Case # 9: A Transplant Dilemma

A 52 year old male with a h/o kidney transplant presents to the emergency department with pain over his transplanted kidney site (right pelvic region). He also notes increased weakness, nausea and a significant decrease in urine output. He denies any fever. He states he is compliant with his anti-rejection medications.

Vitals: T 99.0 HR 105 BP 165/91  RR 18 O2 98% on RA

A bedside ultrasound is performed, what is the next best step in management?

tx_severe hydro

Answer and Learning Points


Insertion of foley catheter. The clip above demonstrates severe hydronephrosis of the patient's transplanted kidney. A foley was inserted in the emergency department with immediate output of 1.5 L of clear urine. The patient was found to be in renal failure secondary to his urinary outlet obstruction. He was admitted to transplant surgery and his renal function improved over the next day; he was discharged home with a leg bag and urology follow up. Below is a repeat ultrasound of his transplanted kidney after drainage of his bladder: 

Learning Points

    • Urinary obstruction in a transplanted kidney can be missed initially as pain over the patient's graft site and decreased urine output is easily contributed to possible rejection or infection.
    • The differential diagnosis of acute renal failure in the transplanted kidney is broad (see table below) and emergency department management should include a thorough evaluation for prerenal, intrinsic and post renal causes, in consultation with a transplant service.
    • All renal transplant patients presenting with acute renal failure should have a formal renal ultrasound with doppler to evaluate the graft however often this is not available immediately and a bedside ultrasound can assist with rapid identification of acute urinary obstruction.


This post was written by Michael Macias, MD, Ultrasound Fellow at UCSD.


    1. Kadambi PV., Brennan DC., Chon J. (2017). Evaluation and diagnosis of the patient with renal allograft dysfunction. In T.W. Post, B. Murphy, & A. Lam (Eds.), UptoDate. Available from
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