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Table of Contents
CASE REPORT
Year : 2021  |  Volume : 15  |  Issue : 3  |  Page : 269-271

Unusual presentation of posttransplant renal artery stenosis - A case report


1 Department of Nephrology, Yashoda Hospital, Hyderabad, Telangana, India
2 Department of Urology, Yashoda Hospital, Hyderabad, Telangana, India
3 Department of Cardiology, Yashoda Hospital, Hyderabad, Telangana, India

Date of Submission21-Sep-2020
Date of Decision10-Jan-2021
Date of Acceptance07-Feb-2021
Date of Web Publication30-Sep-2021

Correspondence Address:
Dr. Sashi Kiran Annavarajula
Departments of Nephrology, Yashoda Hospital, Hyderabad - 500 039, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijot.ijot_118_20

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  Abstract 

Transplant renal artery stenosis (TRAS) is a well-recognized and potentially treatable cause of early graft dysfunction. Recognition of TRAS can sometimes be difficult, and the presentation may mimic acute allograft rejection. A high index of suspicion along with arteriography is crucial in early recognition and management.

Keywords: Angioplasty, magnetic resonance angiogram, transplant renal artery stenosis


How to cite this article:
Annavarajula SK, Suryaprakash B, Kashinatham D, Poddar P. Unusual presentation of posttransplant renal artery stenosis - A case report. Indian J Transplant 2021;15:269-71

How to cite this URL:
Annavarajula SK, Suryaprakash B, Kashinatham D, Poddar P. Unusual presentation of posttransplant renal artery stenosis - A case report. Indian J Transplant [serial online] 2021 [cited 2021 Nov 29];15:269-71. Available from: https://www.ijtonline.in/text.asp?2021/15/3/269/327384


  Introduction Top


Early renal allograft dysfunction following a living-related renal transplant is rare. In instances where this happens, the presentation can sometimes be perplexing and difficult to diagnose. We present here a patient with early graft dysfunction who posed a diagnostic challenge.


  Case Report Top


A 53-year-old gentleman who developed end stage renal disease due to progression of IgA nephropathy underwent a living-related renal transplantation. The kidney donor was his sister and they had a 3/6 HLA match. Induction was with basiliximab and methylprednisolone. The graft kidney had a single renal artery, and it was anastomosed to the internal iliac artery of the recipient end to end. He had profound hypotension during the surgery and needed two inotropes for the next 36 h. There was a delayed graft function, but he did not need dialysis. Hypersensitivity to basiliximab was considered the cause of hypotension after carefully ruling out all the other possibilities. Hence, the second dose of basiliximab was skipped. The graft function was stable till the 7th postoperative day (POD).

An increase in the serum creatinine from 2.3 to 2.6 mg/dl along with a decrease in urine output occurred on the 8th POD. Renal biopsy was performed and the trough level of tacrolimus was estimated. The renal biopsy was opined as borderline T-cell–mediated rejection (TCMS) [Figure 1] and the trough level of tacrolimus was 6.24 mcg/l. The dose of tacrolimus was increased by 1 mg/day, and he was also administered methylprednisolone 500 mg/day for 3 days. The urine output progressively decreased and he became anuric by the 13th POD. His serum creatinine had worsened to 6 mg/dl. In-between, he needed two sessions of hemodialysis on the 10th and 12th POD. He also had worsening of hypertension and hyperkalemia. A second renal biopsy was performed and trough level of tacrolimus was estimated. This renal biopsy was suspicious of calcineurin inhibitor toxicity with no evidence of rejection. Donor-specific antibodies (DSAs) were not detected. The trough level of tacrolimus was 12.4 mcg/l. The dose of tacrolimus was reduced by 0.5 mg/day. The next day, his urine output increased to 500 ml/day. His serum creatinine started to decrease and reached 1.3 mg/dl by the 22nd POD. Despite this, his urine output remained low, his hypertension had worsened, and he had a weight gain of 12 kg. His urine revealed 1+ protein and no red blood cells. Cytomegalovirus was undetectable by quantitative DNA PCR estimation. At this juncture, renal artery stenosis (RAS) was suspected. Doppler examination of the renal artery was opined as normal and magnetic resonance angiogram was suspicious of RAS [Figure 2]. Since the suspicion for RAS was high, he was subjected to renal arteriography. The arteriography revealed significant stenosis of the renal artery at the anastomotic site [Figure 3]. Angioplasty and stent placement were performed. This resulted in gross diuresis. His edema and hypertension disappeared over the next 48 h. Now at 11 months posttransplant, he is normotensive and his serum creatinine is 0.8 mg/dl.
Figure 1: Renal biopsy

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Figure 2: Magnetic resonance angiogram

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Figure 3: Renal arteriography

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  Discussion Top


We present here a patient who developed early transplant renal artery stenosis (TRAS) and anuria. TRAS is a potentially curable cause of early allograft dysfunction which manifests between 3 months and 2 years after transplant[1] and can sometimes present as anuria.[2] The incidence of this complication varies between 1% and 23%, though the incidence of functionally significant TRAS occurs in about 12% of patients.[3] End-to-end anastomosis has a threefold greater risk of stenosis than an end-to-side anastomosis.[4]

There are several features that are interesting in our patient. The first and noteworthy was the development of anuria when the dose of tacrolimus was increased to achieve the therapeutic levels. Tacrolimus is known to cause vasoconstriction but rarely causes anuria in an adult who has undergone renal transplant since calcineurin-induced nephrotoxicity is predominantly nonoliguric.

Second, the renal biopsy (performed twice in this patient) did not show hyperplasia of the juxtaglomerular apparatus but rather showed features of tubulituis, suggestive of borderline TCMS prompting us to increase the dose of tacrolimus.[5] Acute rejection can cause endothelial proliferation, and this may mimic TRAS. There was no evidence of rejection in the second biopsy despite worsening of oliguria and graft function and this prompted us to suspect TRAS.

Third, Doppler ultrasonography which has a very good accuracy in detecting RAS but is operator dependent failed to detect TRAS in our patient.[6] Repeated Doppler examination did not reveal peak systolic velocity or resistive index which could suggest TRAS. Parvus et tardus pattern was conspicuously absent. Magnetic resonance imaging, which is known to have a high false-positive rate, was suggestive of stenosis.[7] Since the suspicion of TRAS was high, an arteriography was performed.


  Conclusion Top


The present patient serves as an illustrative example of the difficulties one can encounter in diagnosing early allograft kidney dysfunction. Since acute rejection is an important cause, the diagnostic uncertainty can sometimes make us to perform a renal biopsy when noninvasive diagnostic modalities are inconclusive. A high index of suspicion of TRAS and early therapeutic intervention would provide an excellent result.

Declaration of patient consent

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

Acknowledgements

Dr. Ravikanth J, Radiologist, and Dr. Sarika, Pathologist, were acknowledged.

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.
Kawaskar K, Balasubramaniyan T, Gopalakrishnan N, Kumar TD, Chandrasekaran K, Sakthirajan R, et al. Incidence and outcome of transplant renal artery stenosis: A single-center experience. Indian J Transplant 2018;12:13-6.  Back to cited text no. 2
  [Full text]  
3.
Audard V, Matignon M, Hemery F, Snanoudj R, Desgranges P, Anglade MC, et al. Risk factors and long-term outcome of transplant renal artery stenosis in adult recipients after treatment by percutaneous transluminal angioplasty. Am J Transplant 2006;6:95-9.  Back to cited text no. 3
    
4.
Jordan ML, Cook GT, Cardella CJ. Ten years of experience with vascular complications in renal transplantation. J Urol 1982;128:689-92.  Back to cited text no. 4
    
5.
Mlinšek G, Jerman A, Kovač D, Lindič J, Mihelič M, Lakic N, et al. A complicated case of transplant renal artery stenosis: A case report and literature review. Int J Transplant Res Med 2015;1:010.  Back to cited text no. 5
    
6.
de Morais RH, Muglia VF, Mamere AE, Garcia Pisi T, Saber LT, Muglia VA, et al. Duplex Doppler sonography of transplant renal artery stenosis. J Clin Ultrasound 2003;31:135-41.  Back to cited text no. 6
    
7.
Loubeyre P, Cahen R, Grozel F, Trolliet P, Pouteil-Noble C, Labeeuw M, et al. Transplant renal artery stenosis. Evaluation of diagnosis with magnetic resonance angiography compared with color duplex sonography and arteriography. Transplantation 1996;62:446-50.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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