•
Ultrasound
Ultrasonic "B" Scanning in the Diagnosis of Complications in Renal Transplant Patients 1 P. Ruben Koehler, M.D., Henry H. Kanemolo, M.D., and J. Gary Maxwell, M.D. B-mode ultrasonography has been used in the evaluation of complications following renal transplantations. The main indications for examining the patientare decreased renal function, clinically suspectedabscesses, or suggestions of a mass in the region of the transplant. In most patients, worsening renal function is due to rejection. In 10 of 50 patients, however, lesions such as Iymphoceles, postoperative hematomas, abscesses, and urine leakage were diagnosed. Ultrasonography proved to be a noninvasive and reliable method for the assessment of these complications. INDEX TERMS: Kidneys, abscess. Kidneys, failure. Kidneys, hemorrhage. Kidneys, transplantation. Kidneys, ultrasound • Lymphoceles
Radiology 119:661-664, June 1976
•
• Table I:
U
LTRASONOGRAPHY has recently become a widely used noninvasive diagnostic tool capable of providing a great deal of useful information about patients who have undergone renal transplantation. Leopold (6) in 1970, Winterberger (12) in 1972, and Bartrum et al. (1) in 1974, described the use of ultrasound to determine the size and calculate the volume of the transplanted kidney. They felt it to be a reliable and reproducible method which is indirectly useful in the diagnosis of transplant rejection. Rejection must be considered among other complications if, postoperatively, a renal transplant does not function well clinically. Common signs are decreases in urine output or increases in the plasma level of creatinine. While we could not reliably calculate renal volumes, we found that in a significant number of patients we were able with ultrasound scanning to detect other complications which were the primary cause of a deteriorating clinical condition.
Positive Ultrasound Scans
No. of patients examined:* No. of patients with positive ultrasound scans" Lymphocele Abscess Hematoma Urine collection Hydronephrosis in transplanted kidney Postoperative hydronephrosis developing in native kidney
50 10 4 4 2 1 1 1
* Several patients had more than one ultrasound scan. t Two patients had 2 or more different complications at different times. CASE REPORTS
CASE I. M.R. is a 37-year-old woman with end-stagerenal failure secondary to chronic glomerulonephritis. The patient received a renal transplant from her sister in June, 1975.Thepostoperative course was unremarkable andthe patient was discharged. Six weeks later she was readmitted because of decreasing renal output, increasing serum creatinine,anda temperature of 39.4°C (103°F). Physical examination revealeda non-tender swelling over the transplant site. Rejection was suspected. Ultrasound revealed a largesonolucent mass 15 em superior and medial to the renal transplant(Fig. 1).The cyst was punctured; its clear yellowish fluid was aspirated andanalyzed. Theextent of the cyst was seenclearly after contrast was injectedinto the space(Fig.2),and the diagnosisof Iymphocele was made. Analysisof the aspiratedfluid showed protein contents of 2 gm/100 ml. Re-explorationsconfirmed the presence of a largemultiloculated retroperitoneallymphocele. Renal functions initially improved postoperatively, but then began to deteriorate. A repeat scan done 14 days after the first revealed hydronephrosis of the renal transplant (Fig. 3), confirmed by a subsequent excretory urogram (Fig. 4). At the same time, the scan showed that a perirenal fluid collection was no longer present.A urethralobstruction was found at surgical exploration, and a diverting nephrostomy performed. Renal functions continued to decrease postoperatively and againthe diagnosis of rejectionwas entertained. The patientcomplained of progressively increasing pain over the surgical site. A third ultrasound scan revealed a subcutaneous or intramuscularfluid coliectlon above and slightly lateral to the renal transplant (Fig. 5). At surgery,a wound hematoma in the abdominal wall was found. This was evacuated, and the urine output markedly improved immediately.
METHOD
Scans of 50 patients were obtained in a supine position with a conventional "B" scanner and a 2.25 MHz transducer. The scans were done along the longitudinal axis of the kidney and at a 90 0 angle to that plane. In some, scans parallel to the sagittal axis of the patient were also done. The area scanned was the entire pelvis and lower abdomen. In normal patients, the transplanted kidney could easily be recognized, with its smooth outline and the internal echoes from the calyceal system and the renal pelvis. The urinary bladder was usually filled, and was identified as such by the echo-free sharply outlined space. Because of external pressure from the transplant, the bladder was usually assymmetrical and not in the midline. In 40 patients the ultrasonic scan was interpreted as normal, and the clinical diagnosis of chronic rejection was confirmed. The examination was abnormal in 10 (TABLE
I).
1 From the Departments of Radiology(P.R.K., H.H.K.) and Surgery (J.G.M.), University of Utah Medical Center, Salt Lake City, Utah, 84132. Accepted for publication in February, 1976. ss
661
662
P.
RUBEN KOEHLER AND OTHERS
CASE II. J. G., a 38-year-old woman with end-stage renal failure secondary to diabetic nephropathy, received a cadaver transplant in May 1975 and had an unremarkable postoperative course. Six weeks after transplantation she was readmitted with a three-day history of increasing malaise, lethargy, and a fever of.38.8°C {102°F}. Physical examination was unremarkable. Because of an interstitial infiltrate seen on the chest radiograph, the possibility of pneumocystitis pneumonia was considered. Ten days after admission, because of progressive deterioration of renal function, a presumptive diagnosis of rejection was made. Ultrasonic examination revealed a sonolucent mass posterior and medial to the transplanted kidney (Fig. 6). Because the borders were ill-defined, the diagnosis of pelvic abscess was made. The patient's condition continued to deteriorate, and she died two days later. Postmortem examination showed a large pelvic abscess adjacent to the kidney. The kidney showed massive necrosis. CASE III. K. S., a 45-year-old white man, received two pediatric cadaver kidneys in April, 1974. He had a 17-year history of chronic
June 1976
glomerulonephritis. Fifteen days postoperatively, because of increasing serum creatinine and decreasing urine output, the clinical diagnosis of rejection was made. Ultrasound examination revealed a 6.0 X 7.5 cm cystic mass anterior to the transplanted kidney. The margins were ill-defined and multiple echoes were seen within the cavity (Fig. 7). Increasing pain, fluctuance, and a fever spiking to 38.2°C (101°F) subsequently developed. Exploratory laparotomy revealed a subcutaneous collection of urine. Both transplanted ureters were necrotic and lying free in the base of the wound.
DISCUSSION
The main indication for examining patients was a decrease in renal function, a search for a clinically suspected abscess, or a suggestion of the presence of a mass in the region of the transplanted kidney. The early postoperative period (a few weeks to a few months after surgery) is when
Fig. 1. CASE I. This is a longitudinal scan showing the transplanted kidney (K), the Iymphocele (L) and the dome of the bladder (B)..The echoes within the kidney are caused by the somewhat dilated collecting system. Fig. 2. CASE I. Radiograph taken after the injection of 20 ml of contrast medium into the Iymphocele. The transplanted kidney indents the Iymphocele. The kidney is outlined by the three metallic markers. Fig. 3. Ultrasound scan done 2 weeks after scan in Figure 1. This is a transverse cut. The dilated collecting system is now clearly seen (C). Fig. 4. Intravenous urogram done the same day as the ultrasound on Figure 3. The oblique view of the transplanted kidney shows the dilated calyces and renal pelvis. Fig. 5. CASE I. Tranverse ultrasound scan over the left flank. The upper margin of the kidney is visualized {K and arrow}. Note the space (H) between the lateral border of the kidney and the abdominal wall, formed by an abdominal wall hematoma which developed following the third operation (see text).
Vol. 119
COMPLICATIONS IN RENAL TRANSPLANT PATIENTS
663
Ultrasound
Fig. 6. CASE II. A. Longitudinal scan 4 cm to the left of the midline. Note the relationship between the kidney (K), bladder (B), and abscess (M). The borders of the abscess are ill-defined. B. Transverse cut taken at the level of the arrow in Figure 6, A. The relationship of the kidney (K) to the abscess (M) is clearly seen.
most complications occur (2). In addition to acute rejection, perinephric or retroperitoneal infection, Iymphoceles, hematomas, hydronephrosis, urine leaks, and changes in the vessels supplying the kidneys are the complications most commonly encountered (9, 11). The therapeutic approach depends on a prompt, accurate diagnosis. A sign common to several of these complications is the decrease in renal function (2, 10) manifested by increased creatinine values. Perirenal fluid collection, particularly Iymphoceles, produces deterioration of renal function, presumably by producing partial ureteral obstruction, although this may not represent the pathophysiologic mechanism in all cases. Ultrasound scanning is a safe and reliable method for differentiating these lesions from acute rejections.
There have been a number of recent publications reporting the accumulation of abnormal quantities of lymph around renal transplants (3, 4, 7, 8). The source of this lymph is probably severed vessels damaged during the preparation of the recipient vessels. Another possible origin is the kidney itself [leakage from injured capsular and hilar lymphatics (8)]. The diagnosis of a Iymphocele is frequently difficult because it is nonspecific. The main clinical signs are: deterioration of renal function, development of a painless fluctuant swelling over the transplanted kidney and, if excretary urography is performed, a mass indenting the bladder (5). When the lymph is drained, renal function quickly returns to the "pre-Iymphocele" state.
Fig. 7. CASE III. A. Longitudinal scan 5 cm to the right of the midline. This patient had two infant kidneys transplanted (K). The sonolucent space within the abdominal wall is clearly seen (U). This was caused by urine collection into the abdominal wall, but such a picture would be indistinguishable from an abdominal wall hematoma or abscess.
B. Transverse cut taken at the level of the arrow in Figure 7, A. The relationship of the kidney (K) to the urine collection (U) is clearly seen.
664
P. RUBEN KOEHLER AND OTHERS
Most of our patients were examined because of deterioration of renal function and suspected rejection. When satisfactory studies could be performed, we were always able to demonstrate the kidney. Patients with open wounds were the most difficult to examine, since in order to obtain a satisfactory scan, good contact between the transducer and the underlying skin is necessary. In patients with rejection, no significant fluid collections around the kidneys were found, and a presumptive diagnosis of chronic rejection was made. Yet in 10 patients we were able to demonstrate the collection of abnormal amounts of fluid around the kidney, and in most instances surgical intervention was necessary to permanently drain the fluid (TABLE I).
Based on the ultrasound scan alone, the differential diagnosis between Iymphocele, hematoma, and urinary leakage is difficult. All show clear echo-free spaces corresponding to the fluid, and the final diagnosis must be based on a combination of the scan, clinical findings, and analysis of the aspirated fluid. Hematomas usually develop shortly after surgery, and will therefore enter differential diagnostic consideration at that time; a drop in the hematocrit values may be indicative. Differentiation between urine leak and Iymphocele may be more difficult, but frequently the diagnosis can be made by excretory urography or analysis of aspirated fluid. Aspiration is preferably done during scanning, since the best location for puncture can be identified; a small (20 gauge) needle can be inserted directly into the space and a sample of the fluid removed. If necessary, contrast medium can be injected at this time to outline the extent of the fluid collection on radiographs (Fig. 2). The diagnosis of an abscess is gen~rally easier, be-
June 1976
cause there are frequently septa within the abscess; because of edema around the lesion, the borders are not as sharp as those found in Iymphoceles or hematomas. Department of Radiology University of Utah Medical Center Salt Lake City, Utah 84132
REFERENCES 1. Bartrum RJ Jr, Smith EH, D'Orsi CJ, et al: The ultrasonic determination of renal transplant volume. J Clin Ultrasound 2:281-285, 1974 2. Christiansen L, Nerstrom B: Perirenal lymph accumulation: a complication of kidney transplantation. Scan JUral Nephrol 8: 245-247, 1974 3. Diethelm AG: Anuria secondary to perirenal Iymphocele: a complication of renal transplantation. South Med J 65:350-352, Mar 1972 4. Inocencio NF, Pierce JM Jr, Rosenberg JC, et al: Renal allograft with massive perirenal accumulation of lymph. Br Med J 3: 452-453, 23 Aug 1969 5. Koehler PR, Kyaw MM: Lymphatic complications following renal transplantation. Radiology 102:539-543, Mar 1972 6. Leopold GR: Renal transplant size measured by reflected ultrasound. Radiology 95:687-689, Jun 1970 7. Pillay VKG, Ing TS, Armbruster KW, et al: Lymphocyst totlowi~g renal transplantation. Can Med Assoc 105:1066, 20 Nov 1971 8. Rashid A. Posen G, Couture R, et al: Accumulation of lymph around the transplanted kidney (Iymphocele) mimicking renal allograft rejection. J UroI111:145-147, Feb 1974 9. Sampson D, Winterberger AR, Murphy GP: Lymphoceles complicating renal allotransplantation. NY State J Mad 73:2710-2713, 15 Nov 1973 10. Schweizer R, Cho S, Kountz SL, et al: Lymphoceles following renal transplantation. Arch Surg 104:42-45, Jan 1972 11. Turcotte JG: Infection and renal transplantation. Surg Clin North Am 52:1501-1512, Dec 1972 12. Winterberger AR, Palma LD, Murphy GP: Ultrasonic testing in human renal allografts. JAMA 219:475-479,24 Jan 1972
Ultrasound
Ultrasonic "B" Scanning in the Diagnosis of Complications in Renal Transplant Patients 1 P. Ruben Koehler, M.D., Henry H. Kanemolo, M.D., and J. Gary Maxwell, M.D. B-mode ultrasonography has been used in the evaluation of complications following renal transplantations. The main indications for examining the patientare decreased renal function, clinically suspectedabscesses, or suggestions of a mass in the region of the transplant. In most patients, worsening renal function is due to rejection. In 10 of 50 patients, however, lesions such as Iymphoceles, postoperative hematomas, abscesses, and urine leakage were diagnosed. Ultrasonography proved to be a noninvasive and reliable method for the assessment of these complications. INDEX TERMS: Kidneys, abscess. Kidneys, failure. Kidneys, hemorrhage. Kidneys, transplantation. Kidneys, ultrasound • Lymphoceles
Radiology 119:661-664, June 1976
•
• Table I:
U
LTRASONOGRAPHY has recently become a widely used noninvasive diagnostic tool capable of providing a great deal of useful information about patients who have undergone renal transplantation. Leopold (6) in 1970, Winterberger (12) in 1972, and Bartrum et al. (1) in 1974, described the use of ultrasound to determine the size and calculate the volume of the transplanted kidney. They felt it to be a reliable and reproducible method which is indirectly useful in the diagnosis of transplant rejection. Rejection must be considered among other complications if, postoperatively, a renal transplant does not function well clinically. Common signs are decreases in urine output or increases in the plasma level of creatinine. While we could not reliably calculate renal volumes, we found that in a significant number of patients we were able with ultrasound scanning to detect other complications which were the primary cause of a deteriorating clinical condition.
Positive Ultrasound Scans
No. of patients examined:* No. of patients with positive ultrasound scans" Lymphocele Abscess Hematoma Urine collection Hydronephrosis in transplanted kidney Postoperative hydronephrosis developing in native kidney
50 10 4 4 2 1 1 1
* Several patients had more than one ultrasound scan. t Two patients had 2 or more different complications at different times. CASE REPORTS
CASE I. M.R. is a 37-year-old woman with end-stagerenal failure secondary to chronic glomerulonephritis. The patient received a renal transplant from her sister in June, 1975.Thepostoperative course was unremarkable andthe patient was discharged. Six weeks later she was readmitted because of decreasing renal output, increasing serum creatinine,anda temperature of 39.4°C (103°F). Physical examination revealeda non-tender swelling over the transplant site. Rejection was suspected. Ultrasound revealed a largesonolucent mass 15 em superior and medial to the renal transplant(Fig. 1).The cyst was punctured; its clear yellowish fluid was aspirated andanalyzed. Theextent of the cyst was seenclearly after contrast was injectedinto the space(Fig.2),and the diagnosisof Iymphocele was made. Analysisof the aspiratedfluid showed protein contents of 2 gm/100 ml. Re-explorationsconfirmed the presence of a largemultiloculated retroperitoneallymphocele. Renal functions initially improved postoperatively, but then began to deteriorate. A repeat scan done 14 days after the first revealed hydronephrosis of the renal transplant (Fig. 3), confirmed by a subsequent excretory urogram (Fig. 4). At the same time, the scan showed that a perirenal fluid collection was no longer present.A urethralobstruction was found at surgical exploration, and a diverting nephrostomy performed. Renal functions continued to decrease postoperatively and againthe diagnosis of rejectionwas entertained. The patientcomplained of progressively increasing pain over the surgical site. A third ultrasound scan revealed a subcutaneous or intramuscularfluid coliectlon above and slightly lateral to the renal transplant (Fig. 5). At surgery,a wound hematoma in the abdominal wall was found. This was evacuated, and the urine output markedly improved immediately.
METHOD
Scans of 50 patients were obtained in a supine position with a conventional "B" scanner and a 2.25 MHz transducer. The scans were done along the longitudinal axis of the kidney and at a 90 0 angle to that plane. In some, scans parallel to the sagittal axis of the patient were also done. The area scanned was the entire pelvis and lower abdomen. In normal patients, the transplanted kidney could easily be recognized, with its smooth outline and the internal echoes from the calyceal system and the renal pelvis. The urinary bladder was usually filled, and was identified as such by the echo-free sharply outlined space. Because of external pressure from the transplant, the bladder was usually assymmetrical and not in the midline. In 40 patients the ultrasonic scan was interpreted as normal, and the clinical diagnosis of chronic rejection was confirmed. The examination was abnormal in 10 (TABLE
I).
1 From the Departments of Radiology(P.R.K., H.H.K.) and Surgery (J.G.M.), University of Utah Medical Center, Salt Lake City, Utah, 84132. Accepted for publication in February, 1976. ss
661
662
P.
RUBEN KOEHLER AND OTHERS
CASE II. J. G., a 38-year-old woman with end-stage renal failure secondary to diabetic nephropathy, received a cadaver transplant in May 1975 and had an unremarkable postoperative course. Six weeks after transplantation she was readmitted with a three-day history of increasing malaise, lethargy, and a fever of.38.8°C {102°F}. Physical examination was unremarkable. Because of an interstitial infiltrate seen on the chest radiograph, the possibility of pneumocystitis pneumonia was considered. Ten days after admission, because of progressive deterioration of renal function, a presumptive diagnosis of rejection was made. Ultrasonic examination revealed a sonolucent mass posterior and medial to the transplanted kidney (Fig. 6). Because the borders were ill-defined, the diagnosis of pelvic abscess was made. The patient's condition continued to deteriorate, and she died two days later. Postmortem examination showed a large pelvic abscess adjacent to the kidney. The kidney showed massive necrosis. CASE III. K. S., a 45-year-old white man, received two pediatric cadaver kidneys in April, 1974. He had a 17-year history of chronic
June 1976
glomerulonephritis. Fifteen days postoperatively, because of increasing serum creatinine and decreasing urine output, the clinical diagnosis of rejection was made. Ultrasound examination revealed a 6.0 X 7.5 cm cystic mass anterior to the transplanted kidney. The margins were ill-defined and multiple echoes were seen within the cavity (Fig. 7). Increasing pain, fluctuance, and a fever spiking to 38.2°C (101°F) subsequently developed. Exploratory laparotomy revealed a subcutaneous collection of urine. Both transplanted ureters were necrotic and lying free in the base of the wound.
DISCUSSION
The main indication for examining patients was a decrease in renal function, a search for a clinically suspected abscess, or a suggestion of the presence of a mass in the region of the transplanted kidney. The early postoperative period (a few weeks to a few months after surgery) is when
Fig. 1. CASE I. This is a longitudinal scan showing the transplanted kidney (K), the Iymphocele (L) and the dome of the bladder (B)..The echoes within the kidney are caused by the somewhat dilated collecting system. Fig. 2. CASE I. Radiograph taken after the injection of 20 ml of contrast medium into the Iymphocele. The transplanted kidney indents the Iymphocele. The kidney is outlined by the three metallic markers. Fig. 3. Ultrasound scan done 2 weeks after scan in Figure 1. This is a transverse cut. The dilated collecting system is now clearly seen (C). Fig. 4. Intravenous urogram done the same day as the ultrasound on Figure 3. The oblique view of the transplanted kidney shows the dilated calyces and renal pelvis. Fig. 5. CASE I. Tranverse ultrasound scan over the left flank. The upper margin of the kidney is visualized {K and arrow}. Note the space (H) between the lateral border of the kidney and the abdominal wall, formed by an abdominal wall hematoma which developed following the third operation (see text).
Vol. 119
COMPLICATIONS IN RENAL TRANSPLANT PATIENTS
663
Ultrasound
Fig. 6. CASE II. A. Longitudinal scan 4 cm to the left of the midline. Note the relationship between the kidney (K), bladder (B), and abscess (M). The borders of the abscess are ill-defined. B. Transverse cut taken at the level of the arrow in Figure 6, A. The relationship of the kidney (K) to the abscess (M) is clearly seen.
most complications occur (2). In addition to acute rejection, perinephric or retroperitoneal infection, Iymphoceles, hematomas, hydronephrosis, urine leaks, and changes in the vessels supplying the kidneys are the complications most commonly encountered (9, 11). The therapeutic approach depends on a prompt, accurate diagnosis. A sign common to several of these complications is the decrease in renal function (2, 10) manifested by increased creatinine values. Perirenal fluid collection, particularly Iymphoceles, produces deterioration of renal function, presumably by producing partial ureteral obstruction, although this may not represent the pathophysiologic mechanism in all cases. Ultrasound scanning is a safe and reliable method for differentiating these lesions from acute rejections.
There have been a number of recent publications reporting the accumulation of abnormal quantities of lymph around renal transplants (3, 4, 7, 8). The source of this lymph is probably severed vessels damaged during the preparation of the recipient vessels. Another possible origin is the kidney itself [leakage from injured capsular and hilar lymphatics (8)]. The diagnosis of a Iymphocele is frequently difficult because it is nonspecific. The main clinical signs are: deterioration of renal function, development of a painless fluctuant swelling over the transplanted kidney and, if excretary urography is performed, a mass indenting the bladder (5). When the lymph is drained, renal function quickly returns to the "pre-Iymphocele" state.
Fig. 7. CASE III. A. Longitudinal scan 5 cm to the right of the midline. This patient had two infant kidneys transplanted (K). The sonolucent space within the abdominal wall is clearly seen (U). This was caused by urine collection into the abdominal wall, but such a picture would be indistinguishable from an abdominal wall hematoma or abscess.
B. Transverse cut taken at the level of the arrow in Figure 7, A. The relationship of the kidney (K) to the urine collection (U) is clearly seen.
664
P. RUBEN KOEHLER AND OTHERS
Most of our patients were examined because of deterioration of renal function and suspected rejection. When satisfactory studies could be performed, we were always able to demonstrate the kidney. Patients with open wounds were the most difficult to examine, since in order to obtain a satisfactory scan, good contact between the transducer and the underlying skin is necessary. In patients with rejection, no significant fluid collections around the kidneys were found, and a presumptive diagnosis of chronic rejection was made. Yet in 10 patients we were able to demonstrate the collection of abnormal amounts of fluid around the kidney, and in most instances surgical intervention was necessary to permanently drain the fluid (TABLE I).
Based on the ultrasound scan alone, the differential diagnosis between Iymphocele, hematoma, and urinary leakage is difficult. All show clear echo-free spaces corresponding to the fluid, and the final diagnosis must be based on a combination of the scan, clinical findings, and analysis of the aspirated fluid. Hematomas usually develop shortly after surgery, and will therefore enter differential diagnostic consideration at that time; a drop in the hematocrit values may be indicative. Differentiation between urine leak and Iymphocele may be more difficult, but frequently the diagnosis can be made by excretory urography or analysis of aspirated fluid. Aspiration is preferably done during scanning, since the best location for puncture can be identified; a small (20 gauge) needle can be inserted directly into the space and a sample of the fluid removed. If necessary, contrast medium can be injected at this time to outline the extent of the fluid collection on radiographs (Fig. 2). The diagnosis of an abscess is gen~rally easier, be-
June 1976
cause there are frequently septa within the abscess; because of edema around the lesion, the borders are not as sharp as those found in Iymphoceles or hematomas. Department of Radiology University of Utah Medical Center Salt Lake City, Utah 84132
REFERENCES 1. Bartrum RJ Jr, Smith EH, D'Orsi CJ, et al: The ultrasonic determination of renal transplant volume. J Clin Ultrasound 2:281-285, 1974 2. Christiansen L, Nerstrom B: Perirenal lymph accumulation: a complication of kidney transplantation. Scan JUral Nephrol 8: 245-247, 1974 3. Diethelm AG: Anuria secondary to perirenal Iymphocele: a complication of renal transplantation. South Med J 65:350-352, Mar 1972 4. Inocencio NF, Pierce JM Jr, Rosenberg JC, et al: Renal allograft with massive perirenal accumulation of lymph. Br Med J 3: 452-453, 23 Aug 1969 5. Koehler PR, Kyaw MM: Lymphatic complications following renal transplantation. Radiology 102:539-543, Mar 1972 6. Leopold GR: Renal transplant size measured by reflected ultrasound. Radiology 95:687-689, Jun 1970 7. Pillay VKG, Ing TS, Armbruster KW, et al: Lymphocyst totlowi~g renal transplantation. Can Med Assoc 105:1066, 20 Nov 1971 8. Rashid A. Posen G, Couture R, et al: Accumulation of lymph around the transplanted kidney (Iymphocele) mimicking renal allograft rejection. J UroI111:145-147, Feb 1974 9. Sampson D, Winterberger AR, Murphy GP: Lymphoceles complicating renal allotransplantation. NY State J Mad 73:2710-2713, 15 Nov 1973 10. Schweizer R, Cho S, Kountz SL, et al: Lymphoceles following renal transplantation. Arch Surg 104:42-45, Jan 1972 11. Turcotte JG: Infection and renal transplantation. Surg Clin North Am 52:1501-1512, Dec 1972 12. Winterberger AR, Palma LD, Murphy GP: Ultrasonic testing in human renal allografts. JAMA 219:475-479,24 Jan 1972
