A Decade Long Struggle: A Young Man's Journey From Renal Transplant to Fatal Refractory Ascites

This case details the clinical course of a 33-year-old man with a history of living with an unrelated renal transplant, who presented with recurrent, massive ascites to be drained every two to three weeks for two years. His post-transplant course was also complicated by chronic antibody-mediated rejection, evidenced by a terminal increase in serum creatinine and a decrease in estimated glomerular filtration rate. Cross-sectional imaging revealed complete obliteration of his central veins and a hypertrophied, edematous transplant kidney anastomosed to the common iliac artery. These findings, in the absence of cirrhosis or cardiac failure, pointed towards renal lymphangiectasia as a consequence of venous outflow obstruction and possible iatrogenic lymphatic injury as the cause of his refractory ascites. This case reinforces the critical role of venous and lymphatic pathology in the differential diagnosis of post-transplant ascites and demonstrates how a multifactorial interaction can lead to a disastrous clinical scenario.