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Table of Contents
CASE REPORT
Year : 2020  |  Volume : 14  |  Issue : 1  |  Page : 75-78

Successful treatment of transplant renal artery stenosis with bare-metal stent in a patient with simultaneous pancreas and kidney transplantation


1 Department of Renal Transplant Surgery, PGIMER, Chandigarh, India
2 Department of Cardiology, PGIMER, Chandigarh, India

Date of Submission14-Aug-2019
Date of Acceptance05-Jan-2020
Date of Web Publication31-Mar-2020

Correspondence Address:
Dr. Deepesh B Kenwar
Department of Renal Transplant Surgery, PGIMER, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijot.ijot_35_19

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  Abstract 


Transplant renal artery stenosis (TRAS) is a well-recognized vascular complication after renal transplantation. It occurs most frequently in the first 6 months after renal transplantation and is a reversible cause of hypertension, volume overload, and graft dysfunction or graft loss. Early diagnosis and endovascular intervention (EVI) result in good outcome. The present report describes a challenging case of TRAS with diagnostic dilemma in a Type I diabetic patient with end-stage renal disease who had undergone a simultaneous pancreas and kidney transplantation. The patient had multiple risk factors for TRAS including atherosclerosis, interruption in immunosuppression due to subacute intestinal obstruction, antibody mediated rejection (ABMR) and tortuosity of the implanted artery. He presented with fluid retention and graft dysfunction without significant hypertension. He was initially diagnosed as ongoing ABMR for which he received antirejection therapy without any significant improvement. He was finally diagnosed as TRAS and successfully salvaged with EVI.

Keywords: Endovascular stenting, simultaneous pancreas and kidney transplantation, transplant renal artery stenosis


How to cite this article:
Shivakumar S P, Kenwar DB, Sharma A, Vijayvergiya R. Successful treatment of transplant renal artery stenosis with bare-metal stent in a patient with simultaneous pancreas and kidney transplantation. Indian J Transplant 2020;14:75-8

How to cite this URL:
Shivakumar S P, Kenwar DB, Sharma A, Vijayvergiya R. Successful treatment of transplant renal artery stenosis with bare-metal stent in a patient with simultaneous pancreas and kidney transplantation. Indian J Transplant [serial online] 2020 [cited 2020 Jul 6];14:75-8. Available from: http://www.ijtonline.in/text.asp?2020/14/1/75/281762




  Introduction Top


Transplant renal artery stenosis (TRAS) is a well-recognized vascular complication after renal transplantation. It occurs most frequently in the first 6 months after kidney transplantation and is a reversible cause of hypertension, volume overload, and graft dysfunction or loss. Its incidence has been reported from 6% to 23% depending on screening and diagnostic criteria.[1],[2] Implicated risk factors include atherosclerosis, cytomegalovirus (CMV) infection, multiple renal arteries, delayed graft function, and, most recently, donor-specific antibodies.[1],[2]

Endovascular intervention (EVI) is accepted as the initial therapy for hemodynamically significant TRAS and composed of percutaneous transluminal angioplasty (PTA) and/or stenting. Procedural success rates for PTA are close to 90% with an incidence of restenosis of 15%–28%.[3]

The present report describes a challenging case of TRAS with diagnostic dilemma in a Type I diabetic patient with end-stage renal disease who had undergone a simultaneous pancreas and kidney (SPK) transplantation. The patient had multiple risk factors for TRAS including atherosclerosis, interruption in immunosuppression due to subacute intestinal obstruction, antibody-mediated rejection (ABMR) and tortuosity of the implanted artery. He presented with fluid retention and graft dysfunction without significant hypertension. He was initially diagnosed as ongoing ABMR for which he received antirejection therapy without any significant improvement. He was finally diagnosed as TRAS and successfully salvaged with EVI.


  Case Report Top


A 44 year old male patient presented with fluid retention and renal dysfunction in the third month after simultaneous pancreas kidney transplant in August 2018. This was his second renal transplant following a graft loss at 7 ½ years after the first transplant. The basic disease which necessitated his first transplantation was diabetic nephropathy due to type 1 diabetes mellitus. The first donor was his father, whose immunologic workup is not available. The allograft function was lost after 7½ years due to chronic ABMR. Subsequently, he underwent SPK transplantation in August 2018. Complement-dependent cytotoxicity crossmatch was done which was negative; Panel Reactive Antibody or Donor Specific Antibody was not done. The patient was induced with antithymocyte globulin 3 mg/kg. He was on triple drug immunosuppression with tacrolimus, mycophenolic acid, and prednisolone. The left kidney was transplanted; during surgery, the recipient's left external iliac artery was heavily calcified and had to be replaced with a vascular allograft from the same deceased donor on which the renal artery was subsequently anastomosed. Slight redundancy of the iliac artery was observed after completion of arterial anastomosis that might have resulted in tortuosity of the renal artery. The pancreatic graft was placed in the right iliac fossa, the splenic artery and superior mesenteric artery Y graft were anastomosed to the right external iliac artery, the portal vein was anastomosed to the inferior vena cava, and the graft duodenum was anastomosed to the proximal jejunum. Total cold ischemia time was 7 h for kidney and 10 h for pancreas. He had an uneventful postoperative course and was discharged after 2 weeks in euglycemic condition without insulin/hypoglycemic agents and a baseline serum creatinine of 1.1 mg%. He was readmitted after 1½ months with adhesive intestinal obstruction. Intestinal obstruction was not resolved with conservative management. Contrast-enhanced computerized tomography of the abdomen revealed a transition point in the distal ileum with normal duodenojejunal anastomosis with contrast passing freely distal to the graft duodenal and native jejunal anastomosis. On exploratory laparotomy, stricture was seen in the distal ileum with adhesive band, for which stricturoplasty with adhesiolysis was done. Intraoperative biopsy was not done, cause of obstruction was stricture with adhesive bands. Blood CMV polymerase chain reaction sent during admission was negative. During the post-operative period the patient was kept on intravenous cyclosporin and hydrocortisone and baseline immunosuppression with tacrolimus mycophenolate mofetil (MMF) and prednisolone was restituted once he was allowed oral. Postoperative period tacrolimus, Mycophenolate mofetil (MMF), and prednisolone were restarted. Over the next 10 days, he developed facial puffiness, pedal edema, reduced urine output, and a weight gain of 7 kg along with a rise in serum creatinine from 1.1 to 2.5 mg%. There was no significant hypertension; the blood sugar levels and pancreatic enzymes remained within normal limits. With the clinical suspicion of acute rejection, graft kidney biopsy was done which revealed features of C4d-negative ABMR. He was treated with high-dose IV immunoglobulin G (500 mg/kg) for 5 days, which resulted in partial improvement of serum creatinine to 1.8 mg%. Duplex ultrasound scan revealed transplant renal artery stenosis with raised peak systolic velocity (PSV) 228 cm/s and resistive index (RI) of 1.0 and parvus tardus waveform with low RI of 0.5 in the intersegmental arteries distal to the stenosis. TRAS was subsequently confirmed with computed tomography angiography (CT) [Figure 1] and on endovascular intervention [Figure 2].
Figure 1: Arrow shows stenotic part of the graft renal artery on the left side at the anastomotic site. Pancreatic graft on the right side

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Figure 2: Arrow shows stenotic part of the graft renal artery. Dotted line shows stenotic segment of the renal artery

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A bare-metal stent was placed across the stenosis in graft renal artery [Figure 3]. Postprocedure imaging showed adequate dilatation of the stenotic part [Figure 4]. The patient had polyuria with fall in creatinine and achieved his baseline serum creatinine of 1.10 mg% value with subsequent resolution of edema. The patient presently euglycemic without insulin or oral hypoglycemic agents and with a stable renal function with serum creatinine of 1.1 mg%. The patient was under follow up till 10 months after the presentation of TRAS when he had 0.71 mg% creatinine and was euglycemic off insulin. The last follow up duplex ultrasound was at 6 months post operatively and it showed a normal PSV of 89cm/sec and RI of 0.7 in the main renal artery at the hilum.
Figure 3: Dotted line shows stent deployment across the stenotic part of the graft renal artery

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Figure 4: Dotted line shows adequate dilatation of stenotic part of the graft renal artery after stent deployment

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  Discussion Top


SPK is the preferred treatment for T1DM with ESRD as it improves patient's quality of life.[4] During SPK, kidney is placed in intraperitoneal location, which may predispose it to TRAS as kidney is more mobile as compared to standard extraperitoneal placement. The incidence of TRAS in renal allograft recipients has been reported from 1% to 23%, depending on the different definitions and diagnostic techniques.[1] The patient in the current report presented with vague symptoms of fluid retention when being treated for ABMR. A high index of suspicion led to prompt diagnosis and treatment resulting in complete recovery of kidney function.

Our patient had several risk factors including atherosclerosis related to long-standing diabetes for the development of TRAS.[5] However, arterial stenosis occurred away from the atherosclerosed area as his iliac artery had also been replaced with donor iliac artery during surgery. Redundancy of external iliac artery might have led to tortuosity/kinking in the posttransplant period. TRAS can be at the site of anastomosis which is due to faulty surgical technique[6] or beyond anastomosis. In our patient TRAS was present at anastomosis site. Low shear stress due to altered flow dynamics in the tortious/kinked area is a known risk factor for the development of intimal hyperplasia[7],[8] and might have resulted in TRAS in the patient. Immune-mediated damage has also been shown to be associated with development of TRAS, which usually causes diffuse involvement of the renal artery. The presence of de novo Class II donor-specific antibodies and episodes of acute rejection have been significantly associated with development of postanastomotic TRAS.[2],[9] Interruption of immunosuppression due to SAIO might have resulted in ABMR. The present case was also being treated for ABMR when TRAS was suspected based on the Doppler findings.

The color Doppler ultrasonography criteria for diagnosis are a PSV higher than 200 cm/s in the renal artery, a RI of lower than 0.5, and a velocity gradient between stenotic and prestenotic segment of >2:1.[9] In the present case renal graft Duplex sonography revealed high peak systolic velocity (PSV) 228 cm/s, RI 1.0 at stenotic part of the renal artery and distal to the stenosis intersegmental arteries showed parvus tardus waveform with Resistive Index of 0.5 suggestive of TRAS. However, CT confirmed the diagnosis by providing three-dimensional images of the vessels. The patient was treated with percutaneous stenting, which is the preferred initial mode of therapy. The intervention procedures include PTA alone or with stent implantation. Although PTA has high success rate of up to 80%, development of restenosis is significantly higher when compared to stenting (28% vs. 8%).[1] There are studies which showed improved patency of Drug Eluting Stents (DES) over Bare Metal stent (BMS) that observed in post anastomotic TRAS may arise from the atherosclerosis mediated or immunologically mediated intimal hyperplasia. BMS was preferred at the anastomotic site as, unlike a DES, it does not obstruct blood flow to the kidney or the leg. BMS was preferred in anastomotic strictures, as our patient had stricture at the site of anastomosis.[3] Stenting in the present case was performed as there was significant residual stenosis after angioplasty. No Clinical parameters like blood pressure or serum creatinine helps in definitive diagnosis of TRAS or kidney perfusion monitoring. Among several procedures, duplex ultrasound is most practical and reproducible, particularly when the hemodynamic changes that accompany a significant stenosis and its effective revascularization have to be monitored serially. Ultrasound is highly reliable in such cases; posttreatment changes in PSV and RI have 100% sensitivity and specificity.[10] Our patient followed with duplex sonography with 6 monthly interval for about 10-month follow-up has normal PSV 89 at hilum (main renal artery) and RI of 0.71.


  Conclusion Top


TRAS is a reversible cause of graft dysfunction and can have vague presentation. Early diagnosis and timely percutaneous treatment can completely reverse graft dysfunction and good long-term outcome.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Bruno S, Remuzzi G, Ruggenenti P. Transplant renal artery stenosis. J Am Soc Nephrol 2004;15:134-41.  Back to cited text no. 1
    
2.
Willicombe M, Sandhu B, Brookes P, Gedroyc W, Hakim N, Hamady M, et al. Postanastomotic transplant renal artery stenosis: Association with de novo class II donor-specific antibodies. Am J Transplant 2014;14:133-43.  Back to cited text no. 2
    
3.
Biederman DM, Fischman AM, Titano JJ, Kim E, Patel RS, Nowakowski FS, et al. Tailoring the endovascular management of transplant renal artery stenosis. Am J Transplant 2015;15:1039-49.  Back to cited text no. 3
    
4.
Lindahl JP, Hartmann A, Horneland R, Holdaas H, Reisæter AV, Midtvedt K, et al. Improved patient survival with simultaneous pancreas and kidney transplantation in recipients with diabetic end-stage renal disease. Diabetologia 2013;56:1364-71.  Back to cited text no. 4
    
5.
Becker BN, Odorico JS, Becker YT, Leverson G, McDermott JC, Grist T, et al. Peripheral vascular disease and renal transplant artery stenosis: A reappraisal of transplant renovascular disease. Clin Transplant 1999;13:349-55.  Back to cited text no. 5
    
6.
Szabo-Pap M, Zadori G, Fedor R, Illesy L, Toth F, Kanyari Z, et al. Surgical complications following kidney transplantations: A single-center study in Hungary. Transplant Proc 2016;48:2548-51.  Back to cited text no. 6
    
7.
Malek AM, Alper SL, Izumo S. Hemodynamic shear stress and its role in atherosclerosis. JAMA 1999;282:2035-42.  Back to cited text no. 7
    
8.
Wong W, Fynn SP, Higgins RM, Walters H, Evans S, Deane C, et al. Transplant renal artery stenosis in 77 patients – Does it have an immunological cause? Transplantation 1996;61:215-9.  Back to cited text no. 8
    
9.
Snider JF, Hunter DW, Moradian GP, Castaneda-Zuniga WR, Letourneau JG. Transplant renal artery stenosis: Evaluation with duplex sonography. Radiology 1989;172:1027-30.  Back to cited text no. 9
    
10.
Bruno S, Ferrari S, Remuzzi G, Ruggenenti P. Doppler ultrasonography in posttransplant renal artery stenosis: A reliable tool for assessing effectiveness of revascularization? Transplantation 2003;76:147-53.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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