Vascular torsion in a renal allograft after placement in the retroperitoneum is rare and has only been reported twice in the literature. It is an extrinsically mediated process that occurs at the vascular pedicle resulting in graft compromise and potential loss. Rapid diagnosis and immediate surgical intervention may salvage allograft function. Herein, we present a unique case of a 42-year-old male that developed renal allograft torsion following a second kidney transplant placed in the retroperitoneum. Immediate detorsion did not resolve allograft dysfunction, and a biopsy revealed acute cellular mediated rejection. After antithymocyte globulin treatment, allograft function was salvaged. A review of the current literature shows that the incidence, morbidity, and long term allograft function of intraperitoneal and extraperitoneal torsion are different. As such, torsion of the retroperitoneal kidney demonstrates encouraging allograft salvage rates. Only the third case reported to date, this serves as a contribution to the growing body of literature in retroperitoneal renal torsion and reviews the risks, medication considerations, diagnostic tests, and treatment modalities in a unique disease process. 1. Introduction Commonly reported short-term complications following kidney transplant include postoperative hemorrhage, thrombosis, urine leak, ureteral stricture, and acute rejection [1, 2]. Thrombosis can occur from intrinsic mediators or extrinsic factors that compromise vascular inflow or outflow [3]. Vascular torsion is an extrinsically mediated, rare, and potentially reversible complication that occurs at the vascular pedicle resulting in graft compromise and/or loss. Rapid diagnosis and immediate surgical intervention may salvage allograft function. However, a delay in diagnosis increases the risk of acute rejection or frank necrosis sometimes requiring transplant nephrectomy [4, 5]. Herein, we present a case complicated by renal torsion and subsequent acute rejection. Early recognition and treatment of both complications allowed for successful salvage of the graft. This case serves as only the third report of renal hilar torsion in retroperitoneal placement of a kidney allograft [6, 7]. 2. Case Report A 42-year-old male with hemodialysis-dependent (HD), end stage renal disease (ESRD) underwent a second deceased donor kidney transplant (DDKT). His past medical history included glomerulonephritis, the etiology of his ESRD, for which he underwent an initial DDKT at the age of 30. Following this first transplant, the patient was diagnosed with
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