Early graft dysfunction following kidney transplantation is commonly attributed to hypoperfusion, rejection, or urological or vascular complications. Venous congestion as a primary mechanism of renal dysfunction remains under-recognized. We report a case of early post-transplant graft dysfunction caused by superior vena cava (SVC) thrombosis–induced congestive nephropathy.

A 32-year-old woman with end-stage kidney disease underwent living donor kidney transplantation after prolonged hemodialysis via a tunneled internal jugular catheter. Despite satisfactory immediate diuresis, she developed progressive oliguria within 12 hours of transplant surgery. Hemodynamics were stable, and Doppler ultrasonography showed patent graft vessels but markedly elevated intrarenal resistive indices with absent end-diastolic flow. She subsequently developed facial and neck edema suggestive of SVC syndrome. Imaging revealed chronic SVC thrombosis with extensive collateralization. Renal allograft biopsy showed features of venous congestion without evidence of rejection.

Initial conservative decongestive therapy led to partial improvement, but definitive endovascular SVC stenting resulted in rapid diuresis, normalization of intrarenal Doppler parameters, and sustained graft recovery.

This case highlights congestive nephropathy as a reversible and often overlooked cause of early graft dysfunction and underscores the importance of considering central venous obstruction in transplant recipients with prior long-term central venous catheter exposure.