• Users Online: 147
  • Print this page
  • Email this page

 
Table of Contents
CASE REPORT
Year : 2017  |  Volume : 11  |  Issue : 3  |  Page : 166-167

Renal transplant in patient of end-stage renal disease with severe pulmonary hypertension


Department of Nephrology, Osmania Medical College, Hyderabad, Telangana, India

Date of Web Publication20-Dec-2017

Correspondence Address:
Dr. Manisha Sahay
Osmania Medical College, Hyderabad, Telangana
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijot.ijot_48_17

Get Permissions

  Abstract 


Pulmonary hypertension is a strong predictor of morbidity and mortality in patients with end stage renal disease and may be considered by many as a relative contra-indication for transplant. In this case report we describe complete resolution of pulmonary hypertension after renal transplantation.

Keywords: End-stage renal disease, pulmonary hypertension, right ventricular systolic pressures


How to cite this article:
Rangineni P, Sahay M, Ismail KM, Vali S. Renal transplant in patient of end-stage renal disease with severe pulmonary hypertension. Indian J Transplant 2017;11:166-7

How to cite this URL:
Rangineni P, Sahay M, Ismail KM, Vali S. Renal transplant in patient of end-stage renal disease with severe pulmonary hypertension. Indian J Transplant [serial online] 2017 [cited 2021 Apr 15];11:166-7. Available from: https://www.ijtonline.in/text.asp?2017/11/3/166/221195




  Introduction Top


Cardiovascular disease is the most common cause of mortality and morbidity in patients with chronic kidney disease. Pulmonary arterial hypertension (PAH) is an overlooked cardiovascular morbidity in these patients. PAH is defined as resting mean pulmonary artery pressure at or above 25 mmHg.[1],[2]

Duration of dialysis, extraosseous pulmonary calcification, high cardiac output due to arteriovenous fistula, anemia, fluid overload, other hormonal and metabolic imbalances associated with uremic milieu, and impaired endothelial function are various mechanisms responsible for the elevation of pulmonary arterial pressures.[2]

It is a strong independent predictor of morbidity and mortality in patients with end-stage renal disease (ESRD) on dialysis and postrenal transplant.[2],[3]

We report a case of severe secondary PAH in a patient of ESRD, which improved after renal transplantation.


  Case Report Top


A 28-year-old male patient was hypertensive and moderately built (body mass index [BMI] – 23) with ESRD secondary to chronic interstitial disease. He was on maintenance hemodialysis thrice a week for 1 year with kt/v of 1.3. He was on erythropoietin and iron therapy (for anemia), antihypertensives, and supportive therapy. During evaluation for renal transplantation, the patient was found to have mild-to-moderate right ventricular dysfunction with moderate PAH with right ventricular systolic pressures (RVSP) of 45 mmHg and mild left ventricular dysfunction (ejection fraction of 40%), which gradually progressed to severe PAH (RVSP – 75 mmHg) over 6 months. Computed tomography pulmonary angiogram showed dilated pulmonary vessels without evidence of thrombus. Pulmonary function test showed restrictive pattern (forced vital capacity [FVC] <50). The patient was advised for more frequent dialysis (4–5 sessions/week), anemia was corrected, hypertension well controlled with strict fluid and salt restriction and triple antihypertensives. The patient was treated with phosphodiesterase inhibitors (tadalafil) for 1 year, without much improvement in symptoms and decrease in pulmonary arterial pressures.

He underwent live-related renal allograft transplant, after 2 years on hemodialysis (donor-father), after thorough counseling regarding anesthesia, surgical and posttransplant complications, and with high-risk consent.

Intraoperative and postoperative period was uneventful. He received triple immunosuppression (Mycophenolate mofetil, tacrolimus, and wysolone) and supportive therapy.

Posttransplantation renal functions improved (serum creatinine – 0.7 mg/dl), dyspnea, chest congestion, and fluid overload subsided. The patient was discharged in stable condition and was on regular follow-up with stable renal functions (serum creatinine 0.9). Two-dimensional (2D)-echocardiogram done after 1 month showed significant reduction in pulmonary pressures (RVSP – 35 mmHg) and improvement in biventricular functions. Pulmonary function test done at 6 month showed increased FVC (60%–80%), and 2D-echo done at the 6th-month posttransplant showed normal right ventricular function with no PAH. He is currently asymptomatic and on regular follow-up.


  Discussion Top


Here, we report a case of ESRD with severe PAH, recovered after renal transplant.

PAH is commonly seen in patients with ESRD. Its prevalence rates vary from 16% to 58% in dialysis patients, etiology being multifactorial and associated with significant morbidity and mortality.[4],[5]

A retrospective study done by Lai et al.[5] in 638 renal transplant patients with PAH showed significant mortality (9.7%) and graft loss (8.6%), but other studies [2],[3],[6],[7] have shown decrease in PAH and improvement in lung functional capacities after renal transplantation. Etiology is multifactorial and is predominantly related to uremia, anemia, fluid overload and vascular calcification.[8],[9],[10]

In our case, the patient had severe PAH which did not respond to supportive therapy such as anemia correction, increase in dose of dialysis, fluid and salt restriction, and medical therapies (phosphodiesterase inhibitors), but significant improvement in the right ventricular and pulmonary arterial pressures was seen postrenal transplant. Improvement could be due to decreased preload, reduced pulmonary congestion, and recovery from uremic milieu.


  Conclusion Top


PAH in ESRD patients carries significant morbidity and mortality. As renal transplantation reduces PAH and improves quality of life, it should be considered as an option even in patients with ESRD and severe PAH.

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.
Alhamad EH, Al-Ghonaim M, Alfaleh HF, Cal JP, Said N. Pulmonary hypertension in end-stage renal disease and post renal transplantation patients. J Thorac Dis 2014;6:606-16.  Back to cited text no. 1
[PUBMED]    
2.
Sise ME, Courtwright AM, Channick RN. Pulmonary hypertension in patients with chronic and end-stage kidney disease. Kidney Int 2013;84:682-92.  Back to cited text no. 2
[PUBMED]    
3.
Abedini M, Sadeghi M, Naini AE, Atapour A, Golshahi J. Pulmonary hypertension among patients on dialysis and kidney transplant recipients. Ren Fail 2013;35:560-5.  Back to cited text no. 3
[PUBMED]    
4.
Bozbas SS, Akcay S, Altin C, Bozbas H, Karacaglar E, Kanyilmaz S, et al. Pulmonary hypertension in patients with end-stage renal disease undergoing renal transplantation. Transplant Proc 2009;41:2753-6.  Back to cited text no. 4
[PUBMED]    
5.
Lai Y-L, Wasse H, Kim W, Patzer R. Association of Pulmonary Hypertension at Kidney Transplant Evaluation and Subsequent Outcomes Following Transplantation [abstract]. Am J Transplant. 2015; 15 (suppl 3). http://atcmeetingabstracts.com/abstract/association-of-pulmonary-hypertension-at-kidney-transplant-evaluation-and-subsequent-outcomes-following-transplantation/. [Last accessed 2017 Dec 09].  Back to cited text no. 5
    
6.
Karacan O, Tutal E, Colak T, Sezer S, Eyüboǧlu FO, Haberal M, et al. Pulmonary function in renal transplant recipients and end-stage renal disease patients undergoing maintenance dialysis. Transplant Proc 2006;38:396-400.  Back to cited text no. 6
    
7.
Guleria S, Agarwal RK, Guleria R, Bhowmik D, Agarwal SK, Tiwari SC, et al. The effect of renal transplantation on pulmonary function and respiratory muscle strength in patients with end-stage renal disease. Transplant Proc 2005;37:664-5.  Back to cited text no. 7
    
8.
Abdelwhab S, Elshinnawy S. Pulmonary hypertension in chronic renal failure patients. Am J Nephrol 2008;28:990-7.  Back to cited text no. 8
[PUBMED]    
9.
Havlucu Y, Kursat S, Ekmekci C, Celik P, Serter S, Bayturan O, et al. Pulmonary hypertension in patients with chronic renal failure. Respiration 2007;74:503-10.  Back to cited text no. 9
[PUBMED]    
10.
Yigla M, Fruchter O, Aharonson D, Yanay N, Reisner SA, Lewin M, et al. Pulmonary hypertension is an independent predictor of mortality in hemodialysis patients. Kidney Int 2009;75:969-75.  Back to cited text no. 10
[PUBMED]    




 

Top
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
Abstract
Introduction
Case Report
Discussion
Conclusion
Introduction
Case Report
Discussion
Conclusion
References

 Article Access Statistics
    Viewed632    
    Printed25    
    Emailed0    
    PDF Downloaded91    
    Comments [Add]    

Recommend this journal