Postanastomotic Transplant Renal Artery Stenosis: Association With De Novo Class II Donor-Specific Antibodies

Abstract

In this study, we analyze the outcomes of transplant renal artery stenosis (TRAS), determine the different anatomical positions of TRAS, and establish cardiovascular and immunological risk factors associated with its development. One hundred thirty-seven of 999 (13.7%) patients had TRAS diagnosed by angiography; 119/137 (86.9%) were treated with angioplasty, of which 113/137 (82.5%) were stented. Allograft survival in the TRASþ intervention, TRASþ nonintervention and TRASÀ groups was 80.4%, 71.3% and 83.1%, respectively. There was no difference in allograft survival between the TRASþ intervention and TRASÀ groups, p ¼ 0.12; there was a difference in allograft survival between the TRASÀ and TRASþ nonintervention groups, p < 0.001, and between the TRASþ intervention and TRASþ nonintervention groups, p ¼ 0.037. TRAS developed at the anastomosis, within a bend/kink or distally. Anastomotic TRAS developed in living donor recipients; postanastomotic TRAS (TRAS-P) developed in diabetic and older patients who received grafts from deceased, older donors. Compared with the TRASÀ group, patients with TRAS-P were more likely to have had rejection with arteritis, odds ratio (OR): 4.83 p ¼ 0.0095, and capillaritis,), p ¼ 0.033. Patients with TRAS-P were more likely to have developed de novo class II DSA compared with TRASÀ patients hazard ratio: 4.41 (2.0-9.73), p < 0.001. TRAS is a heterogeneous condition with TRAS-P having both alloimmune and traditional cardiovascular risk factors.

Tailoring the Endovascular Management of Transplant Renal Artery Stenosis

“…Transplant renal artery stenosis (TRAS) is associated with allograft dysfunction, refractory hypertension and inferior allograft survival in the absence of prompt intervention (1)(2)(3). There is significant variability in the reported incidence of TRAS (1-25%) likely secondary to institutional variation of screening protocols, thresholds for intervention and baseline patient demographics (1)(2)(3)(4)(5)(6)(7)(8).…”

“…There is significant variability in the reported incidence of TRAS (1-25%) likely secondary to institutional variation of screening protocols, thresholds for intervention and baseline patient demographics (1)(2)(3)(4)(5)(6)(7)(8). The management of TRAS is more widely agreed upon with endovascular intervention (EVI) playing a significant role in preserving graft function and prolonging graft survival (1,(9)(10)(11).…”

“…A multitude of studies have made the importance of avoiding the management of TRAS as a single entity abundantly clear (1,3,6,10,25). Accordingly, these studies have employed different metrics and grading systems as a means to classify TRAS to better aid in its diagnosis and management.…”

Graft Arterial Stenosis in Kidney En Bloc Grafts From Very Small Pediatric Donors: Incidence, Timing, and Role of Ultrasound in Screening

“…Prior studies have reported that transplant renal artery stenosis occurs more frequently in patients with episodes of acute rejection and in the presence of donor specific antibodies (14,15), and episodes of acute rejection have been decreasing over time due to improvements in immunosuppressive therapies over time (16).…”

“…A recent publication focusing on transplant renal artery stenosis in single grafts from adult donors suggested that stenosis is a heterogeneous disease process with associations between the location of stenosis (anastomotic vs. postanastomotic) and alloimmunity, recipient cardiovascular risk factors, and living versus deceased donors (15). In the study by Willicombe et al, anastomotic transplant artery stenosis was more likely to develop in living donor recipients, whereas postanastomotic stenosis was associated with older deceased donors (15). Given the absence of stenoses clearly separate from the anastomosis and of more distal stenoses (including of the proper renal arteries) in our cohort, our data suggest that such cases are extremely rare or perhaps nonexistent in EBKT recipients.…”