Restoration of Renal Allograft Function via Reduced-Contrast Percutaneous Revascularization of Transplant Renal Artery Stenosis

Abstract

Transplant renal artery stenosis (TRAS),R enal transplantation is the definitive therapy for end-stage kidney disease and provides substantial lifesaving and quality-of-life benefits for patients who would otherwise undergo dialysis.1 Posttransplantation stenosis of the renal artery-more commonly called TRAS, or transplant renal artery stenosis-is the most frequent vascular complication of kidney transplantation.2 It is implicated in graft dysfunction, concomitant congestive heart failure, and refractory hypertension. Transplant renal artery stenosis is often detected during routine Doppler-ultrasonographic screening of the transplanted kidney or during the clinical evaluation that occurs when graft function deteriorates.3 Percutaneous revascularization of TRAS is indicated to treat graft dysfunction; however, the conventional use of angiography to guide the intervention can put the graft at substantial risk of contrast nephropathy. 4,5 We present a case of TRAS that was discovered during the evaluation for causes of a patient's failing transplanted kidney. Case ReportIn January 2013, a 70-year-old man with end-stage polycystic kidney disease underwent cadaveric kidney transplantation. He had a history of hypertension, transient ischemic attack, and coronary artery disease. In the 4 months after his kidney transplantation, he had hospital admissions for heart failure, gastrointestinal bleeding, and acute coronary syndrome requiring percutaneous coronary intervention. The patient's serum creatinine levels increased steadily during this time, from 1.47 mg/ dL at the time of transplantation to 6.99 mg/dL 5 months after transplantation. The rise in creatinine was attributed to cumulative kidney damage from intra-arterial contrast medium administered during the above-mentioned percutaneous coronary intervention, to acute tubular necrosis from hypotension, and possibly to cardiorenal syndrome. Five months after the transplantation, he presented with refractory pulmonary edema and acute-on-chronic renal failure (serum creatinine level, 6.05 mg/ dL). He was treated with diuresis, which further elevated the creatinine to a peak of 7.31 mg/dL. Hemodialysis was initiated to treat azotemia and volume overload. Biopsy specimens of the transplanted kidney did not reveal any specific cause for his Case Reports

Quiz

“…Unlike the controversial outcomes with renal artery stenosis in nontransplantation patients, improvements in estimated glomerular filtration rate (eGFR) have been reported between 30 and 80 mL/min/1.73 m 2 when transplant perfusion is restored in TRAS and CIAS, 3,4 and there are rare instances of recovery off dialysis. 5 Our patient's kidney function began improving immediately following angioplasty, and 1 week later, she discontinued hemodialysis after a total of 28 days. Her serum creatinine concentration…”

Intravascular ultrasound-supported percutaneous angioplasty of post-kidney transplant renal artery bifurcation stenosis

“…Post-intervention IVUS helped us to achieve optimal results of all the intervened arterial segments, as reported by other authors, especially for native RAS. 15,16 There are only few published case reports about the use of IVUS in TRAS, [17][18][19] and none for the complex bifurcation lesion as was studied in the index case. Touma et al in a series of 17 patients with TRAS reported higher freedom from intervention and stenosis-free patency with stenting compared to balloon angioplasty (88.2% vs. 76.5%).…”

Presence of peripheral artery disease in renal transplant outcomes – Don’t throw the baby out with the bath water

“…Second, PAD may lead to transplant renal artery stenosis and resultant hypertension and progressive renal failure. 7 While rare, this association can lead to graft failure but can easily be mitigated with endovascular therapy. 7 Third, PAD can result in claudication but more importantly can progress to critical limb ischemia (CLI).…”

“…7 While rare, this association can lead to graft failure but can easily be mitigated with endovascular therapy. 7 Third, PAD can result in claudication but more importantly can progress to critical limb ischemia (CLI). The latter, when present with tissue loss and gangrene, can have significant implications in patients who have undergone renal transplant and are maintained on immunosuppressive therapy.…”