Subcapsular hematoma after kidney transplant may result in kidney ischemia and graft loss. In this report, we present a 38 years old male patient who had post-transplant ATN complicated a subcapsular hematoma just after surgery. He had end stage renal disease secondary to chronic glomerulonephritis (hypertension, proteinuria and bilateral atrophic kidneys in abdominal ultra sound (US). He had a living-donor kidney transplant from hissister. At perfusion, there was smalldecapsulatedarea in the lower pole of the transplanted kidney. Capsulotomy was not performed due to possible risks and transplant surgery was completed. After declamping, appropriate renal perfusion and urine output were observed. Early few hours after surgery, decreasedin urine output was observed. Renal Doppler ultrasonography showed decreased diastolic flow and perigraft hematoma about 200ccand resistive index (RI) 0.9 initially that increase to 1 in serial successive Dopplers. The surgical drain is hemorrhagic leading to marked decrease in hemoglobin level that necessitatedto transfuse four units of filtered irradiated RBCS. The plan by surgeon to conserve,so renal biopsy was done revealed moderate ATN. He underwent re-exploration on day 11 due to infected hemorrhagic , huge amount drain fluid (culture and sensitivity from it MARSA), that revealed most of the renal parenchyma was compressed with marked stretching capsule due to subscapular hematoma, the plan to release it by slight dissection of capsule at different directions but not to evacuate it completely for possible bleeding. After surgery, urinary flow increased, renal Doppler ultrasonography findings and renal function gradually improved.
