platelet aggregates and
˜40 unremarkable glomeruli. No thrombi. Acute tubular injury.
Immunoperoxidase revealed widespread CD34 in vascular endothelium without evidence of loss of
Electron microscopy revealed segmental endothelial disruption with denuded capillary basement
The 45 minute biopsy had TMA with endothelial pyknosis and extensive endothelial loss on CD34
immunostaining and EM. In contrast, the donor biopsy had normal CD34 in the vasculature, indicating that
post-perfusion endothelial injury and loss occurred rapidly. Sickled erythrocytes were not evident.
Absence of TMA in the donor biopsy excludes transplanted TMA. Atheroemboli were not evident. Antibody
mediated (hyperacute) rejection was excluded by negative cross match and absence of peritubular capillary
C4d. Ultrastructural evidence of endothelial injury with denudation of capillary basement membranes was
seen in the pre-implantation biopsy. Hence the most likely explanation for these findings is perfusion
- Donor thrombotic microangiopathy (TMA)
- Hyperacute rejection
- Perfusion nephropathy
Thrombotic microangiopathy with rapid endothelial loss consistent with perfusion nephropathy
What is Perfusion Nephropathy?
Perfusion nephropathy was described in 1976 in kidney transplants subjected to cold pulsatile
perfusion preservation  and is characterized by capillary and arteriolar endothelial pyknosis and
loss, with obliterative fibrin-platelet thrombi, identified in perioperative (one-hour) biopsies.
Twenty-one of 36 perfusion preserved kidneys had TMA in 1 hour ( ± 15 mins) biopsies and the lesions were
absent from 41 cryopreserved kidneys. At one month, 9 of 21 (43%) underwent nephrectomy and 9 had serum
creatinine levels >2mg/dl. In contrast, 2 of 15 perfusion preserved kidneys without TMA required
early nephrectomy. Grossly, nephrectomies had a patchy blue appearance. Microscopically there was
extensive cortical necrosis, vascular thrombosis, "proliferative and degenerative vascular changes" and
mononuclear infiltrates in non-necrotic zones. There were no significant differences in warm or cold
ischemia times, perfusion characteristics (duration, pressure, temperature, composition of perfusate),
donor or recipient characteristics, HLA mismatches and DSA (by lymphocytotoxicity assay) between
perfusion preserved kidneys with TMA and those without TMA. The perfusate contained cryoprecipitated
plasma or modified Ringer's albumin, in contrast to University of Wisconsin perfusate used in the current
case, which has no plasma. The cause of TMA was not determined. The possibility of inadvertent exposure
to donor reactive antibodies or cold agglutinins in allogeneic plasma
was not excluded, although
TMA was evident in some kidneys not exposed to plasma. A second study from 1976  extended these
observations by identification of ultrastructural evidence of endothelial injury in pre-implantation
biopsies of allografts that subsequently developed perioperative TMA. A correlation between the severity
of microvascular fibrin deposition in perioperative biopsies and both duration of perfusion time and
perfusion pressure was observed. Graft loss was 46% at three months, and the extent of fibrin deposition
correlated with graft loss. Other studies documented similar features in perioperative biopsies
and nephrectomy specimens had extensive cortical necrosis . More recent larger studies of perfusion
preserved kidneys, from 1990 onwards, were notable for the absence of documented TMA and early graft loss
2. Allograft Nephrectomy :
Gross: 290 gm, cortex and medulla red with petechial hemorrhages, renal veins with abundant firm
LM: Diffuse cortical and medullary coagulation necrosis. Venous thrombi with abundant refractile
erythrocytes. Abundant refractile sickled erythrocytes in glomerular and peritubular capillaries, vasa
recta and veins.
IF: C4d negative. Non-specific reactivity for IgG, IgA, IgM, and C3.
Fibrin – abundant in capillaries and moderate in venous thrombi. Along arterial intimal surface.
Immunoperoxidase: CD61 in glomerular capillaries; few in peritubular capillaries and along arterial
intima. Platelets were sparse in the occluded veins.
EM: abundant sickled erythrocytes containing cytoplasmic fibrils.
The nephrectomy specimen was removed within 24 hours of implantation. In addition to diffuse cortical
and medullary necrosis there was striking renal vein thrombosis (RVT) and abundant capillary and venous
sickled erythrocytes admixed with sparse fibrin and platelets. Electron microscopy confirmed RBC
sickling with cytoplasmic filaments in almost all erythrocytes. Subsequent hemoglobin (Hb) analysis
(HPLC) confirmed HbAS. There were no surgical technical difficulties noted at vascular anastomosis.
Hypercoagulability work-up was negative. Repeat cross match was negative, and the tissue had no
peritubular capillary C4d or vascular immunoglobulin deposition. Renal vein occlusive thrombi have not
been specifically described in perfusion nephropathy.
- Surgical/plumbing problem
- Thrombophilia - (Protein S/C deficiency, factor V Leiden, anti-thrombin III deficiency, anti-phospholipid and anticardiolipin antibodies)
- Hyperacute rejection
- Perfusion nephropathy
Hb evaluation by HPLC revealed 25.6% HbS, indicative of sickle cell trait.
Final Pathologic Diagnosis
1. Renal vein thrombosis and vascular occlusion by sickled erythrocytes with diffuse renal allograft
necrosis (Sickle cell trait).
2. Perfusion nephropathy.
Sickle Cell Nephropathies
Sickle cell disease is caused by a single nucleotide substitution (GAG ® GTG) in the hemoglobin beta
chain gene, with substitution of valine for glutamic acid at position 6 in the b -globin chain of
hemoglobin (Hb) A, which then becomes HbS. Heterozygosity is evident in ~8% of Americans of African
descent, and in Sub-Saharan Africa the frequency is as high as 40-60%. Deoxygenated HbS polymerizes into
long filamentous structures which reduce erythrocyte deformability and impart a sickle-like shape. The
severity of sickle cell vaso-occlusive disease is directly proportional to the degree of polymerization
of HbS, which depends on the erythrocyte HbS concentration and the duration and severity of
deoxygenation. The kidney is frequently affected in sickle cell disease (HbSS) and trait (HbAS), by a
variety of different disorders
Sickle Cell Disease and Renal Transplants
Early graft loss has been reported in sickle cell trait at 2 and 6 weeks in one recipient . A
survey of 24 renal allografts in 21 recipients with HbAS disease revealed 35% graft loss by 1 year
. Early renal allograft loss with RVT and extensive sickling has been noted at days 3 and 6
in patients with HbSS. Graft infarction in HbSS with microvascular
sickling of RBC at 4 months has also been described .
Montgomery  suggested 2 possible pathways
of graft loss (i) acute vaso-occlusive crisis with graft thrombosis and early failure and (ii) recurrent
sickle nephropathy with a more indolent progression.
The pathogenesis of vascular occlusion in HbSS and HbAS disease is complex. Sluggish blood flow and
hypoxia are preconditions for polymerization of HbS and irreversible sickling
Sickled RBCs are
rigid and adhere by by a variety of mechanisms including specific cell surface receptor interactions
principally to post-capillary venular endothelium . RBC adhesion initiates endothelial
activation, resulting in altered secretion of vasoactive compounds, increased adhesiveness for leukocytes
and procoagulant activity . In the present case, perfusion nephropathy probably caused
mechanical/physical endothelial disruption with loss of adhesion and cell death. Exposure of
subendothelial matrix molecules (thrombospondin, laminin, fibronectin, collagen) and endothelial
activation may have initiated coagulation and recruitment of inflammatory cells. Reduced microvascular
red cell velocity, and prolonged erythrocyte hypoxia, favored polymerization of deoxygenated HbS.
Sickled erythrocytes, with increased rigidity and endothelial adhesiveness, further activated
coagulation, and accumulation of inflammatory cells, with eventual vascular occlusion. It seems
plausible that endothelial injury from perfusion nephropathy and TMA together played an important role in
development of sickle cell-associated vascular occlusion, RVT and renal allograft infarction in this
In conclusion, a case of early graft loss attributable to the combined effects of perfusion
nephropathy and (clinically occult) sickle cell trait with resultant RVT, vascular occlusion and graft
necrosis is presented. Patients with sickle cell trait may be at risk for early graft loss.
Table 1. Renal Lesions in Sickle Cell Disorders
|Pathologic finding ||AS ||SS|
|Papillary necrosis ||+ ||+|
|Medullary scars/VR loss ||+ ||+|
|Hemosiderosis ||+ ||+|
|Congestion and RBC impaction ||+ ||+|
|Cortical infarcts ||+ ||+|
|Pyelonephritis ||+ ||+|
|Glomerulomegaly with chronic TMA ||+ ||+|
|Immune complex GN ||+ ||+|
|Focal segmental glomerulosclerosis ||- ||+|
|Neoplasia || |
| Medullary carcinoma ||+ ||+|
| Other renal cell carcinoma ||+ ||+|
Renal allograft, thrombotic microangiopathy, perfusion nephropathy, renal vein thrombosis, sickle
- Spector D, Limas C, Frost JL, et al.: Perfusion nephropathy in human transplants. N Engl J Med 295:1217-1221, 1976
- Sturgill BC, Lobo PI, Bolton WK: Cold-reacting IgM antibody-induced renal allograft failure. Similarity to hyperacute rejection. Nephron 36:125-127, 1984
- Light JA, Annable C, Perloff LJ, et al.: Immune injury from organ preservation. A potential cause of hyperacute rejection in human cadaver kidney transplantation. Transplantation 19:511-516, 1975
- Hill GS, Light JA, Perloff LJ: Perfusion-related injury in renal transplantation. Surgery 79:440-447, 1976
- Gattone VH, 2nd, Filo RS, Evan AP, et al.: Time course of glomerular endothelial injury related to pulsatile perfusion preservation. Transplantation 39:396-399, 1985
- Limas C, Spector D, Wright JR: Histologic changes in preserved cadaveric renal transplants. Am J Pathol 88:403-428, 1977
- Evan AP, Gattone VH, 2nd, Filo RS, et al.: Glomerular endothelial injury related to renal perfusion. A scanning electron microscopic study. Transplantation 35:436-441, 1983
- Plata-Munoz JJ, Muthusamy A, Quiroga I, et al.: Impact of pulsatile perfusion on postoperative outcome of kidneys from controlled donors after cardiac death. Transpl Int 21:899-907, 2008
- Polyak MM, Arrington BO, Stubenbord WT, et al.: The influence of pulsatile preservation on renal transplantation in the 1990s. Transplantation 69:249-258, 2000
- Bhathena DB: Sickling Disorders (Chapter 28), in Heptinstall's Pathology of the Kidney, edited by Jennette JC, Olson JL, Schwartz MM, Silva FG, 5th ed, Philadelphia, Lippincott-Raven, 1998, pp 1231-1246
- Bunn HF: Pathogenesis and treatment of sickle cell disease. N Engl J Med 337:762-769, 1997
- Davis CJ, Jr., Mostofi FK, Sesterhenn IA: Renal medullary carcinoma. The seventh sickle cell nephropathy. Am J Surg Pathol 19:1-11, 1995
- Saborio P, Scheinman JI: Sickle cell nephropathy. J Am Soc Nephrol 10:187-192, 1999
- Chatterjee SN, Lundberg GD, Berne TV: Sickle cell trait: possible contributory cause of renal allograft failure. Urology 11:266-268, 1978
- Chatterjee SN: National study on natural history of renal allografts in sickle cell disease or trait. Nephron 25:199-201, 1980
- Barber WH, Deierhoi MH, Julian BA, et al.: Renal transplantation in sickle anemia and sickle disease. Clin Transplantation 1: 169-175, 1987
- Donnelly PK, Edmunds ME, O'Reilly K: Renal transplantation in sickle cell disease. Lancet 2:229, 1988
- O'Rourke EJ, Laing CM, Khan AU, et al.: Allograft dysfunction in a patient with sickle cell disease. Kidney Int 74:1219-1220, 2008
- Montgomery R, Zibari G, Hill GS, et al.: Renal transplantation in patients with sickle cell nephropathy. Transplantation 58:618-620, 1994
- Kaul DK, Fabry ME: In vivo studies of sickle red blood cells. Microcirculation 11:153-165, 2004
- Frenette PS: Sickle cell vaso-occlusion: multistep and multicellular paradigm. Curr Opin Hematol 9:101-106, 2002
- Nath KA, Grande JP, Croatt AJ, et al.: Transgenic sickle mice are markedly sensitive to renal ischemia-reperfusion injury. Am J Pathol 166:963-972, 2005