Renal artery stenosis after renal transplantation

Restoration of failed renal graft function after successful angioplasty of pressure-resistant renal artery stenosis using a cutting balloon: a case report

This study is the report of a 37-year-old male with a transplanted kidney from a 3.5-year-old donor: the graft had two arteries transplanted with an aortic patch to an external iliac artery. Four months after transplantation, the graft function deteriorated, together with the development of hypertension. Stenosis of both graft arteries was detected and the patient was referred for angioplasty. The angiographic result was suboptimal, nevertheless, the graft function improved and was more or less stable (serum creatinine, 160-200 micromol/l) for 4 years, along with persistently difficult-to-control hypertension. Five years after transplantation, the graft function deteriorated again and severe graft artery restenosis was detected. The restenosis did not respond to dilatation, graft function failed, hypertension decompensated, and left ventricular failure developed. The patient required dialysis. A cutting balloon angioplasty opened the artery, and kidney function was restored after a few days: the serum creatinine level dropped to 140-160 micromol/l, and the glomerular filtration rate (creatinine clearance) to 0.65 ml/min/1.73 m(2). The graft function has now been stable for more than 2 years, however, the hypertension is still difficult to control.

Long-term follow-up of renal transplant patients with renal artery stenosis treated by percutaneous angioplasty

PURPOSE OF THE STUDY

To evaluate if renal angioplasty (PTRA) in patients with transplanted kidney and renal artery stenosis (TRAS) can have long-term effect on hypertension and renal function.

MATERIALS AND METHODS

Within a 24-year time period, 58 PTRAs in 55 adults (three times Re-PTRA) with transplanted kidney were performed. The group included 34 males and 21 females, average age 41+/-10.6 (18-72) years. After exclusion of 7 technical failures, 51 PTRAs were followed at 1 week, 6 months and 1-3 years after PTRA. Hypertension improvement was defined as mean arterial pressure (MAP) decrease of at least 15% from the pre-PTRA value. Graft function was evaluated by serum creatinine (Scr) and creatinine clearance (Ccr) levels, and the improvement was defined as a 20% change. Clinical FU was 3 years.

RESULTS

PTRA technical success was 88.4%. In 51 kidney recipients at the end of FU, blood pressure improved in 65.2% of patients (MAP decreased from 123+/-13.1 to 107+/-12.1 mmHg), but no patient remained normotensive medication free. Graft function improved in 44.8% of patients and was stabilized in 20.7% of them (average Ccr before PTRA: 0.48+/-0.29, after PTRA: 0.78+/-47 ml/s). PTRA complications were observed in 25.5% of procedures, most often with no clinical sequel. Thirty days mortality was 1.8% (one patient).

CONCLUSIONS

PTRA results in kidney recipients are valuable mainly in preserving graft function.

Recommendations for the outpatient surveillance of renal transplant recipients. American Society of Transplantation

Many complications after renal transplantation can be prevented if they are detected early. Guidelines have been developed for the prevention of diseases in the general population, but there are no comprehensive guidelines for the prevention of diseases and complications after renal transplantation. Therefore, the Clinical Practice Guidelines Committee of the American Society of Transplantation developed these guidelines to help physicians and other health care workers provide optimal care for renal transplant recipients. The guidelines are also intended to indirectly help patients receive the access to care that they need to ensure long-term allograft survival, by attempting to systematically define what that care encompasses. The guidelines are applicable to all adult and pediatric renal transplant recipients, and they cover the outpatient screening for and prevention of diseases and complications that commonly occur after renal transplantation. They do not cover the diagnosis and treatment of diseases and complications after they become manifest, and they do not cover the pretransplant evaluation of renal transplant candidates. The guidelines are comprehensive, but they do not pretend to cover every aspect of care. As much as possible, the guidelines are evidence-based, and each recommendation has been given a subjective grade to indicate the strength of evidence that supports the recommendation. It is hoped that these guidelines will provide a framework for additional discussion and research that will improve the care of renal transplant recipients.

Post-transplant renal artery stenosis: impact of therapy on long-term kidney function and blood pressure control

PURPOSE

We assessed the long-term outcome of different treatment methods for transplant renal artery stenosis.

MATERIALS AND METHODS

Outcome data for 23 patients with transplant renal artery stenosis treated during a 16-year period were reviewed and analyzed.

RESULTS

There was a higher incidence of renal artery stenosis in cadaveric donor kidneys compared to living donor kidneys (2% versus 0.3%, p < 0.02), and in cadaveric kidneys from pediatric donors less than 5 years old compared to those from adults (13.2% versus 1.3%, p < 0.01). Six patients underwent primary medical treatment for renal artery stenosis, with a successful outcome in 4 (mean followup plus or minus standard error 57 +/- 22 months) and failure in 2. Of the patients 16 were treated with percutaneous transluminal angioplasty, including 12 who were cured or improved with respect to hypertension (followup 44.7 +/- 7.6 months). Five patients underwent surgical revascularization for renal artery stenosis with postoperative improvement of hypertension (followup 18.8 +/- 11.6 months). Overall, 21 of 23 patients (91%) were treated successfully for transplant renal artery stenosis with cure or improvement of associated hypertension. Posttreatment renal function was stable or improved in 18 patients, while renal function deteriorated due to parenchymal disease in 3.

CONCLUSIONS

Most patients with transplant renal artery stenosis can be treated successfully. Percutaneous transluminal angioplasty is the initial interventive treatment of choice for high grade renal artery stenosis. Surgical revascularization is indicated if percutaneous transluminal angioplasty cannot be done or is unsuccessful.

Aortoiliac surgery in renal transplant patients

Fifteen patients who had undergone renal transplantation 3 months to 25 years earlier were operated on for treatment of complicated aortoiliac atherosclerosis; eight had aneurysms and seven had stenotic or obstructive lesions. Except for the first patient, operated on in 1973, in whom the kidney was protected by general hypothermia, no special measure was used to protect the kidneys. A transient increase in creatinemia occurred in 11 patients during the postoperative period, whereas creatinine values remained unchanged in the other four. All patients had regained renal function identical to the + preoperative state in less than 10 days; three of them had significant improvement as a result of correction of a lesion that was impairing renal blood flow. Results obtained in this series show that protection of the transplant during aortic surgery is not necessary, provided an adequate surgical technique is used. This technique avoids the complex methods employed in the majority of previously reported cases and appears to be a safe procedure.