Prolonged Delayed Renal Graft Function Secondary to Venous Hypertension

Abstract

The case of a 39-year-old highly sensitized woman who underwent second renal transplantation after being on warfarin because of a history of frequent thromboses of her left femoral arteriovenous graft (AVG) is reported here. The patient received a flow cytometric positive crossmatch kidney transplant from a deceased donor. Her posttransplant course was complicated by prolonged delayed graft function (DGF) lasting for 9 months. Antibody-mediated rejection occurred in the immediate postoperative period. This resolved after treatment, and resolution was confirmed by repeat biopsy. Despite this, she had persistent DGF and remained dialysis dependent. A computed tomography scan due to the development of perinephric hematoma after posttransplant biopsy demonstrated venous collateralization around the allograft. At 7 months posttransplant, a venogram during declotting of AVG revealed chronic thrombus in the inferior vena cava (IVC) above the level of native renal veins with a venous gradient of 26 mmHg. After declotting of the graft, iliac venoplasty, and subsequent IVC stent, her renal function continues to improve with a most recent creatinine of 1.4 mg/dL at 36 months posttransplant. Venous hypertension secondary to IVC thrombosis in presence of patent femoral AVG should be considered as a rare cause of prolonged DGF.

Kidney allograft dysfunction due to ipsilateral thigh arteriovenous graft

“…The patient refused graft ligation but recovered with IVC recanalization. 5 Venous congestion should be in the differential diagnosis of allograft dysfunction with ipsilateral lower extremity HD access. It should also be a part of surgical planning in a transplant recipient.…”

“…The Journal of Vascular Access 21 (5) of allograft dysfunction with AV graft patency prompted further investigation. Transplant Doppler ultrasound revealed normal renal parenchyma but absent diastolic flow (Figure 1).…”

The management of lower limb arteriovenous grafts in the perioperative period following renal transplantation

“…Optimal transplant perfusion relies on good arterial inflow and unimpeded venous return. A LL‐AVG may contribute to poor transplant function through interference with both these aspects with either steal syndrome (arterial flow being diverted away from the renal transplant to a low resistance AVG) or pelvic venous hypertension from high flow high‐pressure venous return 4,7,12,13 . Although some authors advocate a contralateral placement of the kidney graft, 8 there is little evidence to suggest that transplant and LL‐AVG laterality play a role in development of flow abnormalities resulting in kidney graft dysfunction.…”

“…A LL‐AVG may relate to future transplantation either directly or indirectly. It has been proposed that a LL‐AVG ipsilateral to the renal transplant could directly compromise the function through either venous hypertension or vascular steal 4‐7 . In addition, patients with a LL‐AVG may be more likely to require post‐operative hemodialysis for the following reasons.…”