|Year : 2020 | Volume
| Issue : 1 | Page : 82-84
Small caliber aortoiliac arteries in a patient undergoing renal transplantation for iga nephropathy
RB Nerli1, Vishal Kadeli2, Aarushi Mishra2, C Shridhar Ghagane3, Neeraj S Dixit3, Murigendra B Hiremath4
1 Department of Urology, J N Medical College, KLE Academy of Higher Education and Research, JNMC Campus; Department of Urology, KLES Kidney Foundation KLES Dr. Prabhakar Kore Hospital and Medical Research Centre, Belagavi, Karnataka, India
2 Department of Urology, J N Medical College, KLE Academy of Higher Education and Research, JNMC Campus, Belagavi, Karnataka, India
3 Department of Urology, KLES Kidney Foundation KLES Dr. Prabhakar Kore Hospital and Medical Research Centre, Belagavi, Karnataka, India
4 Department of Biotechnology and Microbiology, Karnatak University, Dharwad, Karnataka, India
|Date of Submission||30-Apr-2019|
|Date of Acceptance||22-Jan-2020|
|Date of Web Publication||31-Mar-2020|
Dr. R B Nerli
Department of Urology, J N Medical College, KLE Academy of Higher Education and Research, JNMC Campus, Belagavi - 590 010, Karnataka
Source of Support: None, Conflict of Interest: None
IgA nephropathy (IgAN) is a common form of primary glomerulonephritis. Most cases of IgAN are discovered incidentally by abnormal urinalysis (hematuria or proteinuria) and diagnosed by renal biopsy. Nearly 30%–50% of patients with IgAN progress to end-stage renal disease (ESRD) at a follow-up of 25 years. We report a case of small caliber iliac vessels in a patient undergoing renal transplant for ESRD secondary to IgAN.
Keywords: Aortoiliac, disease Doppler ultrasound, recipient, renal transplantation
|How to cite this article:|
Nerli R B, Kadeli V, Mishra A, Ghagane C S, Dixit NS, Hiremath MB. Small caliber aortoiliac arteries in a patient undergoing renal transplantation for iga nephropathy. Indian J Transplant 2020;14:82-4
|How to cite this URL:|
Nerli R B, Kadeli V, Mishra A, Ghagane C S, Dixit NS, Hiremath MB. Small caliber aortoiliac arteries in a patient undergoing renal transplantation for iga nephropathy. Indian J Transplant [serial online] 2020 [cited 2020 Jul 6];14:82-4. Available from: http://www.ijtonline.in/text.asp?2020/14/1/82/281759
| Introduction|| |
Kidney transplantation is the treatment of choice for end-stage renal disease (ESRD). Compared to maintenance dialysis, successful kidney transplantation improves the quality of life and reduces the mortality risk for most patients. All the renal transplant recipients need to undergo a prescribed evaluation process to estimate the risks and benefits of transplantation. The patient must be educated and counseled regarding the risks associated with renal failure and existing comorbidities, as well as the risk of the operative procedure and required immunosuppression. The estimates of graft and patient survival with various options of kidney sources should be discussed to have realistic expectations.
All potential kidney transplant recipients should be carefully evaluated to assess the feasibility of kidney transplantation and to detect and treat coexisting illnesses that may affect graft survival. Certain radiological imaging procedures are routinely performed in all recipients. These include chest radiography, abdominal radiography, abdominal ultrasonography, echocardiography, and coronary stress tests. Many patients before transplants need to undergo a detailed evaluation to assess the native urinary tract or to evaluate whether nephrectomy is necessary (e g., patients with complicated kidney stones or autosomal-dominant polycystic kidney disease). In addition, a significant number of potential kidney transplant recipients could also be having peripheral vascular disease. Patients could be symptomatic or asymptomatic for peripheral vascular disease. Routine screening of the peripheral vascular system is indicated in patients who are chronic tobacco users, diabetics or have many cardiovascular risk factors. Screening involves the evaluation of arterial caliber and calcifications to ascertain whether renal transplantation (RT) is possible and whether any presurgical procedures are necessary (e.g., aortofemoral bypass) and to determine the optimal surgical technique.
Multiplanar and three-dimensional images obtained with multidetector computed tomography (CT) are useful tools to provide the surgeon with the essential information required for adequate management. The indications for multiplanar CT include age >50 years, diabetes or hypertension being the cause of chronic kidney disease, atherosclerotic disease (ischemic heart disease or peripheral arteriopathy), and presence of aortoiliac calcifications on plain radiograph. We report the case of small caliber iliac vessels in a patient undergoing renal transplant for ESRD secondary to IgAN.
| Case Report|| |
A 19-year-old male with the diagnosis of chronic renal failure was scheduled for RT. The patient was earlier diagnosed to have IgA nephropathy (IgAN) and was on maintenance hemodialysis. Renal biopsy revealed chronic sclerosing glomerulonephritis with severe tubular atrophy and interstitial fibrosis >50% and mild arteriosclerosis and hyaline arteriosclerosis. The immunofluorescence study revealed a single core composed of two viable glomeruli. There were diffuse and global, granular deposits predominantly in the mesangium and segmentally along the glomerular capillary loops with antisera to IgA (2+), C3C (1+), KAPPA (1+), and LAMBDA (2+). However, antisera to IgG, IgM, and CLG did not reveal any staining. Echocardiography of the recipient revealed moderate left ventricular dysfunction with an ejection fraction of 35% and global hypokinesia of the left ventricle. The upper limb and lower limb pulses of the recipient were of normal volume and blood pressure was mmHg.
The mother was the donor for the live-related renal transplant. The donor and the recipient were prepared for the transplant as per the hospital protocol and guidelines of the Indian transplant act. Renal CT angiography of the donor showed a single renal artery on the left side [Figure 1]a, [Figure 1]b, [Figure 1]c. The caliber of the left renal artery was 5 mm, and the left renal vein was 8 mm. Both the donor kidneys were normal in shape, size, and appearance. The recipient carried the American Society for Anesthesiology Class IV risk.
|Figure 1: (a-c) Computed tomography renal angiography showing a single renal artery and vein on the left side. The caliber of the left renal artery is 5 mm|
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The recipient underwent the exploration of the right lower abdomen using a modified Gibson's incision. The right external and common iliac veins were of normal caliber. The right external iliac, right common iliac, and lower aortic vessels appeared of narrow caliber, pale in color, and there was evidence of perivascular inflammation. The area around the bifurcation of common iliac vessels on the right side appeared to be plastered to the underlying tissues. The external iliac artery and common iliac artery were dissected from the surrounding tissues. It was decided to perform arterial anastomosis at the level of common iliac artery (end to side) as the caliber was better than the rest. An end-to-side anastomosis was done [Figure 2]a and b]. The immediate postoperative period was uneventful. Urine output on day 1 was 4200 cc, and serum creatinine came down to 2.2 mg%. Serum creatinine came down to 1.1 mg% on the 3rd postoperative day. Color Doppler done on the 2nd and 7th postoperative days showed normal blood flow across the anastomosis with the resistive index of 1.
|Figure 2:(a) Operative photograph shows right common iliac vein of normal caliber and a small caliber right common iliac artery. (b) End-to-side anastomosis between renal artery, vein, and common iliac artery and vein|
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| Discussion|| |
As the indications for RT keeps on the rise, it has led to a large number of recipients with vascular disease and more advanced ages. Patients with chronic renal failure often exhibit some degree of atherosclerosis and arterial wall calcifications due to end-stage renal failure, associated cardiovascular risk factors, and/or hyperparathyroidism. Preoperative vascular assessment of the recipient is necessary and must be performed before including the patient on the waiting list. This initial assessment includes vascular physical examination with femoral artery palpation and color Doppler ultrasound to identify external iliac artery atheroma that could compromise anastomosis viability.
Systemic vasculitis is a group of multisystem diseases that is characterized by the inflammation of blood vessels. The American College of Rheumatology and the Chapel Hill Consensus Conference have both provided with a classification. Currently, the classification system for vasculitis is based on vessel size and clinicopathological features. It is important to recognize and accurately diagnose the type of vasculitis as it is crucial for optimal management. Some patients with vasculitis may have features consistent with more than one type of vasculitis syndrome. Another recognized problem is that a patient may present with one form of vasculitis and develop years later another form.
Our patient was a case of chronic renal failure secondary to IgAN. IgAN is the most common primary glomerulonephritis worldwide. Most cases of IgAN are discovered incidentally by abnormal urinalysis (hematuria or proteinuria) and diagnosed by renal biopsy., Patients with IgAN and histological vasculitic/crescentic lesions are known to have a poor prognosis. The rate of IgAN progression is variable with 30%–50% of patients progressing to ESRD at a follow-up of 25 years. The presence of minimal (<500 mg/day) or no proteinuria generally indicates a good long-term prognosis, whereas hypertension is a contributing factor for the progression of renal impairment. This patient also had small caliber iliac arteries and aorta. The reason could be probably due to vasculitis. Initially starting with IgA vasculitis and progressing to aortoiliac disease. Small caliber vessels make vascular anastomosis during RT difficult and may be associated with a higher complication rate.
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
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]