1
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Fang Y, Hamm JJ, den Hartog FP, Kimenai HJ, de Bruin RW, Minnee RC. Safety and efficacy of kidney transplantation in patients with aortoiliac stenosis: a retrospective cohort study. Int J Surg 2024; 110:992-999. [PMID: 38016127 PMCID: PMC10871560 DOI: 10.1097/js9.0000000000000926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 11/09/2023] [Indexed: 11/30/2023]
Abstract
BACKGROUND The impact of aortoiliac occlusive disease on kidney transplantation remains unclear. This study aims to investigate the clinical outcomes of kidney transplant patients with aortoiliac atherosclerotic stenosis. METHODS Retrospective data from our transplant center were used to identify patients undergoing kidney transplantation between January 2010 and December 2020. Aortoiliac atherosclerotic stenosis was screened and stratified by the Trans-Atlantic Inter-Society Consensus (TASC) II classification. The primary outcome was patient survival. Secondary outcomes were 90-day mortality, death-censored graft survival, graft function, and arterial complications. Propensity score matching was used to match all patients in the stenosis group with patients without stenosis sharing similar characteristics. RESULTS The analysis included 655 patients, 524 without stenosis and 131 with aortoiliac stenosis (95 with TASC A/B stenosis and 36 with TASC C/D stenosis). Recipient age [median (IQR), 66 (60-70) vs. 66 (59-71) years; P =0.47], sex [male: 87 (66%) vs. 355 (68%), P =0.85], and comorbidities were comparable between the stenosis and no-stenosis groups. Forty-six (35%) patients with stenosis were symptomatic. Patient survival was significantly lower in the stenosis group compared with the no-stenosis group (TASC A/B: 30.6% vs. no-stenosis: 44.1%, P =0.013; TASC C/D: 11.4% vs. no-stenosis: 44.1%, P <0.001). The incidence rates of artery dissection, lower extremity ischemia, and acute thrombosis were significantly higher in the stenosis group ( P <0.001). However, death-censored graft survival (TASC A/B: 73.6% vs. no-stenosis: 72.9%, P =0.62; TASC C/D: 58.1% vs. no-stenosis: 72.9%, P =0.16) and graft function were comparable between the groups. CONCLUSIONS Aortoiliac atherosclerotic stenosis significantly impacts patient survival but not graft survival. Our analyses suggest that patients with TASC A/B stenosis have prolonged survival and enhanced quality of life through kidney transplantation. However, for patients with TASC C/D stenosis, kidney transplantation improves quality of life without bringing survival benefits.
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Affiliation(s)
- Yitian Fang
- Erasmus MC Transplant Institute, Department of Surgery, Division of HPB and Transplant Surgery
| | - Julie J.M. Hamm
- Erasmus MC Transplant Institute, Department of Surgery, Division of HPB and Transplant Surgery
| | | | | | - Ron W.F. de Bruin
- Erasmus MC Transplant Institute, Department of Surgery, Division of HPB and Transplant Surgery
| | - Robert C. Minnee
- Erasmus MC Transplant Institute, Department of Surgery, Division of HPB and Transplant Surgery
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2
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Nishimura Y, Khan M, Lee B, Arayangkool C, Zhang J, Palanisamy A, Banerjee D, Izutsu C. Defining optimal blood pressure control for pre-transplant end-stage renal disease patients: scoping review. Blood Press Monit 2023; 28:316-321. [PMID: 37910025 DOI: 10.1097/mbp.0000000000000668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
BACKGROUND Strict blood pressure control is essential to prevent cardiovascular disease and is associated with decreased mortality. However, in patients with end-stage renal disease awaiting renal transplantation, the level of optimal blood pressure control is not yet defined. METHODS Following the PRISMA Extension for Scoping Reviews, we searched MEDLINE and EMBASE for all peer-reviewed articles using keywords including 'end-stage renal disease', 'blood pressure', and 'pre-transplant' from their inception to 7 August 2022. RESULTS Seven observational studies, including one population-based study, were included in the review. Most studies investigated factors associated with post-transplant graft failure or mortality. There was considerable heterogeneity in defining optimal pre-transplant blood pressure measurement frequency among studies (average of three measurements vs. single measurement). One study suggested that low pre-transplant diastolic blood pressure (<50 mmHg) was associated with lower odds of delayed graft failure and mortality. Two studies noted that pre-transplant hypertension, or clinical criteria of hypertension that were present prior to transplant, was associated with post-transplant adverse outcomes. In contrast, one study noted that pre-transplant sustained hypotension with mean blood pressure <80 mmHg, was associated with a higher frequency of delayed graft failure. CONCLUSION This systematic review summarizes the current evidence regarding the relationship between pre-transplant blood pressure control and post-transplant outcomes in end-stage renal disease patients. While the results from the included studies are mixed, more stringent blood pressure control than currently practiced may be beneficial to decrease graft failure and mortality in this patient population.
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Affiliation(s)
- Yoshito Nishimura
- Department of Medicine, John A. Burns School of Medicine, University of Hawai'i, Honolulu, Hawaii, USA
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3
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Madken M, Gotra A, Qazi S, Fairhead T, Burns KD. Successful Endovascular Management of Resistant Hypertension Post Kidney Transplant: A Case Report. Can J Kidney Health Dis 2022; 9:20543581221119896. [PMID: 36160314 PMCID: PMC9493670 DOI: 10.1177/20543581221119896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Indexed: 11/18/2022] Open
Abstract
Rationale: Transplant renal artery stenosis (TRAS) is a well-recognized and potentially reversible
cause of resistant hypertension post transplantation and can affect 1% to 23% of
recipients. Stenosis of the iliac segment proximal to the transplant renal artery
(proximal TRAS) causing dysfunction of the transplanted kidney is less common with
reported incidence of 2% to 3%. Presentation typically occurs between 3 months and 2
years post transplant but may happen at any time. Noninvasive investigations such as
Doppler ultrasound, computed tomography (CT) angiogram, and magnetic resonance angiogram
are useful in initial evaluation, but definitive diagnosis of hemodynamically
significant stenosis often requires formal angiogram. Transplant renal artery stenosis
should be suspected in any kidney transplant recipient with worsening hypertension
and/or deterioration in kidney function which is otherwise unexplained. We present the
case of a kidney transplant recipient with resistant hypertension and impaired graft
function, secondary to severe impairment of graft blood flow from proximal iliac system
occlusion. Presenting concerns of the patient: A 74-year-old female 15 years post live donor kidney transplant presented with graft
dysfunction (serum Cr 229 μmol/L) and resistant hypertension, requiring use of 8
antihypertensive medications. On physical examination, blood pressure was 160/92 mm Hg
with no tenderness over the renal graft in the right lower abdominal quadrant and no
audible bruit in kidney allograft area. Diagnosis: Transplant Doppler ultrasound showed reversal of flow in the right external iliac
artery suggestive of ipsilateral proximal iliac occlusion. Pre-procedure CT demonstrated
severe atherosclerotic burden within the aorta and bilateral iliac systems. The
anastomosed right renal artery appeared patent. Interventions: Conventional angiogram showed occlusion of the right common and proximal external iliac
arteries with retrograde perfusion of the transplant kidney via the contralateral left
iliac system and aorta. Subintimal recanalization of the right iliac system was
performed with angioplasty and kissing stent placement at the aortic bifurcation with
stents extending into the proximal right external iliac artery. Post deployment
angiogram demonstrated renewed patency of the right iliac system, with restoration of
antegrade perfusion to the transplant kidney. Outcomes: The patient’s blood pressure decreased significantly after the procedure, with
improvement in graft function. After 6 months, the patient continued to have optimally
controlled blood pressure (on 3 medications) and stable graft function (serum Cr 74
μmol/L). Teaching points: Our case describes proximal TRAS and the contribution of renal hypoperfusion to
hypertension and impaired graft function, with the potential for reversibility.
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Affiliation(s)
- Mohit Madken
- Division of Nephrology, Department of Medicine, The Ottawa Hospital Research Institute, University of Ottawa, ON, Canada
| | - Akshat Gotra
- Division of Vascular & Interventional Radiology, Department of Medical Imaging, The Ottawa Hospital, University of Ottawa, ON, Canada
| | - Shakeel Qazi
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Todd Fairhead
- Division of Nephrology, Department of Medicine, The Ottawa Hospital Research Institute, University of Ottawa, ON, Canada
| | - Kevin D Burns
- Division of Nephrology, Department of Medicine, The Ottawa Hospital Research Institute, University of Ottawa, ON, Canada
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4
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Miyara SJ, Ortiz CC, Guevara S, Molmenti A, Tamayo-Enriquez G, Cho YM, Cagliani JA, Molinas J, Hayashida K, Shinozaki K, Takegawa R, Krishnasastry KV, Becker LB, Molmenti EP. Transplant Renal Artery Stenosis Revascularization: Common Distal External Iliac Bypass. Int J Angiol 2022; 31:131-133. [DOI: 10.1055/s-0040-1714663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
AbstractStenosis proximal to transplant renal artery anastomoses are complications leading to allograft dysfunction. This study was aimed to evaluate a novel surgical approach to renal allograft revascularization, taking into consideration the length of time elapsed since transplantation. We describe an arterial bypass using a polytetrafluoroethylene (PTFE) graft from the common iliac artery (proximal to the renal artery implantation) to the external iliac artery (distal to the renal artery implantation) that allows the adequate revascularization of both the transplant kidney, as well as the lower extremity. This technique provides several advantages when compared with previously described procedures to revascularize a transplanted kidney with an iliac artery stenosis proximal to the allograft implantation site. Benefits of this technique include (1) no need to repair the stenosis, (2) no need to take down and redo the arterial anastomosis, (3) no need to perform a dissection around the renal hilum of the transplanted kidney, (4) no requirement to address the anastomosis transfer, and (5) no need to perfuse the kidney with preservation fluid at the time of repair and/or (6) avoidance of potential injury to the renal parenchyma and/or hilum during dissections. Adequate perfusion of the organ, as well as of the lower extremity was verified by serial Doppler duplex ultrasound evaluations. Hence, we describe a novel revascularization technique in instances of kidney transplant and lower extremity ischemia.
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Affiliation(s)
- Santiago J. Miyara
- Department of Surgery, Northwell Health, Manhasset, New York, USA
- Department of Emergency Medicine, Northwell Health, Manhasset, New York, USA
- Elmezzi Graduate School of Molecular Medicine, Manhasset, New York, USA
- Feinstein Institutes for Medical Research, Manhasset, New York, USA
| | | | - Sara Guevara
- Department of Surgery, Northwell Health, Manhasset, New York, USA
| | - Alexia Molmenti
- Department of Surgery, Northwell Health, Manhasset, New York, USA
| | | | - Young Min Cho
- Department of Surgery, Northwell Health, Manhasset, New York, USA
| | - Joaquin A. Cagliani
- Department of Surgery, Northwell Health, Manhasset, New York, USA
- Elmezzi Graduate School of Molecular Medicine, Manhasset, New York, USA
| | - Jorge Molinas
- Department of Surgery, Northwell Health, Manhasset, New York, USA
| | - Kei Hayashida
- Department of Emergency Medicine, Northwell Health, Manhasset, New York, USA
- Feinstein Institutes for Medical Research, Manhasset, New York, USA
| | - Koichiro Shinozaki
- Department of Emergency Medicine, Northwell Health, Manhasset, New York, USA
- Feinstein Institutes for Medical Research, Manhasset, New York, USA
| | - Ryosuke Takegawa
- Department of Emergency Medicine, Northwell Health, Manhasset, New York, USA
- Feinstein Institutes for Medical Research, Manhasset, New York, USA
| | | | - Lance B. Becker
- Department of Emergency Medicine, Northwell Health, Manhasset, New York, USA
- Elmezzi Graduate School of Molecular Medicine, Manhasset, New York, USA
- Feinstein Institutes for Medical Research, Manhasset, New York, USA
| | - Ernesto P. Molmenti
- Department of Surgery, Northwell Health, Manhasset, New York, USA
- Department of Emergency Medicine, Northwell Health, Manhasset, New York, USA
- Feinstein Institutes for Medical Research, Manhasset, New York, USA
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5
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Natour AK, Al Adas Z, Nypaver T, Shepard A, Weaver M, Malinzak L, Patel A, Kabbani L. Rate of Ipsilateral Chronic Limb-Threatening Ischemia (CLTI) After Kidney Transplantation: A Retrospective Single-Center Study. Cureus 2022; 14:e25455. [PMID: 35774684 PMCID: PMC9239297 DOI: 10.7759/cureus.25455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/28/2022] [Indexed: 11/23/2022] Open
Abstract
Objective: To analyze whether the rate of lower extremity (LE) ischemia is higher on the ipsilateral side after kidney transplantation. Methods: Our institutional transplant database was retrospectively queried for all patients who received a kidney transplant and underwent subsequent LE revascularization or major limb amputations between January 2004 and July 2020. The one-sample binomial test was used to test whether the LE ipsilateral to the transplanted kidney was at higher risk of peripheral arterial disease (PAD) complications necessitating intervention (major amputation or revascularization). Results: There were 1,964 patients who received a kidney transplant during the study period. Of these, 51 patients (3%) had subsequent LE arterial revascularizations or major amputations. The mean age was 58 ± 10 years, and 37 patients (73%) were male. A total of 33 patients had ipsilateral LE vascular interventions (26 major amputations and seven revascularizations) while 18 patients had contralateral vascular interventions (14 major amputations and four revascularizations) (P = 0.049). The average interval between transplantation and subsequent vascular intervention was 52 months for the ipsilateral intervention group and 41 months for the contralateral intervention group (P = 0.33). Conclusions: In patients who received kidney transplantation and required subsequent LE surgical intervention, we observed an association between the side of transplantation and the risk of future ipsilateral LE arterial insufficiency. Further studies are needed to determine the etiology of this association.
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6
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Ortiz CC, Miyara SJ, Cagliani JA, Cho YM, Guevara S, Hayashida K, Shinozaki K, Clement D, Becker LB, Wang B, Krishnasastry KV, Teperman LW, Molmenti EP. Renal Transplant Artery Inflow Stenosis Treated with Femorofemoral Bypass. Int J Angiol 2020; 30:310-312. [PMID: 34849111 DOI: 10.1055/s-0040-1709502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
In this case report we describe a novel and successful revascularization approach in instances of allograft and distal limb ischemia after kidney transplantation. Stenosis proximal to transplant renal artery anastomoses is a complication leading to allograft dysfunction and/or loss. We present a femorofemoral bypass graft with ringed polytetrafluoroethylene (PTFE). In this occasion, revascularization was achieved by a backflow mechanism. The approach described achieved its goal of revascularizing the allograft as well as the distal extremity, with both short- and long-term successful outcomes. Benefits of this approach when compared with re-implantation or procedures directly involving the transplant renal artery include minimization of ischemic time, no need to repair the stenosis, anastomoses with vessels of greater diameter, no need to perfuse the kidney, no need to take down the renal artery anastomosis, no need to dissect the transplanted kidney, and no further lower extremity ischemia. This approach does not require any proximal temporary inflow occlusion (as seen with stent placement) or clamping of the arterial inflow to the kidney. This procedure was completed without having to infuse any preservation fluid into the kidney.
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Affiliation(s)
| | - Santiago J Miyara
- Department of Surgery, Northwell Health, Manhasset, New York.,Department of Emergency Medicine, Northwell Health, Manhasset, New York.,Elmezzi Graduate School of Molecular Medicine, Manhasset, New York
| | | | - Young Min Cho
- Department of Surgery, Northwell Health, Manhasset, New York
| | - Sara Guevara
- Department of Surgery, Northwell Health, Manhasset, New York
| | - Kei Hayashida
- Department of Emergency Medicine, Northwell Health, Manhasset, New York
| | | | - Damian Clement
- Department of Surgery, Northwell Health, Manhasset, New York
| | - Lance B Becker
- Department of Emergency Medicine, Northwell Health, Manhasset, New York.,Elmezzi Graduate School of Molecular Medicine, Manhasset, New York
| | - Bo Wang
- Department of Surgery, Northwell Health, Manhasset, New York
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7
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OHE H. Aortoiliac Occlusive Disease as a Cause of Allograft Kidney Dysfunction and Refractory Hypertension. KOSIN MEDICAL JOURNAL 2019. [DOI: 10.7180/kmj.2019.34.2.168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Aortoiliac occlusive disease (AIOD), especially proximal to the transplant artery, in kidney transplant patient activates the renin-angiotensin-aldosterone system by limiting graft renal perfusion and causes symptoms that can occur with transplant renal artery stenosis (TRAS) such as refractory hypertension, water retention, and graft renal dysfunction. Immediate clinical suspicion is difficult due to the nature of the progressive disease unlike TRAS. Herein, we present an interesting case of bilateral common iliac artery occlusion (AIOD, TASC II, type C) that manifested as uncontrolled blood pressure and decreased allograft function in a patient who had kidney transplant 17 years ago. The patient was successfully diagnosed with duplex scan, ankle-brachial index (ABI) and computed tomography angiography and treated with percutaneous luminal angioplasty and stent graft insertion.
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8
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Franco A, González Y, Balibrea N, Díaz M, Planells MC, Pérez Contreras FJ. Posterior reversible encephalopathy syndrome. A case in a renal transplant recipient with refractory hypertension due to iliac artery stenosis. Nefrologia 2019; 39:677-679. [PMID: 31103245 DOI: 10.1016/j.nefro.2019.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 02/21/2019] [Indexed: 10/26/2022] Open
Affiliation(s)
- Antonio Franco
- Servicios de Nefrología, Hospital General Universitario de Alicante, Alicante, España.
| | - Yussel González
- Servicios de Nefrología, Hospital General Universitario de Alicante, Alicante, España
| | - Noelia Balibrea
- Servicios de Nefrología, Hospital General Universitario de Alicante, Alicante, España
| | - María Díaz
- Servicios de Nefrología, Hospital General Universitario de Alicante, Alicante, España
| | - Mariana Cecilia Planells
- Servicios de Radiología Intervencionista, Hospital General Universitario de Alicante, Alicante, España
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9
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Sobrino Díaz L, Mosquera Rey V, Rodríguez García M, Alonso Pérez M, Ridao Cano N, Díaz Corte C, Zanabili Al-Sibbai AA. Stenosis of the iliac artery after kidney transplantation as a cause of refractory hypertension and intermittent claudication. Nefrologia 2018; 38:325-327. [PMID: 29731012 DOI: 10.1016/j.nefro.2017.05.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Revised: 03/05/2017] [Accepted: 05/18/2017] [Indexed: 11/30/2022] Open
Affiliation(s)
- Lucía Sobrino Díaz
- Área de Gestión Clínica de Nefrología, Hospital Universitario Central de Asturias, Oviedo, Asturias, España.
| | - Vicente Mosquera Rey
- Servicio de Angiología y Cirugía Vascular, Hospital Universitario Central de Asturias, Oviedo, Asturias, España
| | - Minerva Rodríguez García
- Área de Gestión Clínica de Nefrología, Hospital Universitario Central de Asturias, Oviedo, Asturias, España
| | - Manuel Alonso Pérez
- Servicio de Angiología y Cirugía Vascular, Hospital Universitario Central de Asturias, Oviedo, Asturias, España
| | - Natalia Ridao Cano
- Área de Gestión Clínica de Nefrología, Hospital Universitario Central de Asturias, Oviedo, Asturias, España
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10
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Lee SB, Kang HJ, Kang HJ, Jang SH, Hwang HS, Chang YK, Kim SY, Hong YA. Asymptomatic Common Iliac Artery Stenosis as a Cause of Renal Allograft Dysfunction and Uncontrolled Hypertension. KOREAN JOURNAL OF TRANSPLANTATION 2016. [DOI: 10.4285/jkstn.2016.30.3.133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Sang Bin Lee
- Department of Internal Medicine, Daejeon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Daejeon, Korea
| | - Hyeon Jeong Kang
- Department of Internal Medicine, Daejeon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Daejeon, Korea
| | - Hee Jun Kang
- Department of Internal Medicine, Daejeon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Daejeon, Korea
| | - Sun Hee Jang
- Department of Internal Medicine, Daejeon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Daejeon, Korea
| | - Hyeon Seok Hwang
- Department of Internal Medicine, Daejeon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Daejeon, Korea
| | - Yoon Kyung Chang
- Department of Internal Medicine, Daejeon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Daejeon, Korea
| | - Suk Young Kim
- Department of Internal Medicine, Daejeon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Daejeon, Korea
| | - Yu Ah Hong
- Department of Internal Medicine, Daejeon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Daejeon, Korea
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11
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Turunç V, Eroğlu A, Tabandeh B, Şarkışlalı K, Şener T, Aydın A, Gürol T, Oruğ T. Femoro-femoral Bypass for Graft Salvage in a Renal Transplant Patient With Aorto-iliac Occlusion: A Case Report. Transplant Proc 2015; 47:1511-4. [PMID: 26093754 DOI: 10.1016/j.transproceed.2015.04.060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
As vascular diseases are becoming more prevalent among renal transplant recipients, complications related to renal artery anastomosis are likely to occur more often. Here we report a renal transplant patient treated with femoro-femoral bypass who had renal allograft dysfunction due to aorto-iliac occlusive disease (AIOD) proximal to renal artery anastomosis. We performed living donor renal transplantation in the left iliac fossa of a 41-year-old male. At post-transplant 30 months, he was admitted with hypertension, increase in serum creatinine, and claudication of his left leg. Doppler ultrasonography showed poor flow characteristics of the renal allograft. Total occlusion of the left common iliac artery was diagnosed on angiography. Since endovascular approach was unsuccessful, we performed right-to-left femoro-femoral bypass to provide retrograde blood flow to the renal allograft. The patient was discharged at postoperative day 3 with decreased serum creatinine, normal blood pressure, no claudication, and normal flow characteristics in Doppler ultrasonography. AIOD should be suspected in renal transplant patients in case of hypertension, allograft dysfunction, and ipsilateral leg ischemia. Femoro-femoral bypass is a safe surgical procedure that may be performed in patients who cannot be treated using an endovascular approach.
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Affiliation(s)
- V Turunç
- Goztepe Medical Park Hospital, Organ Transplantation Center, Istanbul, Turkey.
| | - A Eroğlu
- Goztepe Medical Park Hospital, Organ Transplantation Center, Istanbul, Turkey
| | - B Tabandeh
- Department of General Surgery, Bahcesehir University, Istanbul, Turkey
| | - K Şarkışlalı
- Department of Cardiovascular Surgery, Goztepe Medical Park Hospital, Istanbul, Turkey
| | - T Şener
- Department of Cardiovascular Surgery, Goztepe Medical Park Hospital, Istanbul, Turkey
| | - A Aydın
- Department of Cardiology, Bahcesehir University, Istanbul, Turkey
| | - T Gürol
- Department of Cardiology, Bahcesehir University, Istanbul, Turkey
| | - T Oruğ
- Department of General Surgery, Bahcesehir University, Istanbul, Turkey
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12
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Weir MR, Burgess ED, Cooper JE, Fenves AZ, Goldsmith D, McKay D, Mehrotra A, Mitsnefes MM, Sica DA, Taler SJ. Assessment and management of hypertension in transplant patients. J Am Soc Nephrol 2015; 26:1248-60. [PMID: 25653099 DOI: 10.1681/asn.2014080834] [Citation(s) in RCA: 109] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Hypertension in renal transplant recipients is common and ranges from 50% to 80% in adult recipients and from 47% to 82% in pediatric recipients. Cardiovascular morbidity and mortality and shortened allograft survival are important consequences of inadequate control of hypertension. In this review, we examine the epidemiology, pathophysiology, and management considerations of post-transplant hypertension. Donor and recipient factors, acute and chronic allograft injury, and immunosuppressive medications may each explain some of the pathophysiology of post-transplant hypertension. As observed in other patient cohorts, renal artery stenosis and adrenal causes of hypertension may be important contributing factors. Notably, BP treatment goals for renal transplant recipients remain an enigma because there are no adequate randomized controlled trials to support a benefit from targeting lower BP levels on graft and patient survival. The potential for drug-drug interactions and altered pharmacokinetics and pharmacodynamics of the different antihypertensive medications need to be carefully considered. To date, no specific antihypertensive medications have been shown to be more effective than others at improving either patient or graft survival. Identifying the underlying pathophysiology and subsequent individualization of treatment goals are important for improving long-term patient and graft outcomes in these patients.
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Affiliation(s)
- Matthew R Weir
- Division of Nephrology, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland;
| | - Ellen D Burgess
- Division of Renal Medicine, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - James E Cooper
- Division of Renal Disease and Hypertension, Department of Medicine, University of Colorado, Denver, Colorado
| | - Andrew Z Fenves
- Division of Nephrology, Department of Medicine, Harvard Medical School and Massachusetts General Hospital, Boston, Massachusetts
| | - David Goldsmith
- Division of Cardio-Renal Medicine, St. Thomas and Guy's Hospital, London, United Kingdom
| | - Dianne McKay
- Division of Nephrology, Department of Medicine, University of California, San Diego, San Diego, California
| | - Anita Mehrotra
- Division of Nephrology, Department of Medicine, Mount Sinai School of Medicine, New York, New York
| | - Mark M Mitsnefes
- Division of Nephrology, Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio
| | - Domenic A Sica
- Division of Nephrology, Department of Medicine, Virginia Commonwealth University, Richmond, Virginia; and
| | - Sandra J Taler
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota
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13
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Ozban M, Aydin C, Dursun B, Yagci B, Birsen O, Tekin K. Post-kidney transplantation external iliac artery stenosis due to vascular clamp: report of a case. J Vasc Bras 2014. [DOI: 10.1590/jvb.2014.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
We report a case of right external iliac artery stenosis after kidney transplantation surgery caused by vascular clamp application injury. The patient presented with claudication of the ipsilateral lower limb and the lesion was diagnosed angiographically. The patient was treated with endovascular stent placement.
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Affiliation(s)
- Murat Ozban
- Pamukkale University School of Medicine, Turkey
| | | | | | - Baki Yagci
- Pamukkale University School of Medicine, Turkey
| | - Onur Birsen
- Pamukkale University School of Medicine, Turkey
| | - Koray Tekin
- Pamukkale University School of Medicine, Turkey
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14
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T-Stenting-and-Small-Protrusion Technique for Bifurcation Stenoses After End-to-Side Anastomosis of Transplant Renal Artery and External Iliac Artery: Report of Two Cases. Cardiovasc Intervent Radiol 2014; 38:1303-7. [DOI: 10.1007/s00270-014-0974-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Accepted: 06/15/2014] [Indexed: 12/25/2022]
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15
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Pinho A, Sampaio S, Pestana M. Accelerated atherosclerosis after renal transplantation: an unsuspected cause of uncontrolled hypertension. Int J Nephrol Renovasc Dis 2014; 7:295-6. [PMID: 25053893 PMCID: PMC4105269 DOI: 10.2147/ijnrd.s69358] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Ana Pinho
- Department of Nephrology, Faro Hospital, Faro, Portugal ; Department of Nephrology, Hospital São João, Porto, Portugal
| | - Susana Sampaio
- Department of Nephrology, Hospital São João, Porto, Portugal
| | - Manuel Pestana
- Department of Nephrology, Hospital São João, Porto, Portugal ; Medical School and Nephrology Research and Development Unit, University of Porto, Porto, Portugal
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Glebova NO, Brooke BS, Desai NM, Lum YW. Endovascular interventions for managing vascular complication of renal transplantation. Semin Vasc Surg 2014; 26:205-12. [PMID: 25220328 DOI: 10.1053/j.semvascsurg.2014.06.013] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Renal transplantation is a well-established treatment for patients with end-stage renal disease. Although the procedure is commonly undertaken with a high rate of initial technical success, a low but significant risk of vascular complications can develop and ultimately threaten the transplanted kidney. Complications include transplant renal artery stenosis, extraparenchymal and intraparenchymal pseudoaneurysm and arteriovenous fistula formation, and stenosis of native iliac arteries due to aortoiliac occlusive disease. Historically, open surgical correction of these complications has been associated with high morbidity and the risk of graft loss. Endovascular approaches are better tolerated by renal transplantation patients and are used increasingly for management of vascular complications associated with kidney transplantation. We review the contemporary diagnosis and treatment of these complications using endovascular techniques.
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Affiliation(s)
- Natalia O Glebova
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Johns Hopkins Hospital, Baltimore, MD
| | - Benjamin S Brooke
- Division of Vascular Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT
| | - Niraj M Desai
- Division of Transplant Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, MD
| | - Ying Wei Lum
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Johns Hopkins Hospital, Baltimore, MD.
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Aoyama H, Saigo K, Hasegawa M, Akutsu N, Maruyama M, Otsuki K, Matsumoto I, Kawaguchi T, Kitamura H, Asano T, Kenmochi T, Itou T, Matsubara H. Pathologic Findings of Renal Biopsy Were a Helpful Diagnostic Clue of Stenosis of the Iliac Segment Proximal to the Transplant Renal Artery: A Case Report. Transplant Proc 2014; 46:651-3. [DOI: 10.1016/j.transproceed.2013.11.140] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Revised: 11/18/2013] [Accepted: 11/27/2013] [Indexed: 11/25/2022]
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18
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Complications of transplantation. Part 1: renal transplants. Cardiovasc Intervent Radiol 2014; 37:1137-48. [PMID: 24562321 DOI: 10.1007/s00270-014-0851-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2013] [Accepted: 01/13/2014] [Indexed: 12/16/2022]
Abstract
Vascular complications after solid-organ transplantation are not uncommon and may lead to graft dysfunction and ultimately graft loss. A thorough understanding of the surgical anatomy, etiologies, and types of vascular complications, their presentation, and the options for management are important for managing these complex patients. This article reviews the basic surgical anatomy, vascular complications, and endovascular management options of vascular complications in patients with renal transplants.
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19
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Outcomes of endovascular interventions for salvage of renal transplant allografts. J Vasc Surg 2013; 57:1621-7. [DOI: 10.1016/j.jvs.2012.11.117] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2012] [Revised: 11/21/2012] [Accepted: 11/26/2012] [Indexed: 11/19/2022]
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Péret M, Lhommet P, Villemain F, Abraham P, Picquet J, Enon B. [Exercise-induced renal ischemia after kidney transplantation: report of two cases]. ACTA ACUST UNITED AC 2013; 38:52-7. [PMID: 23337795 DOI: 10.1016/j.jmv.2012.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2012] [Accepted: 11/14/2012] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Renal transplant patients are high cardiovascular risk patients. Regular ultrasound surveillance of the renal transplant artery and the iliac artery upstream from the anastomosis is required to detect potential arterial stenosis. The purpose of this article was to illustrate the hemodynamic impact of exercise in such patients and the screening efficiency of Doppler ultrasound stress testing. METHODS Two renal transplant patients were hospitalized in our center for impaired renal function, worsening hypertension, and intermittent claudication. This association of peripheral vascular disease and renal dysfunction led us to perform a Doppler ultrasound stress test to search for vascular stenosis upstream from the graft. Hemodynamic fluctuations in the ipsilateral leg were recorded during flexion-extension exercises. RESULTS Iliac artery lesions were found in both patients: the Doppler examination showed decreased systolic velocity in the graft artery during exercise, compatible with iliac steal syndrome. Surgical treatment was performed in both patients. After surgery, the control Doppler ultrasound stress test showed that systolic flow did not decline in the graft vessels during exercise. Renal function stabilized in one patient and improved in the other; claudication disappeared after surgery. CONCLUSION Doppler ultrasound stress testing can be a valuable tool for detecting exercise-induced renal graft ischemia in transplant patients. Its screening performance should be determined in a larger population before routine use.
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Affiliation(s)
- M Péret
- Service de chirurgie vasculaire et thoracique, CHU d'Angers, 4, rue Larrey, 49033 Angers, France
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21
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Abstract
PURPOSE Despite medical and surgical advances, vascular complications remain common after renal transplant, occurring among 3%-15% of patients. These complications may compromise graft function. This study sought to evaluate the frequency and management of vascular complications after renal transplant. MATERIALS AND METHODS We retrospectively analyzed the 1843 transplantations performed at 2 centers by our team since November 1975. The 1349 male and 494 female patients had an overall mean age of 31.5±11.2 years; (range, 3-66). Grafts were obtained from a living-related donor in 1406 (76.29%) or a deceased donor in the remaining 437 (23.71%). The mean donor age was 40.7±13.7 years (range, 2-76). Of 1843 transplants, multiple vascular anastomoses were performed in 155 cases (8.4%), including 130 involving renal arteries and 25 renal veins. RESULTS Forty-seven vascular complications (2.55%) were observed in 43 procedures (2.33%), most frequently renal artery stenosis (n=14). It was followed by allograft renal artery kinking (n=7), renal vein kinking (n=7), renal artery thrombosis (n=5), renal vein laceration (n=4), renal artery laceration (n=3), renal vein thrombosis (n=2), renal artery disruption (n=2), renal and iliac vein obstructions owing to pressure from a lymphocele (n=1), renal artery and vein obstruction owing to pressure from a hematoma (n=1), or an arteriovenous fistula after percutaneous graft biopsy (n=1). Fifteen of these 47 complications were treated by interventional radiologic procedures. CONCLUSION The vascular complication rates in our patients were somewhat lower than those reported in the literature. A thorough understanding of how complications impair allograft function and survival is essential for adequate treatment. Interventional radiology is invaluable in the postoperative management of transplant-related complications.
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22
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Close to transplant renal artery stenosis and percutaneous transluminal treatment. J Transplant 2011; 2011:219109. [PMID: 21766005 PMCID: PMC3134179 DOI: 10.1155/2011/219109] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2011] [Revised: 04/20/2011] [Accepted: 05/17/2011] [Indexed: 12/19/2022] Open
Abstract
Purpose. To evaluate the efficacy of percutaneous transluminal angioplasty (PTA) in the management of arterial stenosis located close to the allograft anastomosis (close-TRAS). Materials and Methods. 31 patients with renal transplants were admitted to our institution because of persistent hypertension and impairment of transplant renal function and underwent angiography for vascular investigation. 27 were diagnosed suffering from transplant renal artery stenosis (TRAS), whereas 4 had severe iliac artery stenosis proximal to the transplant anastomosis (Prox-TRAS). 3 cases of TRAS coexisted with segmental renal arterial stenosis, whereas 3 other cases of TRAS were caused by kinking and focal stenosis in the middle of the transplanted renal artery. Results. Angioplasty and stenting were successfully applied to all patients with iliac artery stenosis as well as to those with TRAS and segmental artery stenosis. Two of three patients with kinking were well treated with angioplasty and stenting, whereas one treated only with angioplasty necessitated surgery. No major procedure-related complications appeared, and the result was decrease of the serum creatinine level and of the blood pressure. Conclusions. PTA is the appropriate initial treatment of TRAS and close-TRAS, with low morbidity and mortality rates, achieving improvement of graft function and amelioration of hypertension.
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23
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Gill R, Shapiro R, Kayler LK. Management of peripheral vascular disease compromising renal allograft placement and function: review of the literature with an illustrative case. Clin Transplant 2010; 25:337-44. [DOI: 10.1111/j.1399-0012.2010.01351.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Gupta G, Unruh ML, Nolin TD, Hasley PB. Primary care of the renal transplant patient. J Gen Intern Med 2010; 25:731-40. [PMID: 20422302 PMCID: PMC2881977 DOI: 10.1007/s11606-010-1354-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2009] [Revised: 11/30/2009] [Accepted: 03/26/2010] [Indexed: 12/25/2022]
Abstract
There has been a remarkable rise in the number of kidney transplant recipients (KTR) in the US over the last decade. Increasing use of potent immunosuppressants, which are also potentially diabetogenic and atherogenic, can result in worsening of pre-existing medical conditions as well as development of post-transplant disease. This, coupled with improving long-term survival, is putting tremendous pressure on transplant centers that were not designed to deliver primary care to KTR. Thus, increasing numbers of KTR will present to their primary care physicians (PCP) post-transplant for routine medical care. Similar to native chronic kidney disease patients, KTRs are vulnerable to cardiovascular disease as well as a host of other problems including bone disease, infections and malignancies. Deaths related to complications of cardiovascular disease and malignancies account for 60-65% of long-term mortality among KTRs. Guidelines from the National Kidney Foundation and the European Best Practice Guidelines Expert Group on the management of hypertension, dyslipidemia, smoking, diabetes and bone disease should be incorporated into the long-term care plan of the KTR to improve outcomes. A number of transplant centers do not supply PCPs with protocols and guidelines, making the task of the PCP more difficult. Despite this, PCPs are expected to continue to provide general preventive medicine, vaccinations and management of chronic medical problems. In this narrative review, we examine the common medical problems seen in KTR from the PCP's perspective. Medical management issues related to immunosuppressive medications are also briefly discussed.
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Affiliation(s)
- Gaurav Gupta
- Nephrology Division, Department of Medicine, Johns Hopkins University, Baltimore, MD 21205, USA.
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25
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Hedegard W, Saad WE, Davies MG. Management of Vascular and Nonvascular Complications After Renal Transplantation. Tech Vasc Interv Radiol 2009; 12:240-62. [DOI: 10.1053/j.tvir.2009.09.006] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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26
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Lanzman RS, Voiculescu A, Walther C, Ringelstein A, Bi X, Schmitt P, Freitag SM, Won S, Scherer A, Blondin D. ECG-gated nonenhanced 3D steady-state free precession MR angiography in assessment of transplant renal arteries: comparison with DSA. Radiology 2009; 252:914-21. [PMID: 19635833 DOI: 10.1148/radiol.2531082260] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE To evaluate noncontrast material-enhanced steady-state free precession (SSFP) magnetic resonance (MR) angiography in the assessment of transplant renal arteries (RAs) by using digital subtraction angiography (DSA) as the reference standard. MATERIALS AND METHODS This prospective study was approved by the institutional review board; written informed consent was obtained from all participants. In 20 renal allograft recipients scheduled for DSA, the transplant RAs were assessed with electrocardiographically gated nonenhanced SSFP MR angiography performed at 1.5 T; the degree of stenosis was compared with that of DSA. Subjective image quality for SSFP MR angiography was assessed independently by two radiologists on a four-point scale (from 1, nondiagnostic to 4, excellent) in four predefined segments (I, the iliac artery; II, the main transplant artery; III, segmental branches; and IV, parenchymal branches). Sensitivity, specificity, and accuracy of SSFP MR angiography for the detection of relevant (> or =50%) transplant RA stenosis (TRAS) were calculated on a per-artery basis. RESULTS One patient was excluded because SSFP MR angiography failed to adequately visualize the allograft vasculature owing to low cardiac output. The mean image quality assessed by both readers was 3.98 +/- 0.16 (standard deviation), 3.5 +/- 0.68, 2.71 +/- 1.12 and 2.03 +/- 1.09 for segments I, II, III, and IV, respectively (kappa = 0.80). DSA helped identify eight relevant (> or =50%) stenoses in six transplant RAs. Kinking of the transplant artery without relevant stenosis was found in seven patients. The degree of stenosis was overestimated in three patients by using SSFP MR angiography. As compared with DSA, the sensitivity, specificity, and accuracy of SSFP MR angiography to help detect relevant TRAS were 100% (six of six), 88% (14 of 16), and 91% (20 of 22), respectively. CONCLUSION Nonenhanced SSFP MR angiography is a reliable alternative imaging technique for the assessment of transplant RAs in patients for whom contrast-enhanced MR angiography is contraindicated.
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Affiliation(s)
- Rotem S Lanzman
- Institute of Radiology, University Hospital Düsseldorf, Moorenstr 5, 40225 Düsseldorf, Germany.
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27
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Agle SC, Barchman MJ, Haisch CE, Stoner MC. Aortoiliac Intervention with Distal Protection to Salvage a Heterotopic Renal Transplant. Ren Fail 2009; 31:593-6. [DOI: 10.1080/08860220903003388] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Nezami N, Tarzamni M, Argani H, Nourifar M. Doppler Ultrasonographic Indices After Renal Transplantation as Renal Function Predictors. Transplant Proc 2008; 40:94-9. [DOI: 10.1016/j.transproceed.2007.11.036] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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29
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Tarzamni MK, Argani H, Nurifar M, Nezami N. Vascular complication and Doppler ultrasonographic finding after renal transplantation. Transplant Proc 2007; 39:1098-102. [PMID: 17524902 DOI: 10.1016/j.transproceed.2007.02.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVES Vascular complications are common after renal transplantation. In this study we correlated Doppler sonographic indices and transplant kidney function. METHODS We reviewed data on 244 renal transplant patients. Doppler ultrasonographic evaluation was performed during the first 2 weeks after renal transplantation. We determined resistive index (RI) and pulsatility index (PI) in the interlobar arteries and thrombosis of renal and lower limb veins. Serum creatinine (Cr) and cyclosporine levels were evaluated prior to sonographic assessment. RESULTS The mean age of the 142 male and 102 female patients was 36.31 +/- 3.30 years. Prevalence of real artery stenosis was 9.5%. In these patients the mean serum Cr level (2.21 +/- 1.83 mg/dL) was significantly higher than among patients with patent renovascular tributary (1.49 +/- 1.00 mg/dL; P=.03). RI and PI were also significantly correlated with serum Cr(P=.05 and .001, respectively). There was no relationship between cyclosporine level or panel-reactive antibody with RI and PI. Retransplant patients showed higher RI than first renal allograft recipients (0.72 +/- 0.16 vs 0.63 +/- 0.11; P=.006). Serum Cr level was higher among renal allograft recipients with Doppler evidence of thrombosis of the lower limb veins (3.1 +/- 0.98 mg/dL versus 1.56 +/- 1.13 mg/dL; P=.04). CONCLUSIONS RI and PI are two valuable Doppler ultrasonographic markers to determine renal allograft function and related vascular complications.
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Affiliation(s)
- M K Tarzamni
- Department of Radiology, Imam Hospital, Tabriz University of Medical Science, East Azerbaijan, Iran.
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Aikimbaev K, Akgul E, Aksungur E, Demir E, Erken U. Iliac artery stenosis as a cause of posttransplant renal failure and claudication. Int Urol Nephrol 2007; 39:1273-6. [PMID: 17914659 DOI: 10.1007/s11255-007-9284-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2007] [Accepted: 08/22/2007] [Indexed: 11/25/2022]
Abstract
Iliac artery stenosis (IAS) is a rare complication after renal transplantation. We demonstrate a case of ipsilateral external IAS proximally to anastomosis in a kidney recipient, which manifested with renal failure and claudication, and was successfully treated with endovascular stent placement.
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Affiliation(s)
- Kairgeldy Aikimbaev
- Department of Radiology, Faculty of Medicine, Cukurova University, Balcali, Adana, 01330, Turkey.
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Abstract
Kidney transplants have become common surgical procedures, with thousands performed yearly around the world. The surgical techniques for the transplant are well established and the procedure is associated with high success rates. The complication rate associated with the procedure is low, especially when compared to other abdominal organ transplants such as liver and pancreas transplants. Nonetheless, the detection, accurate diagnosis, and timely management of surgical complications occurring after kidney transplant are important tasks of the team managing these patients. A delay in the diagnosis or management of these complications can result in significant morbidity to the recipient, with risk of graft loss and mortality. Most surgical complications involve either the wound or one of the three anastomoses (renal artery, renal vein, or ureter). Examples include wound infection, renal artery or vein thrombosis, and urine leak. Most of these complications will require surgical or radiologic intervention for appropriate management.
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Affiliation(s)
- Abhinav Humar
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA.
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Abstract
These days renal Doppler sonography has been established as a diagnostic tool of the daily nephrological work-up. Extra- and intrarenal flow signals are obtained for different indications. The intrarenal resistive index is the best examined parameter in the literature. However, the results have to be carefully interpreted, because different hemodynamic factors, such as heart rate, stiffness of the aorta as well as observer-dependent factors may have an impact on the level of the resistive index. The value of this non-invasive technique is discussed in detail for different renal diseases, such as acute and chronic renal failure, renal artery stenosis and for patients after renal transplantation. Being aware of several pitfalls which may lead to false results, nephrologists may use renal Doppler sonography as the first screening method of choice in the diagnostic algorithm.
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Affiliation(s)
- Bernd Krumme
- Deutsche Klinik fur Diagnostik, Fachbereich Nephrologie und Hypertensiologie, Wiesbaden, Germany.
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Voiculescu A, Schmitz M, Hollenbeck M, Braasch S, Luther B, Sandmann W, Jung G, Mödder U, Grabensee B. Management of arterial stenosis affecting kidney graft perfusion: a single-centre study in 53 patients. Am J Transplant 2005; 5:1731-8. [PMID: 15943633 DOI: 10.1111/j.1600-6143.2005.00927.x] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
We assessed clinical and duplex sonographic (CDS) findings, and outcome in patients with stenosis of the transplant renal artery (TRAS) or the aorto-iliac segment proximal to the graft (Prox-TRAS) treated with dilatation (PTA), stenting (PTAS) and surgery. From 1988 to 2002, of 1189 patients with renal transplantations, 117 underwent angiography. Fifty-three patients with TRAS (n = 37)/Prox-TRAS (n = 16) were found (4.4%). Clinical presentation included deterioration of hypertension (144 +/- 15/84 +/- 9, 157 +/- 22/90 +/- 10 mmHg; p < 0.001), increase of creatinine (1.7 +/- 0.9, 2.5 +/- 1.3 mg/dL; p = 0.01) and renal failure (n = 12). CDS indicated insufficient perfusion and differentiated between TRAS and Prox-TRAS. From renal transplantation (RTX) until the detection of stenosis pulsatility indices (PI) decreased from 1.2 +/- 0.46 to 0.98 +/- 0.29; (p = 0.001). Fifty-two patients underwent invasive treatment (21 PTA, 10 PTAS and 21 surgery) after which hypertension and creatinine significantly improved. PI increased. Restenosis occurred in 16 (52%) cases of the interventional (PTA 62% and PTAS 30%) and in 3 (14%) of the surgical group (p = 0.011). Hypertension and graft dysfunction due to perfusion problems are rare. Clinical findings are nonspecific but CDS findings are helpful to select patients for angiography. Invasive treatment leads to clinical improvement. Surgery yields better results than PTA, but additional stenting will probably improve the outcome of angioplasty.
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Affiliation(s)
- Adina Voiculescu
- Department of Nephrology, Heinrich-Heine-University, Düsseldorf, Germany.
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McNamara MM, Lockhart ME, Robbin ML. Emergency Doppler evaluation of the liver and kidneys. Radiol Clin North Am 2004; 42:397-415. [PMID: 15136024 DOI: 10.1016/j.rcl.2003.12.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Doppler ultrasound is useful in the emergent evaluation of the liver and kidney transplant patient. Arterial stenosis, pseudoaneurysm, and venous thrombosis are treatable causes of allograft failure that can be detected easily with color and spectral Doppler. Doppler has a limited but important role in the emergent evaluation of the native liver and kidneys, usually involving prior biopsy or instrumentation.
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Affiliation(s)
- Michelle M McNamara
- Abdominal Imaging Section, Department of Radiology, University of Alabama at Birmingham, 619 19th Street South, JTN 353, Birmingham, AL 35249-6830, USA.
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