Late-onset renal vein thrombosis: A case report and review of the literature

Pharmarcomechanical thrombectomy combined with transluminal balloon angioplasty for treating transplant renal vein thrombosis

Renal vein thrombosis (RVT) is a rare vascular complication that occurs after renal transplantation and usually results in irreversible kidney damage and graft loss. We report the case of a patient who underwent right iliac fossa allogeneic kidney transplantation and developed RVT combined with ipsilateral thrombosis from the popliteal to the femoral veins, with extension to the common iliac veins, 4 months after transplantation. Under unfractionated heparin anticoagulation, an Aegisy (Life Tech Scientific Co., Ltd., Shenzhen, China) vena cava filter was placed to prevent pulmonary embolism. Percutaneous mechanical thrombectomy combined with balloon angioplasty was performed to aspirate the thrombus and successfully dilate the narrow venous lumen. The patient's renal function was restored postoperatively. Ultrasonography showed the allograft and ipsilateral lower extremity deep veins to be fluent and patent. To conclude, in patients with RVT after renal transplantation, percutaneous mechanical thrombectomy in conjunction with balloon angioplasty can be performed with desirable outcomes and no severe adverse effects. This method reduces the risk of bleeding from exposure to systemic intravenous thrombolysis and avoids surgery-associated trauma.

Compliance Issues in Managing 21 Hydroxylase Deficiency and their Short/Long-Term Consequences

Objective

To report a case of untreated classic 21 hydroxylase (OH) deficiency congenital adrenal hyperplasia (CAH) in a transgender patient resulting in pulmonary embolisms (PEs) and bilateral adrenal masses.

Methods

A 36-year-old male (birth sex: female) presenting with bilateral PEs in the setting of long-standing, untreated classic 21OH CAH was also found to have bilateral adrenal masses (unconfirmed myelolipomas).

Results

Further history revealed a known diagnosis of CAH. The patient had been treated with glucocorticoid and mineralocorticoid replacement in childhood but stopped taking these medications against medical advice. During his hospital admission, he was noted to have elevated 17-hydroxyprogesterone, low cortisol with elevated ACTH levels, and male-level testosterone measurements. CT of the abdomen/pelvis revealed a 23 cm mass in the left renal fossa and a 2.5 cm mass in the right renal fossa consistent with bilateral adrenal myelolipomas. The patient attended follow-up in clinic, but declined any further hormonal treatment as he identified as male and felt further treatment was unnecessary.

Conclusion

This case demonstrated the unique long-term effects of untreated classic CAH due to 21OH deficiency, including bilateral adrenal myelolipoma, adrenal compensation to the point of producing male-level androgens, and possibly PEs. Treatment with hydrocortisone was recommended to suppress ACTH and it was planned that the patient would eventually start on testosterone (although this would have been complicated by his bilateral PEs). Potential aetiologies for the PEs included vascular compression of the renal artery (which could explain the elevated EPO/erythrocytosis contributing to hypercoagulability) or the renal vein by the adrenal mass.

LEARNING POINTS

Strangulation of intraperitoneal kidney transplant by fallopian tube

Renal allograft strangulation is a rare complication following simultaneous kidney pancreas transplant, often causing graft loss. This case report represents the first documented case of a 35-year-old female who developed renal graft strangulation around the left fallopian tube. Our case outlines a new complication that contributes to graft loss concerning iliac fossa anatomy and variations in female patients, as well as surgical considerations that need to be made prior to transplantation. We recommend measurement of the grafted renal vessels within the iliac fossa and respective surroundings structures to allow for the ideal positioning of the grafted organ.

Transplant renal artery and vein occlusion evaluated with ferumoxytol-enhanced magnetic resonance angiography

BACKGROUND

Compromise of the transplanted vasculature accompanying a kidney allograft can lead to graft failure if not diagnosed and treated expeditiously. Location of the vascular defect in the transplant renal artery or vein is difficult to anticipate, given the variety of etiologies. However, early diagnosis can anticipate further progression of kidney allograft dysfunction. Ferumoxytol-enhanced magnetic resonance angiography (FeMRA) can precisely localize lesions in both the transplant renal artery and vein and provide a comprehensive survey of the vascular conduits of concern. It avoids complications of kidney injury associated with intravenous iodinated contrast that may amplify a diagnosis of delayed graft function or further impair an allograft already compromised by donor-derived vascular disease.

METHODS

We report a case of concomitant and irreversible proximal transplant renal artery and vein stenosis diagnosed by FeMRA and treated with surgical intervention.

RESULTS AND CONCLUSIONS

FeMRA offers a rapid, non-invasive approach to simultaneously diagnose compromised blood flow through the transplant artery and or vein in preparation for definitive correction of the defect.

Lethal Renal Venous Thrombosis Complicating Dehydration in Infancy

A 3-month-old boy presented to hospital in cardiac arrest, dehydrated, with a blood sodium of 158.4 mmol/L. He had been febrile, not feeding normally and refusing fluids. Despite attempts at resuscitation with rehydration, he was declared dead. At autopsy, the kidneys were uniformly enlarged with thrombi within intraparenchymal tributaries of the renal veins bilaterally. Death was due to bilateral renal venous system thrombosis with hypernatremic dehydration. It is likely that the dehydration resulted both from increased requirements for fluid due to fever and from inadequate oral intake. Lethal renal venous thrombosis is a rare multifactorial condition that should be suspected in all infants with histories of hypernatremic dehydration with hypotension. Although there may be no obvious renal vein thrombosis at the time of dissection, microscopy may reveal intraparenchymal venous thromboses. As inherited prothrombotic states are associated with renal venous thrombosis, hematologic evaluation of immediate family members would be in order.

Transplant renal vein thrombosis in a recipient with aberrant venous anatomy

Renal vein thrombosis in a transplanted kidney is an uncommon but critical complication that can result in graft loss if management is delayed. A 31-year-old male with known atresia of the inferior vena cava who received a deceased donor renal transplant 7 years previously presented to hospital with severe graft site pain and a week of nausea, vomiting, and chills. Serum creatinine was markedly elevated from baseline. Sonographic examination revealed external iliac vein thrombosis with extension of the thrombus into the transplant renal vein. Urgent angiographic administration of tissue plasminogen activator and suction thrombectomy was performed, then followed by heparin and clopidogrel post procedure. Within 24 h, his serum creatinine improved, and within 2 weeks returned to his baseline. He was started on lifelong warfarin anti-coagulation to reduce the risk of rethrombosis secondary to his uncorrectable aberrant venous anatomy. Due to the turbulent and sometimes reversed flow in the major veins, lifelong anticoagulation should be strongly considered for such transplant patients with recipient aberrancy of the large veins.