Arterial rupture as the result of fungal arteritis after renal transplantation

Carbapenem-resistant Klebsiella pneumoniae infection causing rupture of graft artery in solid organ recipients: Case report and review of literature

RATIONALE

Donor-derived bacterial infection is a rare cause of morbidity after solid organ transplantation (SOT) but associated with significant morbidity and mortality, deaths caused by carbapenem-resistant Klebsiella pneumoniae (CRKP) infection account for a considerable proportion of postoperation mortality rate in liver and kidney recipients. The arterial rupture as a result of fungal arteritis is occasionally described, while the rupture of graft vascular anastomosis after SOT due to donor-derived CRKP infection is rarely reported.

PATIENTS CONCERNS

We reported 1 patient with donor-derived CRKP infection following liver transplantation and 2 patients following renal transplantation (1 liver and 2 kidneys were from the same donor), who experienced sudden abdominal pain and abdominal hemorrhage almost at the same time after organ transplantation.

DIAGNOSIS

The patients were diagnosed as graft arteries rupture due to corrosion caused by CRKP infection based on computed tomography scan, blood culture, laparotomy, and pulse-field gel electrophoresis.

INTERVENTIONS

Anti-shock treatment, exploratory laparotomy, broad-spectrum antibiotics, and abdominal puncture and drainage were given.

OUTCOMES

The liver recipient survived as well as the liver graft, still under treatment of multiple abdominal infections. The 2 renal recipients were alive after resection of the renal grafts and underwent hemodialysis.

LESSONS

Rupture of graft artery should be foreseen when donor-derived CRKP infection was confirmed and broad-spectrum antibiotics and other interventions need to be considered.

Successful repair of kidney graft artery rupture secondary to infection using a preprocessed homologous "Y"-shaped iliac artery

Objectives

This retrospective study aims to describe novel ways of repair kidney allograft artery rupture secondary to infection using a preprocessed homologous “Y”‐shaped iliac artery.

Methods

Five patients' whose course was complicated by graft arterial rupture were included in the rupture group, and patients who received the kidney from the same donor were included in the control group. In the rupture group, the iliac artery used for revascularization was harvested from a DCD donor, pre‐treated with absolute diethyl ether, followed by absolute alcohol, and then preserved in 75% alcohol. A biopsy of the arterial graft was obtained and stained using hematoxylin and eosin (H&E). Once a patient was diagnosed with kidney allograft arterial rupture by ultrasound, emergency surgery was conducted and the preprocessed “Y”‐shaped iliac artery was used for bridging.

Results

Five patents were included in the rupture group. The “Y”‐shaped iliac artery grafts were successfully preprocessed, H&E staining and electron microscope observation revealed few visible nuclei, with karyorrhexis and karyolysis. There were no significant differences in the long‐term graft survival between two groups.

Conclusions

In conclusion, using preprocessed homologous “Y”‐shaped iliac artery provides a useful method to bridge the vascular defects from kidney graft artery rupture secondary to infection in renal allograft recipients.

Fifty-one cases of fungal arteritis after kidney transplantation: A case report and review of the literature

Fungal arteritis affecting graft arteries is a rare but life-threatening complication in kidney transplantation (KT). Here, we report the case of a patient with Aspergillus arteritis who experienced renal artery rupture 8 days after KT. We also reviewed 50 other reported cases of fungal arteritis after KT. We found that fungal contamination can occur during kidney graft harvest, preservation, and/or transplantation. Typically, early diagnosis, timely antifungal treatment, and emergency surgery seem crucial for avoiding life-threatening vascular complications.

Trichosporon fungal arteritis causing rupture of vascular anastamosis after commercial kidney transplantation: a case report and review of literature

This is a case report of a ruptured vascular anastomosis resulting from fungal arteritis in a commercial renal transplantation. The diagnosis was made quite early posttransplantation (at the 18th posttransplant day); this was proved by histopathologic examination and culture of the vessel wall,which showed Trichosporon fungal infection. The patient underwent operation for control of the bleeding and removal of the graft and of the diseased iliac vascular segment. On reviewing the literature, we found 17 reports of fungal arteritis in solid-organ transplant recipients; our case was the first one to report Trichosporon species as the causative agent. Infection could result from surgical or graft contamination or from preexistent infection in the patient. There is a consensus that the standard of care should include removal of the graft and the diseased iliac vascular segment with an appropriate vascular graft, because simple suturing of the disrupted infected anastomosis generally ends with disastrous recurrent rupture. A high index of suspicion is required to ensure both early diagnosis and appropriate treatment to prevent tragic loss of recipient life.

Use of autogenous internal iliac artery for bridging the external iliac artery after excision of Aspergillus mycotic aneurysm in renal transplant recipients

Repair of vascular defects in the presence of infection remains a challenging task in immunocompromised patients. We report two patients with postrenal transplant Aspergillus mycotic aneurysms of the allograft renal artery involving the external iliac artery which were excised along with the allograft. The defect in the external iliac artery was repaired successfully with interposition of autogenous internal iliac artery graft. Use of an internal iliac artery graft in such settings has been rarely reported in English literature. Autogenous internal iliac artery grafts provide a useful method to bridge the vascular defects created by radical debridement in the presence of fungal infections.

Disseminate fungal infection after acute pancreatitis in a simultaneous pancreas-kidney recipient

Fungal infections after kidney transplantation are a major cause of morbidity and mortality, and Candida infection of the pancreas is considered an infrequent but important agent in necrotizing pancreatitis. We report the case of a 43-year-old Caucasian patient who underwent simultaneous pancreas-kidney transplantation because of diabetes type I, and chronic renal failure with peritoneal dialysis. The postoperative course was complicated by acute pancreatitis due to the thrombosis of the splenic artery of the graft, the subsequent acute rupture of the external iliac artery caused by fungal arteritis (Candida glabrata), and peritonitis a few days later caused by sigmoid perforation with detection of Candida glabrata infection of the resected intestinal tract. The present case remarks that awareness and prevention of fungal infection are major issues in the transplant field. Important information can be added by systematic culture of conservation perfusates but, probably, the best way for early recognition of a critical level of infectious risk remains the routine application of the colonization index screening. In cases of positive results, preemptive antifungal therapy could be warranted.