Dear Editor, We read with interest the recently published case report titled “Page Kidney: A Cause of Acute Renal Allograft Dysfunction.”1 The authors are to be commended for emphasizing the importance of early recognition and timely management of graft compression in the immediate post-transplant period. However, a few clarifications may enhance the interpretability and educational value of the report. The patient is described as having end-stage renal disease; however, baseline preoperative blood pressure values and details of pre-transplant antihypertensive therapy are not provided. This information would be helpful in determining whether the postoperative hypertension represented a new-onset phenomenon or progression of pre-existing disease. In addition, initiating an angiotensin-converting enzyme (ACE) inhibitor in the setting of an acute rise in serum creatinine (from 2.1 to 4.6 mg/dL) is generally approached with caution in renal transplant recipients, particularly before structural or vascular causes of graft dysfunction have been excluded. In the setting of acute graft dysfunction, ACE inhibitor–induced efferent arteriolar dilation may further reduce intraglomerular pressure and glomerular filtration rate, resulting in a rise in serum creatinine and potentially confounding diagnostic assessment.2 While the authors highlight the rarity of the condition, it is worth noting that subcapsular or peri-graft hematoma is a recognized and relatively common postoperative complication, particularly following post-graft biopsy in high-volume renal transplant units. The resulting graft compression, hypertension, hemoglobin decline, and oliguria represent a well-described clinical scenario rather than an exceptional clinical entity. Such cases are often identified early and managed as part of standard postoperative care, without necessarily invoking the eponym “Page kidney.” In high-volume centers, clinically significant hematomas are reported in approximately 1%–4% of cases in the immediate postoperative period.3 However, these collections are notably more frequent as a post-procedural finding following percutaneous allograft biopsy. While major hemorrhage is rare (1%–3.5%), surveillance imaging detects subclinical hematomas in up to 60%–85% of patients following the procedure.4 Following ultrasonographic detection of a perinephric or subcapsular hematoma, contrast-enhanced computed tomography (CECT) is recommended to evaluate for active contrast extravasation and to localize the potential bleeding source. Anticipating and excluding active bleeding preoperatively helps prevent unexpected intraoperative bleeding. When CECT demonstrates a contrast blush suggestive of active arterial bleeding, selective angioembolization may be performed before surgical exploration to secure the culprit vessel. In the absence of arterial blush or demonstrable vascular injury on CECT, the hematoma is more likely to be stable, and surgical evacuation, if indicated for compression, can be undertaken in a more controlled and predictable manner. Nevertheless, the report reinforces the importance of vigilance in the early postoperative period and timely intervention to preserve graft function and optimize outcomes. Sincerely, Financial support and sponsorship: Nil. Conflicts of interest: There are no conflicts of interest.
Thakare et al. (Fri,) studied this question.