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Zhang L, Zou J, Zhou J, Qiu T, Kong C, Wang T, Chen Z, Liu X. Graft survival after percutaneous transluminal renal stenting for transplant renal artery stenosis (TRAS) is worse compared to matched cadaveric grafts without TRAS. Ren Fail 2024; 46:2378211. [PMID: 39082473 PMCID: PMC11293260 DOI: 10.1080/0886022x.2024.2378211] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 05/29/2024] [Accepted: 07/04/2024] [Indexed: 08/03/2024] Open
Abstract
OBJECTIVES Transplant renal artery stenosis (TRAS) is now recognized as a curable disease with a good prognosis if intervention occurs in the early stage. However, the mid-term outcomes of TRAS when treated by percutaneous transluminal angioplasty with stent placement have yet to be fully elucidated. The purpose of this study was to compare mid-term graft and patient survival of TRAS group with a control group. PATIENTS AND METHODS Ninety-two patients were diagnosed of TRAS between January 2016 and January 2022 in our center. Fifty-six pairs of recipients with grafts from the same donor were selected as a study group with TRAS and a control group without TRAS, respectively. All donor kidneys were from deceased organ donation rather than living donors. The primary endpoints were graft and patient survival. The secondary outcomes were changes in renal graft function. RESULTS The mean follow-up time for the TRAS group was 43.6 months, while the mean follow-up time for the control group was 45.3 months. In the TRAS group, the age of patients ranged from 11 to 62 years with 39 males and 17 females. In the control group, the age of patients ranged from 18 to 67 years with 40 males and 16 females. In the TRAS group, there were more patients with diabetic nephropathy as the primary renal disease compared to the control group (5/56 vs 0/56), and the incidence of acute rejection was higher in the TRAS group than in the control group (12/56 vs 3/56). Eight patients in the TRAS group and one patient in the control group experienced graft loss (p = .019). Four patients in the TRAS group and four patients in the control group died with functional renal allograft during the follow-up time (p = .989). The levels of eGFR did not differ significantly between the two groups in the first three years after kidney transplant (p > .05). Patients in the TRAS group had worse graft functionality (eGFR, 44.96 ± 18.9 vs 54.9 ± 19.6 mL/min) in the fourth year when compared with the control group (p = .01). CONCLUSIONS The graft function deteriorated faster, and graft survival was lower in the TRAS group treated by stent placement when compared with a control group without TRAS over the mid-term.
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Affiliation(s)
- Long Zhang
- Department of Organ Transplantation, The People’s Hospital Affiliated Wuhan University, Wuhan, China
| | - Jilin Zou
- Department of Organ Transplantation, The People’s Hospital Affiliated Wuhan University, Wuhan, China
| | - Jiangqiao Zhou
- Department of Organ Transplantation, The People’s Hospital Affiliated Wuhan University, Wuhan, China
| | - Tao Qiu
- Department of Organ Transplantation, The People’s Hospital Affiliated Wuhan University, Wuhan, China
| | - Chenyang Kong
- Department of Organ Transplantation, The People’s Hospital Affiliated Wuhan University, Wuhan, China
| | - Tianyu Wang
- Department of Organ Transplantation, The People’s Hospital Affiliated Wuhan University, Wuhan, China
| | - Zhongbao Chen
- Department of Organ Transplantation, The People’s Hospital Affiliated Wuhan University, Wuhan, China
| | - Xiuheng Liu
- Department of Urinary Surgery, The People’s Hospital Affiliated Wuhan University, Wuhan, China
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Martin PJP, Willicombe M, Roufosse C. Angiotensin II Type-1 Receptor Antibody in Solid Organ Transplantation - Is It Time to Test? Transpl Int 2024; 37:13280. [PMID: 39606688 PMCID: PMC11598415 DOI: 10.3389/ti.2024.13280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2024] [Accepted: 10/15/2024] [Indexed: 11/29/2024]
Abstract
Angiotensin II type-1 receptor antibody (AT1R-Ab) has been mooted as a potential effector of both acute and chronic antibody mediated rejection (AMR). A growing body of literature on the topic is now coming under scrutiny in the context of the evolving Banff AMR diagnostic classification system and refinement of recommendations for histocompatibility testing by the Sensitization in Transplantation Assessment of Risk (STAR) workgroup. This mini-review discusses the latest understanding of pathophysiological mechanisms, clinical evidence for the pathogenicity of AT1R-Ab, and methods of laboratory testing.
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Affiliation(s)
- Paul James Patrick Martin
- Department of Immunology and Inflammation, Imperial College London, Hammersmith Campus, London, United Kingdom
- Imperial College Renal and Transplant Centre, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Michelle Willicombe
- Department of Immunology and Inflammation, Imperial College London, Hammersmith Campus, London, United Kingdom
- Imperial College Renal and Transplant Centre, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Candice Roufosse
- Department of Immunology and Inflammation, Imperial College London, Hammersmith Campus, London, United Kingdom
- Department of Histopathology, Northwest London Pathology NHS Trust, Charing Cross Hospital, London, United Kingdom
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3
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Choudhary D, Vijayvergiya R, Kishore K, Subramani VN, Banoth M, Reddy Perugu SP, Mandwar M, Bamaniya B, Panjathia A, Gupta P, Patil SKS, Sethi J, Gorsi U, Singh S, Kenwar D, Sharma A. Vascular Reconstruction of Multiple Renal Arteries-A Risk Factor for Transplant Renal Artery Stenosis: Insight From a Matched Case-Control Study. Transpl Int 2024; 37:13298. [PMID: 39575124 PMCID: PMC11580035 DOI: 10.3389/ti.2024.13298] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2024] [Accepted: 10/07/2024] [Indexed: 11/24/2024]
Abstract
Transplant Renal Artery Stenosis (TRAS) is the leading vascular complication following kidney transplantation (KT), causing premature allograft loss and increased post-KT mortality. While risk factors for TRAS, such as prolonged cold ischemia time and delayed graft function, are well-documented in deceased donor-KT, the risk factors remain less clearly defined in living donor-KT. This matched case-control study, conducted at a leading national transplant center predominantly performing living donor-KT, evaluated risk factors and long-term outcomes of clinical TRAS (cTRAS). cTRAS cases diagnosed from January 2009 to December 2022 were matched with four control kidney transplant recipients (KTRs) in a study powered to assess whether ex-vivo arterial vascular reconstruction of multiple renal arteries (VR-MRA) increases the risk of cTRAS. Among 2,454 KTs, 28 KTRs (1.14%) were diagnosed with cTRAS around 3.62 ± 1.04 months post-KT, with renal allograft dysfunction (92.86%) as the most common presenting feature. Notably, 27 cTRAS cases were successfully treated with endovascular intervention, yielding favorable outcomes over a 6-180 months follow-up period. The study identified ex-vivo VR-MRA as an independent risk factor for cTRAS (P < 0.001). cTRAS cases receiving timely treatment exhibited long-term outcomes in graft and patient survival similar to control KTRs. Early screening and timely intervention for cTRAS post-KT may improve graft and patient outcomes.
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Affiliation(s)
- Devprakash Choudhary
- Department of Renal Transplant Surgery, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | | | - Kamal Kishore
- Department of Biostatistics, PGIMER, Chandigarh, India
| | - Vanji Nathan Subramani
- Department of Renal Transplant Surgery, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Mohan Banoth
- Department of Renal Transplant Surgery, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Sai Praneeth Reddy Perugu
- Department of Renal Transplant Surgery, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Milind Mandwar
- Department of Renal Transplant Surgery, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Bharat Bamaniya
- Department of Renal Transplant Surgery, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Arun Panjathia
- Department of Renal Transplant Surgery, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Parul Gupta
- Department of Hospital Administration, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Shiva Kumar S. Patil
- Department of Renal Transplant Surgery, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | | | - Ujjwal Gorsi
- Department of Radiology, PGIMER, Chandigarh, India
| | - Sarbpreet Singh
- Department of Renal Transplant Surgery, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Deepesh Kenwar
- Department of Renal Transplant Surgery, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ashish Sharma
- Department of Renal Transplant Surgery, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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4
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Pu X, Wang B, Pan J, Yu X, Dai W, He Y. Endovascular Treatment for Transplant Renal Artery Stenosis: 10 Years' Experience from a Single Center. Kidney Blood Press Res 2024; 49:821-830. [PMID: 39236687 DOI: 10.1159/000541125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Accepted: 08/22/2024] [Indexed: 09/07/2024] Open
Abstract
INTRODUCTION Transplant renal artery stenosis (TRAS) is a common post-renal transplant complication. Although endovascular treatment is widely used to treat TRAS, previous research has been limited by small sample sizes. This article aimed to present the clinical outcomes of endovascular treatment for TRAS in a large sample. METHODS Between January 2010 and December 2019, this study included patients with TRAS who were admitted to our center. All patients' clinical symptoms, comorbidities, imaging data, treatment, and follow-up results were reviewed retrospectively. RESULTS Seventy two patients participated in this study. The median time between renal transplantation and TRAS was 5.25 months. Out of 72 patients, 55 (76.4%) received balloon dilatation in conjunction with stent deployment, 10 (13.9%) received drug-coated balloon dilatation alone, and 7 (9.7%) received balloon dilatation alone. The median follow-up period was 27 months. Primary patency rates were 100%, 81.8%, 74.5%, 64.6%, and 61.8% at 1, 3, 6, 12, and 24 months. A total of 23 patients were found to have restenosis during follow-up, with 6 (26.1%) requiring reintervention and none remaining restenosis after the second treatment. In the subgroup analysis of the three types of stenosis, patients with transplant renal stenosis at the anastomosis had a significantly higher rate of primary patency. Between endovascular treatments, the primary patency rate, postoperative creatinine clearance, and mean systolic blood pressure did not differ significantly. CONCLUSION Endovascular treatment resulted in favorable short-term patency as well as effective relief of renal dysfunction and renal hypertension in TRAS patients.
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Affiliation(s)
- Xibin Pu
- Department of General Surgery, Haiyan People's Hospital, Hangzhou, China
| | - Bing Wang
- Department of Vascular Surgery, The First Affiliated Hospital of Zhejiang University, Hangzhou, China
| | - Jun Pan
- Department of Vascular Surgery, The First Affiliated Hospital of Zhejiang University, Hangzhou, China
| | - Xinyu Yu
- Department of Vascular Surgery, The First Affiliated Hospital of Zhejiang University, Hangzhou, China
| | - Wei Dai
- Department of General Surgery, Haiyan People's Hospital, Hangzhou, China
| | - Yangyan He
- Department of Vascular Surgery, The First Affiliated Hospital of Zhejiang University, Hangzhou, China
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5
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Calzas Montalvo C, Medina-Polo J, Miranda Utrera NR, Juste Álvarez S, de la Calle Moreno A, Caro González MP, Santos Perez de la Blanca R, Hernández Arroyo M, Peña Vallejo E, Teigell Tobar J, Duarte Ojeda JM, Pamplona Casamayor M, Tejido Sánchez Á, García González L, Arrébola Pajares A, Sánchez Guerrero Á, Rodríguez de la Calle J, Rodríguez Antolín A. Transplant renal artery stenosis: Study of incidence using doppler ultrasound, risk factors and analysis is effect in graft outcomes. Actas Urol Esp 2024; 48:177-183. [PMID: 37574014 DOI: 10.1016/j.acuroe.2023.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 06/24/2023] [Accepted: 06/26/2023] [Indexed: 08/15/2023]
Abstract
INTRODUCTION AND OBJECTIVES Transplant renal artery stenosis (TRAS) is a vascular complication after kidney transplantation which estimated incidence is 13%. It could cause refractory arterial hypertension, kidney dysfunction and premature death in transplant recipients. METHODS We carried out a retrospective study including every patient who underwent renal transplantation between 2014 and 2020. They were evaluated with a systematic post-transplant renal Doppler ultrasound. To identify independent risk factors for transplant renal artery stenosis we performed a multivariate analysis. RESULTS Seven hundred twenty-four kidney transplants were included, 12% were living donors and 88% were deceased donors. The mean age was 54.8 in recipients and 53 in donors. Transplant renal artery stenosis was diagnosed in 70 (10%) recipients, the majority in the first 6 months after surgery. 51% of patients with transplant renal artery stenosis were managed conservatively. The multivariate analysis showed diabetes mellitus, graft rejection, arterial resuture and donor body mass index as independent risk factors for transplant renal artery stenosis. Survival of the grafts with transplant renal artery stenosis was 98% at 6 months and 95% at two years. CONCLUSIONS The systematic performance of Doppler ultrasound in the immediate post-transplant period diagnosed 10% of transplant renal artery stenosis in our cohort. Despite the above risk factors, an adequate monitoring and treatment could avoid the increased risk of graft loss in patients with transplant renal artery stenosis.
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Affiliation(s)
- C Calzas Montalvo
- Servicio de Urología, Hospital Universitario 12 de Octubre imas12, Madrid, Spain.
| | - J Medina-Polo
- Servicio de Urología, Hospital Universitario 12 de Octubre imas12, Madrid, Spain
| | - N R Miranda Utrera
- Servicio de Urología, Hospital Universitario 12 de Octubre imas12, Madrid, Spain
| | - S Juste Álvarez
- Servicio de Urología, Hospital Universitario 12 de Octubre imas12, Madrid, Spain
| | - A de la Calle Moreno
- Servicio de Urología, Hospital Universitario 12 de Octubre imas12, Madrid, Spain
| | - M P Caro González
- Servicio de Urología, Hospital Universitario 12 de Octubre imas12, Madrid, Spain
| | | | - M Hernández Arroyo
- Servicio de Urología, Hospital Universitario 12 de Octubre imas12, Madrid, Spain
| | - E Peña Vallejo
- Servicio de Urología, Hospital Universitario 12 de Octubre imas12, Madrid, Spain
| | - J Teigell Tobar
- Servicio de Urología, Hospital Universitario 12 de Octubre imas12, Madrid, Spain
| | - J M Duarte Ojeda
- Servicio de Urología, Hospital Universitario 12 de Octubre imas12, Madrid, Spain
| | - M Pamplona Casamayor
- Servicio de Urología, Hospital Universitario 12 de Octubre imas12, Madrid, Spain
| | - Á Tejido Sánchez
- Servicio de Urología, Hospital Universitario 12 de Octubre imas12, Madrid, Spain
| | - L García González
- Servicio de Urología, Hospital Universitario 12 de Octubre imas12, Madrid, Spain
| | - A Arrébola Pajares
- Servicio de Urología, Hospital Universitario 12 de Octubre imas12, Madrid, Spain
| | - Á Sánchez Guerrero
- Servicio de Radiología, Hospital Universitario 12 de Octubre imas12, Madrid, Spain
| | | | - A Rodríguez Antolín
- Servicio de Urología, Hospital Universitario 12 de Octubre imas12, Madrid, Spain
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Tian X, Ji B, Niu X, Duan W, Wu X, Cao G, Zhang C, Zhao J, Wang Z, Gu Y, Cao H, Qin T, Shao F, Yan T. Efficacy and safety of low-dose aspirin on preventing transplant renal artery stenosis: a prospective randomized controlled trial. Chin Med J (Engl) 2023; 136:541-549. [PMID: 36914946 PMCID: PMC10106233 DOI: 10.1097/cm9.0000000000002574] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Indexed: 03/16/2023] Open
Abstract
BACKGROUND Transplant renal artery stenosis (TRAS) is a vascular complication after kidney transplantation associated with poor outcomes. This study aimed to analyze the efficacy and safety of low-dose aspirin for preventing TRAS. METHODS After kidney transplantation, patients were enrolled from January 2018 to December 2020 in Henan Provincial People's Hospital. A total of 351 enrolled recipients were randomized to an aspirin group with low-dose intake of aspirin in addition to standard treatment ( n = 178), or a control group with only standard treatment ( n = 173). The patients was initially diagnosed as TRAS (id-TRAS) by Doppler ultrasound, and confirmed cases were diagnosed by DSA (c-TRAS). RESULTS In the aspirin and control groups, 15.7% (28/178) and 22.0% (38/173) of the recipients developed id-TRAS, respectively, with no statistical difference. However, for c-TRAS, the difference of incidence and cumulative incidence was statistically significant. The incidence of c-TRAS was lower in the aspirin group compared with the control group (2.8% [5/178] vs. 11.6% [20/173], P = 0.001). Kaplan-Meier estimates and Cox regression model identified the cumulative incidence and hazard ratio (HR) of TRAS over time in two groups, showing that recipients treated with aspirin had a significantly lower risk of c-TRAS than those who were not treated (log-rank P = 0.001, HR = 0.23, 95% confidence interval [CI]: 0.09-0.62). The levels of platelet aggregation rate ( P < 0.001), cholesterol ( P = 0.028), and low-density lipoprotein cholesterol ( P = 0.003) in the aspirin group were decreased compared with the control group in the third-month post-transplantation. For the incidence of adverse events, there was no statistical difference. CONCLUSION Clinical application of low-dose aspirin after renal transplant could prevent the development of TRAS with no significant increase in adverse effects. TRIAL REGISTRATION Clinicaltrials.gov, NCT04260828.
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Affiliation(s)
- Xiangyong Tian
- Department of Urology, Henan Provincial People's Hospital, Henan Provincial Clinical Research Center for Kidney Disease, Zhengzhou University People's Hospital, Henan University People’ Hospital Zhengzhou, Henan 450003, China
| | - Bingqing Ji
- Department of Urology, Henan Provincial People's Hospital, Henan Provincial Clinical Research Center for Kidney Disease, Zhengzhou University People's Hospital, Henan University People’ Hospital Zhengzhou, Henan 450003, China
| | - Xiaoge Niu
- Department of Nephrology, Henan Provincial People's Hospital, Henan Provincial Key Laboratory of Kidney Disease and Immunology, Henan Provincial Clinical Research Center for Kidney Disease, Zhengzhou University People's Hospital, Henan University People’ Hospital Zhengzhou, Henan 450003, China
| | - Wenjing Duan
- Department of the Clinical Research Center, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Henan University People’ Hospital Zhengzhou, Henan 450003, China
| | - Xiaoqiang Wu
- Department of Urology, Henan Provincial People's Hospital, Henan Provincial Clinical Research Center for Kidney Disease, Zhengzhou University People's Hospital, Henan University People’ Hospital Zhengzhou, Henan 450003, China
| | - Guanghui Cao
- Department of Urology, Henan Provincial People's Hospital, Henan Provincial Clinical Research Center for Kidney Disease, Zhengzhou University People's Hospital, Henan University People’ Hospital Zhengzhou, Henan 450003, China
| | - Chan Zhang
- Department of Urology, Henan Provincial People's Hospital, Henan Provincial Clinical Research Center for Kidney Disease, Zhengzhou University People's Hospital, Henan University People’ Hospital Zhengzhou, Henan 450003, China
| | - Jingge Zhao
- Department of the Clinical Research Center, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Henan University People’ Hospital Zhengzhou, Henan 450003, China
| | - Zhiwei Wang
- Department of Urology, Henan Provincial People's Hospital, Henan Provincial Clinical Research Center for Kidney Disease, Zhengzhou University People's Hospital, Henan University People’ Hospital Zhengzhou, Henan 450003, China
| | - Yue Gu
- Department of Nephrology, Henan Provincial People's Hospital, Henan Provincial Key Laboratory of Kidney Disease and Immunology, Henan Provincial Clinical Research Center for Kidney Disease, Zhengzhou University People's Hospital, Henan University People’ Hospital Zhengzhou, Henan 450003, China
| | - Huixia Cao
- Department of Nephrology, Henan Provincial People's Hospital, Henan Provincial Key Laboratory of Kidney Disease and Immunology, Henan Provincial Clinical Research Center for Kidney Disease, Zhengzhou University People's Hospital, Henan University People’ Hospital Zhengzhou, Henan 450003, China
| | - Tao Qin
- Department of Hepatobiliary and Pancreatic Surgery, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Henan University People’ Hospital Zhengzhou, Henan 450003, China
| | - Fengmin Shao
- Department of Nephrology, Henan Provincial People's Hospital, Henan Provincial Key Laboratory of Kidney Disease and Immunology, Henan Provincial Clinical Research Center for Kidney Disease, Zhengzhou University People's Hospital, Henan University People’ Hospital Zhengzhou, Henan 450003, China
| | - Tianzhong Yan
- Department of Urology, Henan Provincial People's Hospital, Henan Provincial Clinical Research Center for Kidney Disease, Zhengzhou University People's Hospital, Henan University People’ Hospital Zhengzhou, Henan 450003, China
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Verloh N, Doppler M, Hagar MT, Kulka C, von Krüchten R, Neubauer J, Weiß J, Röthele E, Schneider J, Jänigen B, Uller W. Interventional Management of Vascular Complications after Renal Transplantation. ROFO-FORTSCHR RONTG 2023; 195:495-504. [PMID: 36863368 DOI: 10.1055/a-2007-9649] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
BACKGROUND Kidney transplantations are increasing due to demographic changes and are the treatment of choice for end-stage renal disease. Non-vascular and vascular complications may occur in the early phase after transplantation and at later stages. Overall postoperative complications after renal transplantations occur in approximately 12 % to 25 % of renal transplant patients. In these cases, minimally invasive therapeutic interventions are essential to ensure long-term graft function. This review article focuses on the most critical vascular complications after renal transplantation and highlights current recommendations for interventional treatment. METHOD A literature search was performed in PubMed using the search terms "kidney transplantation", "complications", and "interventional treatment". Furthermore, the 2022 annual report of the German Foundation for Organ Donation and the EAU guidelines for kidney transplantation (European Association of Urology) were considered. RESULTS AND CONCLUSION Image-guided interventional techniques are favorable compared with surgical revision and should be used primarily for the treatment of vascular complications. The most common vascular complications after renal transplantation are arterial stenoses (3 %-12.5 %), followed by arterial and venous thromboses (0.1 %-8.2 %) and dissection (0.1 %). Less frequently, arteriovenous fistulas or pseudoaneurysms occur. In these cases, minimally invasive interventions show a low complication rate and good technical and clinical results. Diagnosis, treatment, and follow-up should be performed in an interdisciplinary approach at highly specialized centers to ensure the preservation of graft function. Surgical revision should be considered only after exhausting minimally invasive therapeutic strategies. KEY POINTS · Vascular complications after renal transplantation occur in 3 % to 15 % of patients.. · Image-guided interventional procedures should be performed primarily to treat vascular complications of renal transplantation.. · Minimally invasive interventions have a low complication rate with good technical and clinical outcomes.. CITATION FORMAT · Verloh N, Doppler M, Hagar MT et al. Interventional Management of Vascular Complications after Renal Transplantation. Fortschr Röntgenstr 2023; DOI: 10.1055/a-2007-9649.
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Affiliation(s)
- Niklas Verloh
- Department of Diagnostic and Interventional Radiology, Medical Center-University of Freiburg, Germany
| | - Michael Doppler
- Department of Diagnostic and Interventional Radiology, Medical Center-University of Freiburg, Germany
| | - Muhammad Taha Hagar
- Department of Diagnostic and Interventional Radiology, Medical Center-University of Freiburg, Germany
| | - Charlotte Kulka
- Department of Diagnostic and Interventional Radiology, Medical Center-University of Freiburg, Germany
| | - Ricarda von Krüchten
- Department of Diagnostic and Interventional Radiology, Medical Center-University of Freiburg, Germany
| | - Jakob Neubauer
- Department of Diagnostic and Interventional Radiology, Medical Center-University of Freiburg, Germany
| | - Jakob Weiß
- Department of Diagnostic and Interventional Radiology, Medical Center-University of Freiburg, Germany
| | - Elvira Röthele
- Department of Medicine IV, Medical Center-University of Freiburg, Germany
| | - Johanna Schneider
- Department of Medicine IV, Medical Center-University of Freiburg, Germany
| | - Bernd Jänigen
- Department of General and Visceral Surgery, Medical Center-University of Freiburg, Germany
| | - Wibke Uller
- Department of Diagnostic and Interventional Radiology, Medical Center-University of Freiburg, Germany
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8
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Alexandrou ME, Ferro CJ, Boletis I, Papagianni A, Sarafidis P. Hypertension in kidney transplant recipients. World J Transplant 2022; 12:211-222. [PMID: 36159073 PMCID: PMC9453294 DOI: 10.5500/wjt.v12.i8.211] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 06/07/2022] [Accepted: 08/06/2022] [Indexed: 02/05/2023] Open
Abstract
Kidney transplantation is considered the treatment of choice for end-stage kidney disease patients. However, the residual cardiovascular risk remains significantly higher in kidney transplant recipients (KTRs) than in the general population. Hypertension is highly prevalent in KTRs and represents a major modifiable risk factor associated with adverse cardiovascular outcomes and reduced patient and graft survival. Proper definition of hypertension and recognition of special phenotypes and abnormal diurnal blood pressure (BP) patterns is crucial for adequate BP control. Misclassification by office BP is commonly encountered in these patients, and a high proportion of masked and uncontrolled hypertension, as well as of white-coat hypertension, has been revealed in these patients with the use of ambulatory BP monitoring. The pathophysiology of hypertension in KTRs is multifactorial, involving traditional risk factors, factors related to chronic kidney disease and factors related to the transplantation procedure. In the absence of evidence from large-scale randomized controlled trials in this population, BP targets for hypertension management in KTR have been extrapolated from chronic kidney disease populations. The most recent Kidney Disease Improving Global Outcomes 2021 guidelines recommend lowering BP to less than 130/80 mmHg using standardized BP office measurements. Dihydropyridine calcium channel blockers and angiotensin-converting enzyme inhibitors/angiotensin-II receptor blockers have been established as the preferred first-line agents, on the basis of emphasis placed on their favorable outcomes on graft survival. The aim of this review is to provide previous and recent evidence on prevalence, accurate diagnosis, pathophysiology and treatment of hypertension in KTRs.
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Affiliation(s)
- Maria-Eleni Alexandrou
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki 54642, Greece
| | - Charles J Ferro
- Department of Renal Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2WB, United Kingdom
| | - Ioannis Boletis
- Department of Nephrology, Laiko General Hospital, National and Kapodistrian University, Athens 11527, Greece
| | - Aikaterini Papagianni
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki 54642, Greece
| | - Pantelis Sarafidis
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki 54642, Greece
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9
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Ghareeb A, Alhamid N, Hassan Q, Nahas MA. Percutaneous transluminal interventions of transplant renal artery stenosis: A case series study. Ann Med Surg (Lond) 2022; 77:103563. [PMID: 35432989 PMCID: PMC9006739 DOI: 10.1016/j.amsu.2022.103563] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 03/29/2022] [Accepted: 03/31/2022] [Indexed: 11/25/2022] Open
Abstract
Introduction and importance: Transplant renal artery stenosis (TRAS) is a well-recognized vascular complication after kidney transplant that can lead to graft loss, when it is diagnosed early and treated appropriately it may prevent kidney damage and related systemic squeals. Case presentation This case-series represents our center experience in managing TRAS using percutaneous transluminal angioplasty [either balloon angioplasty (PTA) or stent placement (PTAS)] in 11 patients. Clinical discussion All treated patients experienced immediate total recovery of renal function and normalization of arterial blood pressure without any drug or reducing the number of drugs used; no complications related to the intervention were reported. Conclusion PTA or PTAS of TRAS can be considered safe and effective when it diagnosed and treated early.
Transplant renal artery stenosis is a vascular complication after kidney transplant that can lead to graft loss. When it is diagnosed and treated appropriately it prevents kidney damage and systemic sequelae. Endovascular intervention is the treatment of choice for Transplant renal artery stenosis or other arterial complications that may compromise the transplant kidney vitality. Percutaneous transluminal angioplasty either balloon angioplasty or stent placement is considered safe and effective.
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10
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Transplant Renal Artery Stenosis: Underrecognized, Not So Rare, but Curable Complication. Transplant Proc 2022; 54:976-980. [DOI: 10.1016/j.transproceed.2022.03.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 03/06/2022] [Accepted: 03/14/2022] [Indexed: 11/24/2022]
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Safety And Efficacy of Drug Eluting Stents for Treatment of Transplant Renal Artery Stenosis. Ann Vasc Surg 2022; 87:245-253. [DOI: 10.1016/j.avsg.2022.03.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 03/09/2022] [Accepted: 03/29/2022] [Indexed: 11/20/2022]
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Barteczko MLM, Orellana HC, Santos GRF, Galhardo A, Kanhouche G, Faccinetto ACB, Júnior HT, Pestana JOM, de Paola ÂAV, Barbosa AHP. Long-term clinical outcomes of patients with nonsignificant transplanted renal artery stenosis. BMC Nephrol 2022; 23:61. [PMID: 35135498 PMCID: PMC8826676 DOI: 10.1186/s12882-022-02691-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 02/01/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Transplant renal artery stenosis (TRAS) is the main vascular complication of kidney transplantation. For research and treatment purposes, several authors consider critical renal artery stenosis to be greater than 50%, and percutaneous intervention is indicated in this scenario. However, there are no reports in the current literature on the evolution of patients with less than 50% stenosis. METHOD This retrospective study included data from all patients who underwent kidney transplantation and were suspected of having TRAS after transplantation with stenosis under 50% independent of age and were referred for angiography at a single centre between January 2007 and December 2014. RESULTS During this period, 6,829 kidney transplants were performed at Hospital do Rim, 313 of whom had a clinical suspicion of TRAS, and 54 of whom presented no significant stenosis. The average age was 35.93 years old, the predominant sex was male, and most individuals (94.4%) underwent dialysis before transplantation. In most cases in this group, transplants occurred from a deceased donor (66.7%). The time between transplantation and angiography was less than one year in 79.6% of patients, and all presented nonsignificant TRAS. Creatinine levels, systolic blood pressure, diastolic blood pressure and glomerular filtration rate improved over the long term. The outcomes found were death and allograft loss. CONCLUSION Age, sex and ethnic group of patients were factors that did not interfere with the frequency of renal artery stenosis. The outcomes showed that in the long term, most patients evolve well and have improved quality of life and kidney function, although there are cases of death and kidney loss.
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Affiliation(s)
- Manoela Linhares Machado Barteczko
- Department of Medicine, Cardiology Discipline, Federal University of Sao Paulo-UNIFESP, Sao Paulo Hospital, R. Napoleão de Barros, 715 - Vila Clementino, Sao Paulo/SP, 04024-002, Brazil.
| | - Henry Campos Orellana
- Department of Medicine, Cardiology Discipline, Federal University of Sao Paulo-UNIFESP, Sao Paulo Hospital, R. Napoleão de Barros, 715 - Vila Clementino, Sao Paulo/SP, 04024-002, Brazil
| | - Gustavo Rocha Feitosa Santos
- Department of Medicine, Cardiology Discipline, Federal University of Sao Paulo-UNIFESP, Sao Paulo Hospital, R. Napoleão de Barros, 715 - Vila Clementino, Sao Paulo/SP, 04024-002, Brazil
| | - Attílio Galhardo
- Department of Medicine, Cardiology Discipline, Federal University of Sao Paulo-UNIFESP, Sao Paulo Hospital, R. Napoleão de Barros, 715 - Vila Clementino, Sao Paulo/SP, 04024-002, Brazil
| | - Gabriel Kanhouche
- Department of Medicine, Cardiology Discipline, Federal University of Sao Paulo-UNIFESP, Sao Paulo Hospital, R. Napoleão de Barros, 715 - Vila Clementino, Sao Paulo/SP, 04024-002, Brazil
| | - Ana Carolina Buso Faccinetto
- Department of Medicine, Cardiology Discipline, Federal University of Sao Paulo-UNIFESP, Sao Paulo Hospital, R. Napoleão de Barros, 715 - Vila Clementino, Sao Paulo/SP, 04024-002, Brazil
| | - Hélio Tedesco Júnior
- Department of Medicine, Cardiology Discipline, Federal University of Sao Paulo-UNIFESP, Sao Paulo Hospital, R. Napoleão de Barros, 715 - Vila Clementino, Sao Paulo/SP, 04024-002, Brazil
- Division of Nephrology, Hospital Do Rim E Hipertensao, UNIFESP, São Paulo/SP, Brazil
| | - José Osmar Medina Pestana
- Department of Medicine, Cardiology Discipline, Federal University of Sao Paulo-UNIFESP, Sao Paulo Hospital, R. Napoleão de Barros, 715 - Vila Clementino, Sao Paulo/SP, 04024-002, Brazil
- Division of Nephrology, Hospital Do Rim E Hipertensao, UNIFESP, São Paulo/SP, Brazil
| | - Ângelo Amato Vincenzo de Paola
- Department of Medicine, Cardiology Discipline, Federal University of Sao Paulo-UNIFESP, Sao Paulo Hospital, R. Napoleão de Barros, 715 - Vila Clementino, Sao Paulo/SP, 04024-002, Brazil
| | - Adriano Henrique Pereira Barbosa
- Department of Medicine, Cardiology Discipline, Federal University of Sao Paulo-UNIFESP, Sao Paulo Hospital, R. Napoleão de Barros, 715 - Vila Clementino, Sao Paulo/SP, 04024-002, Brazil
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Assessment and management of transplant renal artery stenosis. A literature review. Ann Vasc Surg 2022; 82:13-29. [PMID: 35108560 DOI: 10.1016/j.avsg.2022.01.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 01/07/2022] [Accepted: 01/10/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND transplant renal artery stenosis (TRAS) following kidney transplantation is a possible cause of graft failure. This review aimed to summarize the evidence about physiopathology, diagnosis and early and late effectiveness of the endovascular treatment (EVT), including angioplasty and stenting procedures. METHODS a literature research was performed using Pubmed, Scopus and the Cochrane Library databases (January 2000 to September 2020) according to PRISMA guidelines. Studies were included if they describe EVT, percutaneous transluminal angioplasty or stent placement of TRAS, published in English and with a minimum of ten patients. RESULTS 56 studies were included. TRAS incidence ranges from 1% up to 12% in transplanted kidneys. The TRAS risk factors were: elderly donor and recipient, cytomegalovirus match status, Class II Donor Specific Antibodies (DSA), expanded donor criteria, delayed graft functioning and other anatomical and technical factors. The highest frequency of TRAS presentation is after 3-6 months after kidney transplantation. The most frequent localization of stenosis was para-anastomotic (ranging from 25% to 78%). In 9 studies, all patients were treated by percutaneous transluminal angioplasty (PTA), in 16 studies all patients received percutaneous transluminal stenting (PTS) and in 21 series patients received either PTA or PTS. The Twelve months patency rates after EVT ranged from 72% to 94%. The overall complication rate was 9%, with pseudoaneurysms and hematomas as most frequent complications. CONCLUSION TRAS can be successfully and safely treated through an endovascular approach. Stent delivery seems to guarantee a higher patency rate compared to simple angioplasty, however further studies are needed to confirm these results.
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Prasad S, Singh V, Yachha M, Phadke R, Bhadauria D. Endovascular management of vascular complications in renal allograft - An observational study. INDIAN JOURNAL OF TRANSPLANTATION 2022. [DOI: 10.4103/ijot.ijot_15_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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15
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Kanhouche G, Santos GRF, Orellana HC, Galhardo A, Faccinetto ACB, Barteczko MLM, de Carvalho LSF, Taddeo JB, Foresto RD, Moises VA, Tedesco-Silva H, Pestana JM, Barbosa AHP. Risk factors of transplant renal artery stenosis in kidney transplant recipients. Clinics (Sao Paulo) 2022; 77:100087. [PMID: 35931001 PMCID: PMC9350869 DOI: 10.1016/j.clinsp.2022.100087] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 01/14/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Transplant Renal Artery Stenosis (TRAS) is a recognized vascular complication after kidney transplantation. The overall risk predictors of TRAS are poorly understood. METHODS Retrospective analysis of patients with suspected TRAS (Doppler ultrasound PSV > 200 cm/s) who underwent angiographic study in a single center between 2007 and 2014. All patients with stenosis > 50% were considered with TRAS. Stenosis restricted in the body of the artery was also analyzed in a subgroup. RESULTS 274 patients were submitted to a renal angiography and 166 confirmed TRAS. TRAS group featured an older population (46.3 ± 11.0 vs. 40.9 ±14.2 years; p = 0.001), more frequent hypertensive nephropathy (30.1% vs. 15.7%; p = 0.01), higher incidence of Delayed Graft Function (DGF) (52.0% vs. 25.6%; p < 0.001) and longer Cold Ischemia Time (CIT) (21.5 ± 10.6 vs. 15.7 ± 12.9h; p < 0.001). In multivariable analyses, DGF (OR = 3.31; 95% CI 1.78‒6.30; p < 0.0001) was independent risk factors for TRAS. DM and CIT showed a tendency towards TRAS. The compound discriminatory capacity of the multivariable model (AUC = 0.775; 95% CI 0.718‒0.831) is significantly higher than systolic blood pressure and creatinine alone (AUC = 0.62; 95% CI 0.558-0.661). In body artery stenosis subgroup, DGF (OR = 1.86; 95% CI 1.04‒3.36; p = 0.03) and Diabetes Mellitus (DM) (OR = 2.44; 95% CI 1.31‒4.60; p = 0.005) were independent risk factors for TRAS. CONCLUSION In our transplant population, DGF increased more than 3-fold the risk of TRAS. In the subgroup analysis, both DGF and DM increases the risk of body artery stenosis. The addition of other factors to hypertension and renal dysfunction may increase diagnostic accuracy. TRAS TRIAL REGISTRED: clinicaltrials.gov (n° NCT04225338).
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Affiliation(s)
- Gabriel Kanhouche
- Cardiology Division, Hospital São Paulo, Universidade Federal de São Paulo, São Paulo, SP, Brazil.
| | | | - Henry Campos Orellana
- Cardiology Division, Hospital São Paulo, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Attilio Galhardo
- Cardiology Division, Hospital São Paulo, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | | | | | | | - Julia Bernardi Taddeo
- Nephrology Division, Hospital do Rim, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Renato Demarchi Foresto
- Nephrology Division, Hospital do Rim, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Valdir Ambrósio Moises
- Cardiology Division, Hospital São Paulo, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Helio Tedesco-Silva
- Nephrology Division, Hospital do Rim, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - José Medina Pestana
- Nephrology Division, Hospital do Rim, Universidade Federal de São Paulo, São Paulo, SP, Brazil
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Hinojosa-Gonzalez DE, Salgado-Garza G, Torres-Martinez M, Villegas-De Leon SU, Bueno-Gutierrez LC, Herrera-Carrillo FE, Gonzalez-Urquijo M, Segura Ibarra V, Fabiani MA, Flores-Villalba E. Endovascular Treatment of Transplant Renal Artery Stenosis: A Systematic Review and Meta-analysis. J Endovasc Ther 2021; 29:294-306. [PMID: 34399594 DOI: 10.1177/15266028211038593] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Endovascular treatment through either percutaneous transluminal angioplasty (PTA) alone or stenting has been previously used as a treatment for transplant renal artery stenosis (TRAS). This review aimed to investigate the results of endovascular treatment for renal artery stenosis in transplanted kidneys as compared with the outcomes of interventions, medical management, and graft survival in non-TRAS patients. METHODS A systematic review of PubMed, Google Scholar, Cochrane, and Scopus was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines in which studies that reported outcomes of the treatment of TRAS via the endoluminal approach were identified, and their results were meta-analyzed. RESULTS Fifty-four studies with a total of 1522 patients were included. A significant reduction of serum creatinine level was found, favoring the stenting group, with a mean difference of 0.68 mg/dL (95% confidence interval (CI), 0.17-1.19; Z=2.60, p=0.0009). Comparison of pre- and post-intervention values of any intervention revealed a significant decrease in overall serum creatinine level (0.65 mg/dL; 95% CI, 0.40-0.90; Z=5.09, p=0.00001), overall blood pressure, with a mean difference of 11.12 mmHg (95% CI, 7.29-14.95; Z=5.59, p=0.00001), mean difference in the use of medications (0.77; 95% CI, 0.29-1.24; p=0.002), and peak systolic velocity (190.05; 95% CI, 128.41-251.69; p<0.00001). The comparison of serum creatinine level between endovascular interventions and best medical therapy favored endovascular intervention, with a mean difference of 0.23 mg/dL (95% CI, 0.14-0.32; Z=5.07, p<0.00001). Graft survival was similar between the treated patients and those without TRAS (hazard ratio, 0.98; 95% CI, 0.75-1.28; p=0.091). The overall pooled success rate was 89%, and the overall complication rate was 10.4%, with the most prevalent complication being arterial dissection. CONCLUSION The endovascular treatment of TRAS improves graft preservation and renal function and hemodynamic parameters. PTA + stenting appears to be a more effective option to PTA alone in the stabilization of renal function, with additional benefits from decreased restenosis rates. Further high-quality studies could expand on these findings.
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Affiliation(s)
| | - Gustavo Salgado-Garza
- Escuela de Medicina y Ciencias de la Salud, Tecnologico de Monterrey, Monterrey, NL, Mexico
| | | | | | | | | | | | - Victor Segura Ibarra
- Escuela de Medicina y Ciencias de la Salud, Tecnologico de Monterrey, Monterrey, NL, Mexico.,Escuela de Ingeniería y Ciencias, Tecnologico de Monterrey, Monterrey, NL, Mexico
| | | | - Eduardo Flores-Villalba
- Escuela de Medicina y Ciencias de la Salud, Tecnologico de Monterrey, Monterrey, NL, Mexico.,Escuela de Ingeniería y Ciencias, Tecnologico de Monterrey, Monterrey, NL, Mexico
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Hypertension in kidney transplantation: a consensus statement of the 'hypertension and the kidney' working group of the European Society of Hypertension. J Hypertens 2021; 39:1513-1521. [PMID: 34054055 DOI: 10.1097/hjh.0000000000002879] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Hypertension is common in kidney transplantation recipients and may be difficult to treat. Factors present before kidney transplantation, related to the transplantation procedure itself and factors developing after transplantation may contribute to blood pressure (BP) elevation in kidney transplant recipients. The present consensus is based on the results of three recent systematic reviews, the latest guidelines and the current literature. The current transplant guidelines, which recommend only office BP assessments for risk stratification in kidney transplant patients should be reconsidered, given the presence of white-coat hypertension and masked hypertension in this population and the better prediction of adverse outcomes by 24-h ambulatory BP monitoring as indicated in recent systematic reviews. Hypertension is associated with adverse kidney and cardiovascular outcomes and decreased survival in kidney transplant recipients. Current evidence suggests calcium channel blockers could be the preferred first-step antihypertensive agents in kidney transplant patients, as they improve graft function and reduce graft loss, whereas no clear benefit is documented for renin-angiotensin system inhibitor use over conventional treatment in the current literature. Randomized control trials demonstrating the clinical benefits of BP lowering on kidney and major cardiovascular events and recording patient-related outcomes are still needed. These trials should define optimal BP targets for kidney transplant recipients. In the absence of kidney transplant-specific evidence, BP targets in kidney transplant recipients should be similar to those in the wider chronic kidney disease population.
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18
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Wahab SA, Abraham B, Bailey A, Choe KA. Imaging findings of en bloc simultaneous liver-kidney transplantation. Abdom Radiol (NY) 2021; 46:1876-1890. [PMID: 33083870 DOI: 10.1007/s00261-020-02824-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 10/01/2020] [Accepted: 10/10/2020] [Indexed: 10/23/2022]
Abstract
Simultaneous liver-kidney transplantations (SLKTs) are increasing in incidence, and the en bloc surgical approach is associated with a unique spectrum of vascular complications. En bloc SLKTs have a common arterial supply from the celiac axis and post-operative assessment with Doppler ultrasound can help to localize vascular lesions as either proximal in the shared arterial supply or distal in the organ-specific arteries. Venous complications predominantly include thrombosis or stenosis of the portal vein, hepatic veins, renal vein, or IVC, but have a much lower incidence. Radiologists familiar with the post-operative anatomy and complications can provide meaningful and accurate assessment to help direct clinical care. The purpose of this article is to provide a targeted review of SLKT, review the post-surgical anatomy associated with en bloc SLKT, and review the imaging evaluation of vascular complications associated with SLKT.
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Shoji K, Zen K, Shiotsu Y, Nakamura T, Yanishi K, Ushigome H, Kusaba T, Tamagaki K, Matoba S. Successful Endovascular Treatment for Very-Late-Onset and Acute Progressive Multiple Transplant Renal Segmental Artery Stenoses: A Case Report. Transplant Proc 2020; 53:1262-1267. [PMID: 33272651 DOI: 10.1016/j.transproceed.2020.09.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 09/22/2020] [Indexed: 12/17/2022]
Abstract
PURPOSE To report the endovascular treatment for acute progressive and very-late-onset multiple segmental small-artery stenoses in transplanted kidney parenchyma presenting with rapidly deteriorating renal function and refractory hypertension in a 65-year-old man. CASE REPORT Nineteen years ago, the patient received a living renal transplant via end-to-end anastomosis of the right internal iliac artery for kidney failure caused by chronic glomerulonephritis. His transplant renal function (creatinine: 0.9 mg/dL) and blood pressure were stable for 18 years. Then rapid worsening of renal function (creatinine: 2.5 mg/dL) and refractory hypertension occurred. Magnetic resonance angiography and renal angiography showed multiple small segmental artery stenoses in the transplanted kidney. At the 1-month follow-up consultation, total occlusion of 2 branches traversing the inferior pole of the kidney was observed, revealing acute progression of artery stenosis. Balloon angioplasty was successfully performed on those branches; renal function improved (creatinine: 1.3 mg/dL), and blood pressure was sufficiently controlled. CONCLUSIONS This is a rare case that revealed very-late-onset multiple segmental renal artery stenoses with acute progression in the transplant kidney. Even multiple small segmental artery stenoses can reduce transplant renal function in the chronic phase and progress rapidly. Early percutaneous transluminal angioplasty may thus be feasible and important for preventing graft loss.
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Affiliation(s)
- Keisuke Shoji
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan.
| | - Kan Zen
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yayoi Shiotsu
- Department of Nephrology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Tsukasa Nakamura
- Department of Organ Transplantation and General Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Kenji Yanishi
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hidetaka Ushigome
- Department of Organ Transplantation and General Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Tetsuro Kusaba
- Department of Nephrology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Keiichi Tamagaki
- Department of Nephrology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Satoaki Matoba
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
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20
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Tantisattamo E, Molnar MZ, Ho BT, Reddy UG, Dafoe DC, Ichii H, Ferrey AJ, Hanna RM, Kalantar-Zadeh K, Amin A. Approach and Management of Hypertension After Kidney Transplantation. Front Med (Lausanne) 2020; 7:229. [PMID: 32613001 PMCID: PMC7310511 DOI: 10.3389/fmed.2020.00229] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 05/04/2020] [Indexed: 12/14/2022] Open
Abstract
Hypertension is one of the most common cardiovascular co-morbidities after successful kidney transplantation. It commonly occurs in patients with other metabolic diseases, such as diabetes mellitus, hyperlipidemia, and obesity. The pathogenesis of post-transplant hypertension is complex and is a result of the interplay between immunological and non-immunological factors. Post-transplant hypertension can be divided into immediate, early, and late post-transplant periods. This classification can help clinicians determine the etiology and provide the appropriate management for these complex patients. Volume overload from intravenous fluid administration is common during the immediate post-transplant period and commonly contributes to hypertension seen early after transplantation. Immunosuppressive medications and donor kidneys are associated with post-transplant hypertension occurring at any time point after transplantation. Transplant renal artery stenosis (TRAS) and obstructive sleep apnea (OSA) are recognized but common and treatable causes of resistant hypertension post-transplantation. During late post-transplant period, chronic renal allograft dysfunction becomes an additional cause of hypertension. As these patients develop more substantial chronic kidney disease affecting their allografts, fibroblast growth factor 23 (FGF23) increases and is associated with increased cardiovascular and all-cause mortality in kidney transplant recipients. The exact relationship between increased FGF23 and post-transplant hypertension remains poorly understood. Blood pressure (BP) targets and management involve both non-pharmacologic and pharmacologic treatment and should be individualized. Until strong evidence in the kidney transplant population exists, a BP of <130/80 mmHg is a reasonable target. Similar to complete renal denervation in non-transplant patients, bilateral native nephrectomy is another treatment option for resistant post-transplant hypertension. Native renal denervation offers promising outcomes for controlling resistant hypertension with no significant procedure-related complications. This review addresses the epidemiology, pathogenesis, and specific etiologies of post-transplant hypertension including TRAS, calcineurin inhibitor effects, OSA, and failed native kidney. The cardiovascular and survival outcomes related to post-transplant hypertension and the utility of 24-h blood pressure monitoring will be briefly discussed. Antihypertensive medications and their mechanism of actions relevant to kidney transplantation will be highlighted. A summary of guidelines from different professional societies for BP targets and antihypertensive medications as well as non-pharmacological interventions, including bilateral native nephrectomy and native renal denervation, will be reviewed.
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Affiliation(s)
- Ekamol Tantisattamo
- Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA, United States.,Nephrology Section, Department of Medicine, Tibor Rubin Veterans Affairs Medical Center, VA Long Beach Healthcare System, Long Beach, CA, United States.,Section of Nephrology, Department of Internal Medicine, Multi-Organ Transplant Center, William Beaumont Hospital, Oakland University William Beaumont School of Medicine, Royal Oak, MI, United States
| | - Miklos Z Molnar
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, United States.,Methodist University Hospital Transplant Institute, Memphis, TN, United States.,Division of Transplant Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, United States
| | - Bing T Ho
- Division of Nephrology and Hypertension, Department of Medicine, Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Uttam G Reddy
- Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA, United States.,Nephrology Section, Department of Medicine, Tibor Rubin Veterans Affairs Medical Center, VA Long Beach Healthcare System, Long Beach, CA, United States
| | - Donald C Dafoe
- Division of Transplantation, Department of Surgery, University of California Irvine School of Medicine, Orange, CA, United States
| | - Hirohito Ichii
- Division of Transplantation, Department of Surgery, University of California Irvine School of Medicine, Orange, CA, United States
| | - Antoney J Ferrey
- Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA, United States.,Nephrology Section, Department of Medicine, Tibor Rubin Veterans Affairs Medical Center, VA Long Beach Healthcare System, Long Beach, CA, United States
| | - Ramy M Hanna
- Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA, United States
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA, United States.,Nephrology Section, Department of Medicine, Tibor Rubin Veterans Affairs Medical Center, VA Long Beach Healthcare System, Long Beach, CA, United States
| | - Alpesh Amin
- Department of Medicine, University of California Irvine School of Medicine, Orange, CA, United States
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21
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Qi R, Qi G, Zhu D, Wang J. Diagnosis and Treatment of Early Transplant Renal Artery Stenosis: Experience From a Center in Eastern China. Transplant Proc 2020; 52:179-185. [PMID: 31901326 DOI: 10.1016/j.transproceed.2019.11.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 10/12/2019] [Accepted: 11/02/2019] [Indexed: 01/20/2023]
Abstract
Few studies have focused on the clinical characteristics of transplant renal artery stenosis (TRAS) with early onset. Sixteen cases diagnosed with TRAS in our center from January 2014 to August 2018 were retrospectively analyzed. Sixteen transplant patients without TRAS were selected as controls. The median diagnostic time for TRAS was 47.5 days after transplantation. No significant difference was observed between the TRAS group and the control group. The serum creatinine level (Scr), estimated glomerular filtration rate, systolic/diastolic blood pressure, graft artery peak systolic velocity (PSV), and resistive index of intersegmental artery (RI-ISA) between the 2 groups were (5.55 ± 3.49) and (1.89 ± 0.85) mg/dL; (17.83 ± 14.94) and (49.39 ± 19.96) mL/min; (143.50 ± 9.49)/(86.14 ± 7.38) and (130.38 ± 18.86)/(82.81 ± 12.52) mm Hg; (3.39 ± 1.57) and (1.31 ± 0.51) m/s; and (0.51 ± 0.10) and (0.67 ± 0.13), respectively. All showed statistical significance except the diastolic blood pressure. The Scr, estimated glomerular filtration rate, systolic/diastolic blood pressure, graft artery PSV, and RI-ISA in the TRAS group prior and after treatment were (5.55 ± 3.49) and (3.20 ± 1.50) mg/dL; (17.83 ± 14.94) and (25.60 ± 13.29) mL/min; (143.50 ± 9.49)/(86.14 ± 7.38) and (128.07 ± 16.16)/(75.71 ± 7.56) mm Hg; (3.39 ± 1.57) and (2.00 ± 1.04) m/s; and (0.51 ± 0.10) and (0.61 ± 0.10); all showed statistical significance. Receiver operating characteristic analysis showed an area under curve of 0.8616 for PSV and 0.8535 for RI-ISA in diagnosing TRAS. Patients with TRAS in our center showed a unique characteristic of early onset. The most prominent clinical symptom of TRAS is increasing Scr level instead of refractory hypertension. Screening of color Doppler flow imaging with a graft artery PSV >2.5 m/s and RI-ISA <0.5 could yield a preliminary diagnosis of TRAS. Percutaneous transluminal angioplasty/stenting could effectively improve allograft function as well as color Doppler flow imaging indexes.
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Affiliation(s)
- Ruochen Qi
- Department of Urology, Zhongshan Hospital, Fudan University, Shanghai, P.R. China; Shanghai Medical College, Fudan University Shanghai, P.R. China; Shanghai Key Laboratory of Organ Transplantation, Shanghai, P. R. China
| | - Guisheng Qi
- Department of Urology, Zhongshan Hospital, Fudan University, Shanghai, P.R. China; Shanghai Key Laboratory of Organ Transplantation, Shanghai, P. R. China
| | - Dong Zhu
- Department of Urology, Zhongshan Hospital, Fudan University, Shanghai, P.R. China; Shanghai Key Laboratory of Organ Transplantation, Shanghai, P. R. China
| | - Jina Wang
- Department of Urology, Zhongshan Hospital, Fudan University, Shanghai, P.R. China; Shanghai Key Laboratory of Organ Transplantation, Shanghai, P. R. China.
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Long-term Outcomes after Transplant Renal Artery Stenosis Surgery. Ann Vasc Surg 2019; 54:261-268. [DOI: 10.1016/j.avsg.2018.05.066] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 05/12/2018] [Accepted: 05/21/2018] [Indexed: 12/23/2022]
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Patel U, Kumar S, Johnson OW, Jeon JH, Das R. Long-term Graft and Patient Survival after Percutaneous Angioplasty or Arterial Stent Placement for Transplant Renal Artery Stenosis: A 21-year Matched Cohort Study. Radiology 2018; 290:555-563. [PMID: 30398440 DOI: 10.1148/radiol.2018181320] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Purpose To compare long-term graft and patient survival after percutaneous angioplasty (PTA) or stent placement for transplant renal artery stenosis (TRAS) with a control cohort without TRAS. Materials and Methods This is a retrospective matched cohort study of 41 patients (median age, 49 years; range, 18-72 years), including 27 male patients (median age, 48 years; range, 18-67 years) and 14 female patients (median age, 52 years; range, 24-68 years), with TRAS from December 1995 through 2016. Primary end points were death-censored graft and patient survival, compared by using log-rank test and Cox proportional regression. Secondary outcomes were improvement in renal function, blood pressure (BP), and complications. Results Twenty-four patients underwent PTA and 17 received stent placements. Ten-year graft survival was 92.1% (range, 83.2%-100%) versus 81.4% (range, 67.8%-95.3%) (P = .56), and 10-year patient survival was 89.9% (79.1%-100%) versus 84.7% (72.1%-97.5%) (P = .49), for the study and control groups, respectively. Five patients (12%) resumed dialysis in each group and a total of 17 patients died (eight in the study group and nine in the control group). Most patients died with a functioning graft (seven of eight in the study group and seven of nine in the control group). Posttreatment median systolic and diastolic BP improved by 12% and 7.4%, respectively, and serum creatinine improved by 27%. Normal systolic BP and serum creatinine level at 1 year after treatment were associated with better survival for patients (P = .04; hazard ratio [HR], 1.04; 95% confidence interval [CI]: 1.0, 1.075) and grafts (P < .001; HR, 1.02; 95% CI: 1.0, 1.027). Other covariates, including PTA versus renal stent placement, intra-arterial pressure gradient greater than 10%, diastolic BP, age at transplantation, sex, graft type, rejection, and delayed graft function, were not significant. Five patients (12.2%) had a complication (Society of Interventional Radiology class A, two of 41 [4.9%]; class B, two of 41 [4.9%]; and class D, one of 41 [2.4%]); 30-day graft loss and patient mortality were zero. Conclusion Long-term graft and patient survival after endovascular correction of transplant renal artery stenosis (TRAS) was similar to that without TRAS and most patients avoided returning to dialysis. © RSNA, 2018 Online supplemental material is available for this article. See also the editorial by Dickey and Durrani in this issue.
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Affiliation(s)
- Uday Patel
- From the Department of Interventional Radiology, St George's University Hospitals NHS Foundation Trust and Medical School, Blackshaw Road, London SW17 0QT, England (U.P., R.D.); Centre for Medical Imaging, University College London, London, England (S.K.); Department of Vascular Surgery, Guy's and St Thomas' Hospital, London, England (O.W.J.); and Department of Radiology, Royal Sussex County Hospital, Brighton, England (J.H.J.)
| | - Shankar Kumar
- From the Department of Interventional Radiology, St George's University Hospitals NHS Foundation Trust and Medical School, Blackshaw Road, London SW17 0QT, England (U.P., R.D.); Centre for Medical Imaging, University College London, London, England (S.K.); Department of Vascular Surgery, Guy's and St Thomas' Hospital, London, England (O.W.J.); and Department of Radiology, Royal Sussex County Hospital, Brighton, England (J.H.J.)
| | - Oscar William Johnson
- From the Department of Interventional Radiology, St George's University Hospitals NHS Foundation Trust and Medical School, Blackshaw Road, London SW17 0QT, England (U.P., R.D.); Centre for Medical Imaging, University College London, London, England (S.K.); Department of Vascular Surgery, Guy's and St Thomas' Hospital, London, England (O.W.J.); and Department of Radiology, Royal Sussex County Hospital, Brighton, England (J.H.J.)
| | - Justyn Hwee Jeon
- From the Department of Interventional Radiology, St George's University Hospitals NHS Foundation Trust and Medical School, Blackshaw Road, London SW17 0QT, England (U.P., R.D.); Centre for Medical Imaging, University College London, London, England (S.K.); Department of Vascular Surgery, Guy's and St Thomas' Hospital, London, England (O.W.J.); and Department of Radiology, Royal Sussex County Hospital, Brighton, England (J.H.J.)
| | - Raj Das
- From the Department of Interventional Radiology, St George's University Hospitals NHS Foundation Trust and Medical School, Blackshaw Road, London SW17 0QT, England (U.P., R.D.); Centre for Medical Imaging, University College London, London, England (S.K.); Department of Vascular Surgery, Guy's and St Thomas' Hospital, London, England (O.W.J.); and Department of Radiology, Royal Sussex County Hospital, Brighton, England (J.H.J.)
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Nicholson ML, Yong C, Trotter PB, Grant L, Hosgood SA. Risk factors for transplant renal artery stenosis after live donor transplantation. Br J Surg 2018; 106:199-205. [DOI: 10.1002/bjs.10997] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 06/07/2018] [Accepted: 08/09/2018] [Indexed: 11/05/2022]
Abstract
Abstract
Background
Renal transplant surgeons are making increasing use of live donor kidneys with multiple renal arteries. This study aimed to identify independent risk factors for the development of transplant renal artery stenosis (TRAS) in the modern era of complex arterial reconstruction for multiple vessels.
Methods
Multivariable logistic regression analysis with a stepwise variable deletion model was used to identify risk factors for the development of TRAS in a consecutive series of live donor kidney transplants.
Results
Of 506 kidney transplants, 19 (3·8 per cent) had evidence of significant TRAS on CT angiography. Functional TRAS, defined by improvement in BP control or renal function after correction of a stenosis by angioplasty, occurred in 13 of 506 patients (2·6 per cent). Independent risk factors for TRAS were: use of an explanted internal iliac artery graft from the recipient (odds ratio (OR) 4·95; P = 0·020) and total ischaemia time (OR 1·82; P = 0·010). TRAS was associated with a lower 5-year allograft survival rate (79 versus 88·7 per cent; P = 0·020) but only one graft loss was attributed directly to TRAS. The 5-year allograft survival rate after internal iliac artery grafting was 86 per cent.
Conclusion
Although use of an internal iliac artery graft is an independent risk factor for TRAS after live donor kidney transplantation, this technique is still a useful option for complex arterial reconstruction.
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Affiliation(s)
- M L Nicholson
- Department of Infection, Immunity and Inflammation, University of Leicester, Leicester, UK
- Department of Surgery, University of Cambridge, Cambridge, UK
| | - C Yong
- Department of Surgery, University of Cambridge, Cambridge, UK
| | - P B Trotter
- Department of Surgery, University of Cambridge, Cambridge, UK
| | - L Grant
- Department of Surgery, University of Cambridge, Cambridge, UK
| | - S A Hosgood
- Department of Infection, Immunity and Inflammation, University of Leicester, Leicester, UK
- Department of Surgery, University of Cambridge, Cambridge, UK
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Abstract
Vascular complications are a significant source of morbidity and mortality among renal transplant recipients. Imaging using ultrasound, CT, and MRI plays a key role in diagnosing such complications. This review focuses on the major vascular complications of renal grafts, which include transplant renal arterial and venous stenoses, arterial and venous thromboses, arteriovenous fistulas, and pseudoaneurysms. Etiology, diagnostic modalities useful for diagnosis, and imaging appearance will be presented.
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Affiliation(s)
- Ghaneh Fananapazir
- Department of Radiology, University of California Davis Medical Center, 4860 Y Street Suite 3100, Sacramento, CA, 95817, USA.
| | - Christoph Troppmann
- Department of Surgery, University of California Davis Medical Center, 2315 Stockton Blvd # 1018, Sacramento, CA, 95817, USA
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Ng ZQ, Lim W, He B. Outcomes of Kidney Transplantation by Using the Technique of Renal Artery Anastomosis First. Cureus 2018; 10:e3223. [PMID: 30405998 PMCID: PMC6205881 DOI: 10.7759/cureus.3223] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2018] [Accepted: 08/28/2018] [Indexed: 01/01/2023] Open
Abstract
Introduction The surgical technique for kidney transplantation has been well established: the renal vein is anastomosed first, followed by renal artery anastomosis. Alternatively, the renal artery can be anastomosed first and then the renal vein for kidney transplantation. However, there is a lack of data on the outcomes of kidney transplantation by using this alternative approach. The objective of this paper was to review the outcomes of kidney transplant by using this approach. Methods A review of 205 consecutive kidney transplants was conducted. All kidney transplants were performed by doing renal artery anastomosis first and then the renal vein. Data were collected, including vascular/urological complications and kidney graft function. Results All transplants were performed successfully with no occurrence of renal artery/vein thrombosis and urine leakage. There were five cases of renal artery stenosis that were managed with endovascular intervention. There was no recurrence on follow-up. One ureteric stenosis required surgical reconstruction. Conclusions This alternative vascular anastomotic technique is efficient and safe. It avoids flip-flopping the kidney graft during the vessel anastomoses and may be more practical in minimally invasive surgery for a kidney transplant due to the space constraint.
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Affiliation(s)
- Zi Qin Ng
- WA Liver & Kidney Transplant Service, Sir Charles Gairdner Hospital, Perth, AUS
| | - Wai Lim
- Nephrology, Sir Charles Gairdner Hospital, Perth, AUS
| | - Bulang He
- WA Liver & Kidney Transplant Service, Sir Charles Gairdner Hospital, Perth, AUS
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Territo A, Gausa L, Alcaraz A, Musquera M, Doumerc N, Decaestecker K, Desender L, Stockle M, Janssen M, Fornara P, Mohammed N, Siena G, Serni S, Sahin S, Tuǧcu V, Basile G, Breda A. European experience of robot-assisted kidney transplantation: minimum of 1-year follow-up. BJU Int 2018; 122:255-262. [PMID: 29645355 DOI: 10.1111/bju.14247] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES To evaluate functional results, graft survival and late complications in patients who underwent robot-assisted kidney transplantation (RAKT) and who had a minimum of 1 year of follow-up data, and to analyse the correlations between surgical data and functional results at a minimum of 1-year postoperatively and between renal function in the immediate postoperative period and after 1 year. MATERIALS AND METHODS A common prospectively collected RAKT database was created by the European Robotic Urological Section (ERUS) RAKT working group, which included eight different European centres. In each centre RAKTs were performed with kidneys from living donors. Data on demographic variables, surgical results, graft survival, functional outcomes (creatinine and estimated glomerular filtration rate [eGFR]) on postoperative days 7 and 30 and at 1 year, and late complications were extracted from the common database. RESULTS A total of 147 RAKTs were performed by the ERUS RAKT working group. Of the 147 patients, 83 had at least 1-year follow-up (mean [range] 21 [13-27] months). Of these 83 patients, 30 were women. The patients' median (range) age was 43 (30-75) years, body mass index was 25.3 (20-40) kg/m2 , pre-transplantation serum creatinine was 517 (198-1 414) μmol/L and estimated GFR (eGFR) was 10 (3-29) mL/min per 1.73 m2 . Of the 83 cases, 46 were pre-emptive. The median (range) overall ischaemia time was 116 (53-377) min. The median (range) rewarming time was 60 (35-110) min. At 1-year follow-up, the median (range) serum creatinine was 131 (66-244) μmol/L, with a median (range) eGFR of 57.4 (28-97) mL/min per 1.73 m2 . There was no statistically significant difference between functional data at postoperative day 30 and those at 1 year for creatinine (P = 0.78) or eGFR (P = 0.91). Regarding the correlation between the surgical data and the functional outcomes, the data showed that overall operating time and rewarming time did not affect the graft function at 1 year. Three cases of graft loss occurred as a result of massive arterial thrombosis within the first postoperative week. Late complications comprised one case of ureteric stenosis and one case of graft pyelonephritis. No late vascular complications or cases of incisional hernia were recorded. CONCLUSION Findings at 1-year follow-up indicate RAKT from a living donor to be a safe procedure in a properly selected group of recipients. RAKT was associated with a low complication rate and there was maintenance of excellent graft survival and function. This is the first and largest study to report functional results after RAKT from a living donor with a minimum follow-up of 1 year.
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Affiliation(s)
- Angelo Territo
- Department of Urology, Fundaciò Puigvert, Autonoma University of Barcelona, Barcelona, Spain
| | - Lluis Gausa
- Department of Urology, Fundaciò Puigvert, Autonoma University of Barcelona, Barcelona, Spain
| | - Antonio Alcaraz
- Department of Urology, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Mireia Musquera
- Department of Urology, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Nicolas Doumerc
- Department of Urology and Renal Transplantation, University Hospital of Rangueil, Toulouse, France
| | | | - Liesbeth Desender
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
| | - Michael Stockle
- Department of Urology, University Saarland, Homburg/Saar, Germany
| | - Martin Janssen
- Department of Urology, University Saarland, Homburg/Saar, Germany
| | - Paolo Fornara
- Department of Urology, University Hospital Halle (Saale), Halle, Germany
| | - Nasreldin Mohammed
- Department of Urology, University Hospital Halle (Saale), Halle, Germany
| | - Giampaolo Siena
- Department of Urology, Careggi Hospital, University of Florence, Florence, Italy
| | - Sergio Serni
- Department of Urology, Careggi Hospital, University of Florence, Florence, Italy
| | - Selcuk Sahin
- Bakirkoy Sadi Konuk Training and Research Hospital Centre, Istanbul, Turkey
| | - Volkan Tuǧcu
- Bakirkoy Sadi Konuk Training and Research Hospital Centre, Istanbul, Turkey
| | - Giuseppe Basile
- Department of Urology, Fundaciò Puigvert, Autonoma University of Barcelona, Barcelona, Spain
| | - Alberto Breda
- Department of Urology, Fundaciò Puigvert, Autonoma University of Barcelona, Barcelona, Spain
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Standardized Duplex Ultrasound-Based Protocol for Early Diagnosis of Transplant Renal Artery Stenosis: Results of a Single-Institution Retrospective Cohort Study. BIOMED RESEARCH INTERNATIONAL 2018; 2018:2580181. [PMID: 29850493 PMCID: PMC5925009 DOI: 10.1155/2018/2580181] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/01/2017] [Revised: 10/16/2017] [Accepted: 10/25/2017] [Indexed: 01/13/2023]
Abstract
Transplant renal artery stenosis (TRAS) is the most frequent vascular complication after kidney transplantation (KT) and has been associated with potentially reversible refractory hypertension, graft dysfunction, and reduced patient survival. The aim of the study is to describe the outcomes of a standardized Duplex Ultrasound- (DU-) based screening protocol for early diagnosis of TRAS and for selection of patients potentially requiring endovascular intervention. We retrospectively reviewed our prospectively collected database of KT from January 1998 to select patients diagnosed with TRAS. The follow-up protocol was based on a risk-adapted, dynamic subdivision of eligible KT patients in different risk categories (RC) with different protocol strategies (PS). Of 598 patients included in the study, 52 (9%) patients had hemodynamically significant TRAS and underwent percutaneous angioplasty (PTA) and stent placement. Technical and clinical success rates were 97% and 90%, respectively. 7 cases of restenosis were recorded at follow-up and treated with re-PTA plus stenting. Both DU imaging and clinical parameters improved after stent placement. Prospective high-quality studies are needed to test the efficacy and safety of our protocol in larger series. Accurate trial design and standardized reporting of patient outcomes will be key to address the current clinical needs.
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29
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Li X, Zhang J, Meng Y, Yang L, Wang F, Li B, Zhang X. Transplant renal artery stenosis caused by the stretch of an artey branch: a case report and literature review. BMC Nephrol 2018. [PMID: 29523086 PMCID: PMC5845193 DOI: 10.1186/s12882-018-0856-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background Renal transplant is the preferred treatment option for these patients with end-stage renal disease. Transplant renal artery stenosis (TRAS) is one of the most common and serious vascular complications after renal transplantation, and most of the TRAS occurred in the anastomosis. The complication must be diagnosed and treated timely, otherwise the function of transplanted kidney may be losed. Case presentation A 46-year-old male with end-stage renal disease of unknown cause received a cadaveric renal transplant one year ago. Although three antihypertensive medications were administrated, his blood pressure gradually increased to 190/120 mmHg 3 weeks posttransplantation. Also the level of creatinine increased to 194 μmol/L.Color Doppler ultrasonography indicated a decreased resistance index (RI) in intrarenal arteries and increased blood flow of the transplant renal artery, therefore, a vascular complication of TRAS was suspected. Arteriography was performed and demonstrated TRAS caused by stretch of an artery branch, and the TRAS occurred in the distal site of the anastomosis instead of the anastomosis. Percutaneous transluminal bare stent implantation treatment was successfully performed. Satisfactory clinical efficacy with improvement in transplant renal function and renovascular hypertension was achieved after the interventional treatment. Conclusion To our knowledge this is the first reported case of TRAS caused by stretch of an artery branch. When refractory hypertension and allograft dysfunction are presented posttransplantation, TRAS should be suspected. Color Doppler ultrasonography as a non-invasive examination may provide some valuable information, three-dimention CT can be useful for further diagnosis, but is seldom necessary. Arteriography provides the definitive diagnosis of TRAS. Percutaneous transluminal stent implantation treatment of TRAS has high success rate with minimal invasion and complications. When an artery branch situated on the stenosis, a bare stent rather than covered stent is the preferred choice.
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Affiliation(s)
- Xiaohang Li
- Department of Hepatobiliary Surgery and Organ Transplant, First Affiliated Hospital, China Medical University, No.155, Nanjing North Street, Shenyang, Liaoning Province, 110001, People's Republic of China
| | - Jialin Zhang
- Department of Hepatobiliary Surgery and Organ Transplant, First Affiliated Hospital, China Medical University, No.155, Nanjing North Street, Shenyang, Liaoning Province, 110001, People's Republic of China.
| | - Yiman Meng
- Department of Hepatobiliary Surgery and Organ Transplant, First Affiliated Hospital, China Medical University, No.155, Nanjing North Street, Shenyang, Liaoning Province, 110001, People's Republic of China
| | - Lei Yang
- Department of Hepatobiliary Surgery and Organ Transplant, First Affiliated Hospital, China Medical University, No.155, Nanjing North Street, Shenyang, Liaoning Province, 110001, People's Republic of China
| | - Fengshan Wang
- Department of Hepatobiliary Surgery and Organ Transplant, First Affiliated Hospital, China Medical University, No.155, Nanjing North Street, Shenyang, Liaoning Province, 110001, People's Republic of China
| | - Baifeng Li
- Department of Hepatobiliary Surgery and Organ Transplant, First Affiliated Hospital, China Medical University, No.155, Nanjing North Street, Shenyang, Liaoning Province, 110001, People's Republic of China
| | - Xitong Zhang
- Department of Intervention, First Affiliated Hospital, China Medical University, No.155, Nanjing North Street, Shenyang, Liaoning Province, 110001, People's Republic of China
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30
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Chen LX, De Mattos A, Bang H, Vu CT, Gandhi M, Alnimri M, Gallay B, Fananapazir G. Angioplasty vs stent in the treatment of transplant renal artery stenosis. Clin Transplant 2018; 32:e13217. [DOI: 10.1111/ctr.13217] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2018] [Indexed: 12/30/2022]
Affiliation(s)
- Ling-Xin Chen
- Section of Transplant Nephrology; Department of Medicine; University of California Davis School of Medicine; Sacramento CA USA
| | - Angelo De Mattos
- Section of Transplant Nephrology; Department of Medicine; University of California Davis School of Medicine; Sacramento CA USA
| | - Heejung Bang
- Division of Biostatistics; Department of Public Health Sciences; University of California Davis School of Medicine; Sacramento CA USA
| | - Catherine T. Vu
- Department of Radiology; University of California Davis School of Medicine; Sacramento CA USA
| | - Mehul Gandhi
- Section of Transplant Nephrology; Department of Medicine; University of California Davis School of Medicine; Sacramento CA USA
| | - Muna Alnimri
- Section of Transplant Nephrology; Department of Medicine; University of California Davis School of Medicine; Sacramento CA USA
| | - Brian Gallay
- Section of Transplant Nephrology; Department of Medicine; University of California Davis School of Medicine; Sacramento CA USA
| | - Ghaneh Fananapazir
- Department of Radiology; University of California Davis School of Medicine; Sacramento CA USA
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Gomes Júnior MPM, Alves CMR, Barbosa AHP, Caixeta A, Batista MC, Pestana JOM, Carvalho AC. Initial experience with the use of fractional flow reserve in the hemodynamic evaluation of transplant renal artery stenosis. Catheter Cardiovasc Interv 2018; 91:820-826. [DOI: 10.1002/ccd.27476] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Revised: 11/07/2017] [Accepted: 11/25/2017] [Indexed: 12/29/2022]
Affiliation(s)
- Manuel Pereira Marques Gomes Júnior
- Interventional Cardiology Catheterization Laboratory Unit, Cardiology Division, Universidade Federal de São Paulo, Escola Paulista de Medicina, UNIFESP/EPM, São Paulo; SP Brazil
| | - Cláudia Maria Rodrigues Alves
- Interventional Cardiology Catheterization Laboratory Unit, Cardiology Division, Universidade Federal de São Paulo, Escola Paulista de Medicina, UNIFESP/EPM, São Paulo; SP Brazil
| | - Adriano Henrique Pereira Barbosa
- Interventional Cardiology Catheterization Laboratory Unit, Cardiology Division, Universidade Federal de São Paulo, Escola Paulista de Medicina, UNIFESP/EPM, São Paulo; SP Brazil
| | - Adriano Caixeta
- Interventional Cardiology Catheterization Laboratory Unit, Cardiology Division, Universidade Federal de São Paulo, Escola Paulista de Medicina, UNIFESP/EPM, São Paulo; SP Brazil
| | - Marcelo Costa Batista
- Departament of Nefrology; Universidade Federal de São Paulo, Escola Paulista de Medicina, UNIFESP/EPM; São Paulo SP Brazil
| | - José Osmar Medina Pestana
- Departament of Nefrology; Universidade Federal de São Paulo, Escola Paulista de Medicina, UNIFESP/EPM; São Paulo SP Brazil
| | - Antônio Carlos Carvalho
- Cardiology Division; Universidade Federal de São Paulo, Escola Paulista de Medicina, UNIFESP/EPM; São Paulo SP Brazil
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Screening for Transplant Renal Artery Stenosis: Ultrasound-Based Stenosis Probability Stratification. AJR Am J Roentgenol 2017; 209:1064-1073. [PMID: 28858538 DOI: 10.2214/ajr.17.17913] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE The objective of our study was to evaluate which spectral Doppler ultrasound parameters are useful in patients with clinical concern for transplant renal artery stenosis (TRAS) and create mathematically derived prediction models that are based on these parameters. MATERIALS AND METHODS The study subjects included 120 patients with clinical signs of renal dysfunction who had undergone ultrasound followed by angiography (either digital subtraction angiography or MR angiography) between January 2005 and December 2015. Five ultrasound variables were evaluated: ratio of highest renal artery velocity to iliac artery velocity, highest renal artery velocity, spectral broadening, resistive indexes, and acceleration time. Angiographic studies were categorized as either showing no stenosis or showing stenosis. Reviewers assessed the ultrasound examinations for TRAS using all five variables, which we refer to as the full model, and using a reduced number of variables, which we refer to as the reduced-variable model; sensitivities and specificities were generated. RESULTS Ninety-seven patients had stenosis and 23 had no stenosis. The full model had a sensitivity and specificity of 97% and 91%, respectively. The reduced-variable model excluded the ratio and resistive index variables without affecting sensitivity and specificity. We applied cutoff values to the variables in the reduced-variable model, which we refer to as the simple model. Using these cutoff values, the simple model showed a sensitivity and specificity of 96% and 83%. The simple model was able to categorize patients into four risk categories for TRAS: low, intermediate, high, and very high risk. CONCLUSION We propose a simple model that is based on highest renal artery velocity, distal spectral broadening, and acceleration time to classify patients into risk categories for TRAS.
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Carpenter DJ, Mohan S, Ratner LE, Schlossberg P. Combined Percutaneous Transrenal and Transfemoral Endovascular Recanalization and Angioplastic Reconstruction of a Disrupted Transplant Renal Artery Stent: A Novel Salvage Technique. Am J Transplant 2017; 17:1119-1124. [PMID: 27862938 PMCID: PMC5484052 DOI: 10.1111/ajt.14115] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Revised: 10/12/2016] [Accepted: 11/02/2016] [Indexed: 01/25/2023]
Abstract
Renal artery stenosis is the most common vascular complication following renal transplantation. Percutaneous endovascular transluminal angioplasty with stenting is the treatment of choice for clinically significant renal artery stenosis. The authors present a case describing a novel combined transrenal parenchyma and transfemoral approach to repairing a disrupted transplant renal artery stent. The patient's allograft renal artery stenosis was initially managed via the standard percutaneous approach, but during follow-up the stent became disrupted and crushed, causing partial occlusion of the renal artery. This was manifested by persistently elevated serum creatinine values, lower extremity edema, and four-medication hypertension. After a failed traditional percutaneous transfemoral attempt, the authors were able to successfully access the renal arterial system via a combined transrenal and transfemoral approach, using an upper-pole artery through the renal parenchyma. This transrenal approach used a 3 Fr system, allowing the authors to get a wire across the stent, which they were previously unable to do. With wire access, they performed a balloon angioplastic reconstruction to restore the stent's patency, resulting in a reduction in serum creatinine, lower extremity edema, and blood pressure. This technique avoided a potentially difficult reoperative repair without immediate complication and provides a method for vascular access to the renal arterial system in select patients.
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Affiliation(s)
- Dustin J. Carpenter
- Department of Surgery, Division of General Surgery, Columbia University Medical Center, New York, New York
| | - Sumit Mohan
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York,The Columbia University Renal Epidemiology (CURE) Group, New York, New York
| | - Lloyd E. Ratner
- Department of Surgery, Division of Transplantation, Columbia University Medical Center, New York, New York
| | - Peter Schlossberg
- Department of Radiology, Division of Interventional Radiology, Columbia University Medical Center, New York, New York
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5 Years Experience With Drug Eluting and Bare Metal Stents as Primary Intervention in Transplant Renal Artery Stenosis. Transplant Direct 2017; 3:e128. [PMID: 28361112 PMCID: PMC5367745 DOI: 10.1097/txd.0000000000000643] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 11/23/2016] [Indexed: 01/16/2023] Open
Abstract
Background Transplant renal artery stenosis (TRAS) is a common vascular complication after kidney transplantation and is associated with refractory hypertension, volume overload, and graft injury or loss. This article describes 5-year outcomes of endovascular intervention for TRAS with bare metal and drug eluting stents (DES). Methods We investigated, as a prospective cohort study, patient and graft outcomes after the targeted use of DES for vessel diameter less than 5 mm and bare metal stents (BMS) for vessel diameter greater than 5 mm as the primary management for TRAS. Results From March 2008 to November 2014, 57 patients were stented for hemodynamically significant TRAS; 29 received DES, 26 received BMS, and 2 patients received both stent types. They were followed up for a mean of 35.1 ± 22.8 months; a subset of these patients who all received DES were followed up for 61.7 ± 17.5 months. Mean serum creatinine declined from 2.87 ± 1.5 mg/dL at the time of intervention to 1.98 ± 0.76 mg/dL (P < 0.001) at one month follow-up and was 1.96 ±0.92 mg/dL (P < 0.001) at 35.1 ± 22.8 months. Mean systolic blood pressure declined from 159.05 ± 19.68 mm Hg at time of intervention to 135.65 ± 15.10 mm Hg (P < 0.001) at most recent visit. Clinically driven restenosis requiring repeat revascularization occurred in 15.7% of patients. Conclusions Primary stenting with DES and BMS is both successful in the initial treatment of TRAS and also produced an immediate and long-term reduction in serum creatinine and systolic blood pressure.
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Wang HY, Liu LS, Cao HM, Li J, Deng RH, Fu Q, Zhang HX, Fei JG, Wang CX. Hemodynamics in Transplant Renal Artery Stenosis and its Alteration after Stent Implantation Based on a Patient-specific Computational Fluid Dynamics Model. Chin Med J (Engl) 2017; 130:23-31. [PMID: 28051019 PMCID: PMC5221107 DOI: 10.4103/0366-6999.196569] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background: Accumulating studies on computational fluid dynamics (CFD) support the involvement of hemodynamic factors in artery stenosis. Based on a patient-specific CFD model, the present study aimed to investigate the hemodynamic characteristics of transplant renal artery stenosis (TRAS) and its alteration after stent treatment. Methods: Computed tomography angiography (CTA) data of kidney transplant recipients in a single transplant center from April 2013 to November 2014 were reviewed. The three-dimensional geometry of transplant renal artery (TRA) was reconstructed from the qualified CTA images and categorized into three groups: the normal, stenotic, and stented groups. Hemodynamic parameters including pressure distribution, velocity, wall shear stress (WSS), and mass flow rate (MFR) were extracted. The data of hemodynamic parameters were expressed as median (interquartile range), and Mann–Whitney U-test was used for analysis. Results: Totally, 6 normal, 12 stenotic, and 6 stented TRAs were included in the analysis. TRAS presented nonuniform pressure distribution, adverse pressure gradient across stenosis throat, flow vortex, and a separation zone at downstream stenosis. Stenotic arteries had higher maximal velocity and maximal WSS (2.94 [2.14, 3.30] vs. 1.06 [0.89, 1.15] m/s, 256.5 [149.8, 349.4] vs. 41.7 [37.8, 45.3] Pa at end diastole, P = 0.001; 3.25 [2.67, 3.56] vs. 1.65 [1.18, 1.72] m/s, 281.3 [184.3, 364.7] vs. 65.8 [61.2, 71.9] Pa at peak systole, P = 0.001) and lower minimal WSS and MFRs (0.07 [0.03, 0.13] vs. 0.52 [0.45, 0.67] Pa, 1.5 [1.0, 3.0] vs. 11.0 [8.0, 11.3] g/s at end diastole, P = 0.001; 0.08 [0.03, 0.19] vs. 0.70 [0.60, 0.81] Pa, 2.0 [1.3, 3.3] vs. 16.5 [13.0, 20.3] g/s at peak systole, P = 0.001) as compared to normal arteries. Stent implantation ameliorated all the alterations of the above hemodynamic factors except low WSS. Conclusions: Hemodynamic factors were significantly changed in severe TRAS. Stent implantation can restore or ameliorate deleterious change of hemodynamic factors except low WSS at stent regions.
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Affiliation(s)
- Hong-Yang Wang
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong 510080, China
| | - Long-Shan Liu
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong 510080, China
| | - Hai-Ming Cao
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong 510080, China
| | - Jun Li
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong 510080, China
| | - Rong-Hai Deng
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong 510080, China
| | - Qian Fu
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong 510080, China
| | - Huan-Xi Zhang
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong 510080, China
| | - Ji-Guang Fei
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong 510080, China
| | - Chang-Xi Wang
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong 510080; Guangdong Provincial Key Laboratory on Organ Donation and Transplant Immunology, Guangzhou, Guangdong 510080, China
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Robinson KA, Kriegshauser JS, Dahiya N, Young SW, Czaplicki CD, Patel MD. Detection of transplant renal artery stenosis: determining normal velocities at the renal artery anastomosis. Abdom Radiol (NY) 2017; 42:254-259. [PMID: 27539123 DOI: 10.1007/s00261-016-0876-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Renal artery anastomosis peak systolic velocity (RAA PSV) exceeding 250 cm/s and a ratio of the renal artery to the adjacent external iliac artery (RAA:EIA) exceeding 1.8 historically suggest significant transplant renal artery stenosis (TRAS). However, the range of RAA PSV in transplants without TRAS has not been established. METHODS A retrospective review of renal transplants at a single institution over 5 years was performed identifying patients without graft dysfunction, failure, or refractory hypertension. RAA PSV obtained during interval postoperative sonograms was recorded. RESULTS Of 1141 patients, 844 met the inclusion criteria. Mean RAA PSV for 377 patients evaluated within 2 days of transplant measured 195 cm/s; RAA PSV exceeded 250 cm/s in 97 patients (26%). Mean RAA PSV for 820 patients evaluated 1-month post-transplant measured 206 cm/s; RAA PSV exceeded 250 cm/s in 224 patients (27%). Mean RAA PSV for 785 patients evaluated 4-month post-transplant measured 203 cm/s; RAA PSV exceeded 250 cm/s in 201 patients (26%). Mean RAA PSV for 766 patients evaluated 1-year post-transplant measured 189 cm/s; RAA PSV exceeded 250 cm/s in 141 patients (18%). At each of the given time points, 24%-34% of normal patients had RAA-to-EIA ratios greater than 1.8. CONCLUSION Approximately, 26% of patients without TRAS have RAA PSV > 250 cm/s in the first 9 months, and 18% do at 1 year. Similar findings also occurred with regards to the RAA-to-EIA ratio threshold of 1.8. In isolation, a PSV over 250 cm/s or 1.8 ratio threshold for suspicion of TRAS will lead to a large number of false-positive assessments.
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Affiliation(s)
- Kristin A Robinson
- Department of Diagnostic Radiology, Mayo Clinic Hospital, 5777 East Mayo Blvd, Phoenix, AZ, 85054, USA.
| | - J Scott Kriegshauser
- Department of Diagnostic Radiology, Mayo Clinic Hospital, 5777 East Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Nirvikar Dahiya
- Department of Diagnostic Radiology, Mayo Clinic Hospital, 5777 East Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Scott W Young
- Department of Diagnostic Radiology, Mayo Clinic Hospital, 5777 East Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Christopher D Czaplicki
- Department of Diagnostic Radiology, Mayo Clinic Hospital, 5777 East Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Maitray D Patel
- Department of Diagnostic Radiology, Mayo Clinic Hospital, 5777 East Mayo Blvd, Phoenix, AZ, 85054, USA
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Wang L, Liu B, Yan J, Wang Y, Wang W, Wang W, Chang H, Wang H, Wang C, Li Z, Li Y. Interventional Therapy for Transplant Renal Artery Stenosis Is Safe and Effective in Preserving Allograft Function and Improving Hypertension. Vasc Endovascular Surg 2016; 51:4-11. [PMID: 28100159 DOI: 10.1177/1538574416682157] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Purpose: To evaluate the outcomes of percutaneous intervention (PI) for transplant renal artery stenosis (TRAS). Materials and Methods: Doppler ultrasonography was used as the screening tool, and angiography was the diagnostic method for TRAS. The indications for PI were (1) a reduction in lumen diameter of >50% or (2) a mean pressure gradient of >15 mm Hg. Technical success was assessed immediately after the procedure. The short-term results of stenosis were evaluated by serum creatinine (Scr) levels and blood pressure (BP). The long-term results were assessed by graft survival and renal function. Results: From October 2009 to July 2015, a total of 660 patients had kidney transplantation and 22 cases underwent PI. The technical success was 100%. The mean Scr level preintervention was 321.6 ± 167.2 (range, 171.3-862.0) μmol/L, and it decreased to 145.3 ± 44.7 (range, 74.3-260.8) μmol/L 1 month postintervention ( P < .001). Blood pressure was also improved at 1 month postintervention, as assessed by systolic (157.0 ± 13.0 vs 131.0 ± 11.0 mm Hg, P < .001), diastolic (95.0 ± 5.0 vs 77.0 ± 9.0 mm Hg, P < .001), and mean arterial pressure (116.0 ± 7.0 vs 95.0 ± 9.0 mm Hg, P < .001). The patency rate was 100%, 91.7%, and 85.7% at 1, 3, and 12 months, respectively. The secondary patency rate was 100%. Graft survival was 100% during follow-up. There was no significant deterioration in graft function or BP ( P > .05) postintervention when compared to posttransplantation. Conclusions: Percutaneous intervention for TRAS is safe and results in significant improvement both in allograft function and in BP.
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Affiliation(s)
- Lili Wang
- Department of Interventional Medicine, the Second Hospital of Shandong University, Jinan, China
| | - Bin Liu
- Department of Interventional Medicine, the Second Hospital of Shandong University, Jinan, China
| | - Jieke Yan
- Department of Kidney Transplantation, the Second Hospital of Shandong University, Jinan, China
| | - Yongzheng Wang
- Department of Interventional Medicine, the Second Hospital of Shandong University, Jinan, China
| | - Wujie Wang
- Department of Interventional Medicine, the Second Hospital of Shandong University, Jinan, China
| | - Wei Wang
- Department of Interventional Medicine, the Second Hospital of Shandong University, Jinan, China
| | - Haiyang Chang
- Department of Interventional Medicine, the Second Hospital of Shandong University, Jinan, China
| | - Hongwei Wang
- Department of Kidney Transplantation, the Second Hospital of Shandong University, Jinan, China
| | - Changjun Wang
- Department of Radiology, The Jiyang People’s Hospital, Jinan, Shandong, China
| | - Zheng Li
- Department of Interventional Medicine, the Second Hospital of Shandong University, Jinan, China
| | - Yuliang Li
- Department of Interventional Medicine, the Second Hospital of Shandong University, Jinan, China
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Unique Considerations When Managing Hypertension in the Transplant Patient. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2016. [PMID: 27815930 DOI: 10.1007/5584_2016_87] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/29/2024]
Abstract
For the select fortunate recipients of organ transplants, transplantation affords the rare opportunity for a new life. Given the scarcity of organs for transplantation, it is imperative that the health of transplant recipients be optimized in order to fully benefit from this gift of life. Unfortunately, hypertension is highly prevalent in the transplant population and it is considered a major cardiovascular risk factor contributing to mortality and morbidity in this population. In this chapter, we expound on the epidemiology, unique pathophysiology, evaluation, and management of hypertension as it pertains to the solid organ transplant recipient. In addition, a brief commentary is made on the subject of hypertension following living kidney donation, and practical aspects of management of hypertension in the solid organ recipient are summarized at the end of the chapter.
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Kolli KP, LaBerge JM. Interventional Management of Vascular Renal Transplant Complications. Tech Vasc Interv Radiol 2016; 19:228-36. [PMID: 27641457 DOI: 10.1053/j.tvir.2016.06.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Renal transplantation is the therapy of choice in patients with end stage renal disease. Although transplant rejection remains the most common complication after renal transplantation, vascular anatomical complications occur in 1%-23% of renal transplant recipients. Interventional radiologists play an important role in the management of these complications. This review discusses the role of image-guided interventions within the context of multidisciplinary patient management. Particular emphasis is given to anatomical considerations unique to this patient population, techniques used for image-guided interventions, and outcomes of image-guided interventions.
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Affiliation(s)
- Kanti Pallav Kolli
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA.
| | - Jeanne M LaBerge
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA
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Bent C, Fananapazir G, Tse G, Corwin MT, Vu C, Santhanakrishnan C, Perez RV, Troppmann C. Graft arterial stenosis in kidney en bloc grafts from very small pediatric donors: incidence, timing, and role of ultrasound in screening. Am J Transplant 2015; 15:2940-6. [PMID: 26153092 DOI: 10.1111/ajt.13365] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Revised: 03/29/2015] [Accepted: 04/25/2015] [Indexed: 01/25/2023]
Abstract
In previous studies with different donor selection criteria and noncontemporary surgical techniques, graft arterial stenosis (GAS) has been reported to occur more frequently in adult recipients of pediatric en bloc renal allografts (EBKT) as compared to single adult donor allografts. The purpose of our study was to evaluate the incidence of GAS within our EBKT recipient population and to evaluate clinical and imaging features of those cases with GAS. In a retrospective cohort study, we analyzed 182 EBKT performed at a single institution. We identified cases of suspected GAS based on clinical factors, lab results, and noninvasive imaging. Diagnosis of GAS was confirmed by digital subtraction angiography. Two EBKT recipients (1.1% of 182) had angiographically confirmed GAS at 2.5 and 4.5 months after transplant. In both cases, the stenoses were short segment within the proximal (perianastomotic) donor aorta, color Doppler ultrasound demonstrated peak systolic velocities of >400 cm/s, and poststenotic parvus tardus waveforms were present. Both patients underwent angioplasty and demonstrated postintervention improvement in renal function and blood pressure. Restenosis did not occur during follow up. In conclusion, recipients of EBKT have a low incidence of GAS, similar to the lowest reported for adult single allografts.
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Affiliation(s)
- C Bent
- Department of Radiology, University of California, Davis, Sacramento, CA
| | - G Fananapazir
- Department of Radiology, University of California, Davis, Sacramento, CA
| | - G Tse
- Department of Radiology, University of California, Davis, Sacramento, CA
| | - M T Corwin
- Department of Radiology, University of California, Davis, Sacramento, CA
| | - C Vu
- Department of Radiology, University of California, Davis, Sacramento, CA
| | | | - R V Perez
- Department of Surgery, University of California, Davis, Sacramento, CA
| | - C Troppmann
- Department of Surgery, University of California, Davis, Sacramento, CA
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Ali A, Mishler D, Taber T, Agarwal D, Yaqub M, Mujtaba M, Goggins W, Sharfuddin A. Long-term outcomes of transplant recipients referred for angiography for suspected transplant renal artery stenosis. Clin Transplant 2015; 29:747-55. [DOI: 10.1111/ctr.12574] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/02/2015] [Indexed: 11/28/2022]
Affiliation(s)
- Anum Ali
- Division of Nephrology; Department of Medicine; Indiana University School of Medicine; Indianapolis IN USA
| | - Dennis Mishler
- Division of Nephrology; Department of Medicine; Indiana University School of Medicine; Indianapolis IN USA
| | - Tim Taber
- Division of Nephrology; Department of Medicine; Indiana University School of Medicine; Indianapolis IN USA
| | - David Agarwal
- Division of Interventional Radiology; Department of Radiology; Indiana University School of Medicine; Indianapolis IN USA
| | - Muhammad Yaqub
- Division of Nephrology; Department of Medicine; Indiana University School of Medicine; Indianapolis IN USA
| | - Muhammad Mujtaba
- Division of Nephrology; Department of Medicine; Indiana University School of Medicine; Indianapolis IN USA
| | - William Goggins
- Division of Transplant Surgery; Department of Surgery; Indiana University School of Medicine; Indianapolis IN USA
| | - Asif Sharfuddin
- Division of Nephrology; Department of Medicine; Indiana University School of Medicine; Indianapolis IN USA
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A Systematic Review of Outcomes Following Percutaneous Transluminal Angioplasty and Stenting in the Treatment of Transplant Renal Artery Stenosis. Cardiovasc Intervent Radiol 2015; 38:1573-88. [DOI: 10.1007/s00270-015-1134-z] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Accepted: 05/10/2015] [Indexed: 12/19/2022]
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43
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Biederman DM, Fischman AM, Titano JJ, Kim E, Patel RS, Nowakowski FS, Florman S, Lookstein RA. Tailoring the endovascular management of transplant renal artery stenosis. Am J Transplant 2015; 15:1039-49. [PMID: 25703133 DOI: 10.1111/ajt.13105] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Revised: 11/11/2014] [Accepted: 11/11/2014] [Indexed: 01/25/2023]
Abstract
In this study we analyze the different types of endovascular interventions (EVIs) in de novo transplant renal artery stenosis (TRAS) and its anatomical subtypes to examine any variation in recovery of allograft function, blood pressure control, EVI patency and allograft survival with respect to EVI type (DES: drug-eluting stent, BMS: bare-metal stent, PTA: percutaneous transluminal angioplasty). Forty-five patients underwent a total of 50 primary EVIs (DES: 18, BMS: 26, PTA: 6). Patients were stratified according to medical co-morbidities, graft characteristics, biopsy results, clinical presentation and TRAS anatomic subtypes (anastomotic: 26, postanastomotic: 17, bend-kink: 2). There was significant improvement in allograft function and mean arterial blood pressure (MAP) control across all interventions (pre-EVI-creatinine [CR]: 2.8 ± 1.4, post-EVI-Cr: 2.1 ± 0.7, p < 0.001; pre-EVI-MAP: 117 ± 16, post-EVI-MAP: 112 ± 17, p = 0.03) with no significant difference among EVI types. There was no significant difference in allograft survival with respect to EVI type. Patency was significantly higher in EVIs performed with DES and BMS compared to PTA (p = 0.001). In the postanastomotic TRAS subtype, patency rates were significantly higher in DES compared to BMS (p = 0.012) in vessels of comparable reference diameter (≤5 mm).
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Affiliation(s)
- D M Biederman
- Department of Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, NY
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Chen W, Kayler LK, Zand MS, Muttana R, Chernyak V, DeBoccardo GO. Transplant renal artery stenosis: clinical manifestations, diagnosis and therapy. Clin Kidney J 2014; 8:71-8. [PMID: 25713713 PMCID: PMC4310434 DOI: 10.1093/ckj/sfu132] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2014] [Accepted: 11/13/2014] [Indexed: 01/04/2023] Open
Abstract
Transplant renal artery stenosis (TRAS) is a well-recognized vascular complication after kidney transplant. It occurs most frequently in the first 6 months after kidney transplant, and is one of the major causes of graft loss and premature death in transplant recipients. Renal hypoperfusion occurring in TRAS results in activation of the renin–angiotensin–aldosterone system; patients usually present with worsening or refractory hypertension, fluid retention and often allograft dysfunction. Flash pulmonary edema can develop in patients with critical bilateral renal artery stenosis or renal artery stenosis in a solitary kidney, and this unique clinical entity has been named Pickering Syndrome. Prompt diagnosis and treatment of TRAS can prevent allograft damage and systemic sequelae. Duplex sonography is the most commonly used screening tool, whereas angiography provides the definitive diagnosis. Percutaneous transluminal angioplasty with stent placement can be performed during angiography if a lesion is identified, and it is generally the first-line therapy for TRAS. However, there is no randomized controlled trial examining the efficacy and safety of percutaneous transluminal angioplasty compared with medical therapy alone or surgical intervention.
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Affiliation(s)
- Wei Chen
- Department of Medicine , University of Rochester School of Medicine and Dentistry , Rochester, NY , USA ; Department of Medicine , Albert Einstein College of Medicine , Bronx, NY , USA
| | - Liise K Kayler
- Department of Surgery , Albert Einstein College of Medicine , Bronx, NY , USA
| | - Martin S Zand
- Department of Medicine , University of Rochester School of Medicine and Dentistry , Rochester, NY , USA
| | - Renu Muttana
- Department of Medicine , Maimonides Medical Center , Brooklyn, NY , USA
| | - Victoria Chernyak
- Department of Radiology , Albert Einstein College of Medicine , Bronx, NY , USA
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