|
1
|
Stigler J, Tiefenthaler M. Value and limitations of sonography in kidney transplant recipients with special attention to the resistive index - An update. FRONTIERS IN NEPHROLOGY 2022; 2:997839. [PMID: 37675004 PMCID: PMC10479591 DOI: 10.3389/fneph.2022.997839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 08/15/2022] [Indexed: 09/08/2023]
Abstract
Kidney transplantation has become the standard treatment for end-stage renal disease. Even though the success rates are high, early and late post-transplant complications remain a major clinical problem due to the risk of graft failure. Therefore, it is of highest interest to early diagnose post-transplant complications. Ultrasound with color coded Duplex analysis plays a crucial role in imaging mechanical and vascular complications. In this article, we give an update of the visualizable complications in kidney transplant recipients and discuss the value of resistive index (RI) measurement with its limitations in allograft rejection.
Collapse
Affiliation(s)
| | - Martin Tiefenthaler
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Innsbruck, Austria
| |
Collapse
|
|
2
|
Madken M, Gotra A, Qazi S, Fairhead T, Burns KD. Successful Endovascular Management of Resistant Hypertension Post Kidney Transplant: A Case Report. Can J Kidney Health Dis 2022; 9:20543581221119896. [PMID: 36160314 PMCID: PMC9493670 DOI: 10.1177/20543581221119896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Indexed: 11/18/2022] Open
Abstract
Rationale: Transplant renal artery stenosis (TRAS) is a well-recognized and potentially reversible
cause of resistant hypertension post transplantation and can affect 1% to 23% of
recipients. Stenosis of the iliac segment proximal to the transplant renal artery
(proximal TRAS) causing dysfunction of the transplanted kidney is less common with
reported incidence of 2% to 3%. Presentation typically occurs between 3 months and 2
years post transplant but may happen at any time. Noninvasive investigations such as
Doppler ultrasound, computed tomography (CT) angiogram, and magnetic resonance angiogram
are useful in initial evaluation, but definitive diagnosis of hemodynamically
significant stenosis often requires formal angiogram. Transplant renal artery stenosis
should be suspected in any kidney transplant recipient with worsening hypertension
and/or deterioration in kidney function which is otherwise unexplained. We present the
case of a kidney transplant recipient with resistant hypertension and impaired graft
function, secondary to severe impairment of graft blood flow from proximal iliac system
occlusion. Presenting concerns of the patient: A 74-year-old female 15 years post live donor kidney transplant presented with graft
dysfunction (serum Cr 229 μmol/L) and resistant hypertension, requiring use of 8
antihypertensive medications. On physical examination, blood pressure was 160/92 mm Hg
with no tenderness over the renal graft in the right lower abdominal quadrant and no
audible bruit in kidney allograft area. Diagnosis: Transplant Doppler ultrasound showed reversal of flow in the right external iliac
artery suggestive of ipsilateral proximal iliac occlusion. Pre-procedure CT demonstrated
severe atherosclerotic burden within the aorta and bilateral iliac systems. The
anastomosed right renal artery appeared patent. Interventions: Conventional angiogram showed occlusion of the right common and proximal external iliac
arteries with retrograde perfusion of the transplant kidney via the contralateral left
iliac system and aorta. Subintimal recanalization of the right iliac system was
performed with angioplasty and kissing stent placement at the aortic bifurcation with
stents extending into the proximal right external iliac artery. Post deployment
angiogram demonstrated renewed patency of the right iliac system, with restoration of
antegrade perfusion to the transplant kidney. Outcomes: The patient’s blood pressure decreased significantly after the procedure, with
improvement in graft function. After 6 months, the patient continued to have optimally
controlled blood pressure (on 3 medications) and stable graft function (serum Cr 74
μmol/L). Teaching points: Our case describes proximal TRAS and the contribution of renal hypoperfusion to
hypertension and impaired graft function, with the potential for reversibility.
Collapse
Affiliation(s)
- Mohit Madken
- Division of Nephrology, Department of Medicine, The Ottawa Hospital Research Institute, University of Ottawa, ON, Canada
| | - Akshat Gotra
- Division of Vascular & Interventional Radiology, Department of Medical Imaging, The Ottawa Hospital, University of Ottawa, ON, Canada
| | - Shakeel Qazi
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Todd Fairhead
- Division of Nephrology, Department of Medicine, The Ottawa Hospital Research Institute, University of Ottawa, ON, Canada
| | - Kevin D Burns
- Division of Nephrology, Department of Medicine, The Ottawa Hospital Research Institute, University of Ottawa, ON, Canada
| |
Collapse
|
|
3
|
Sjekavica I, Novosel L, Rupčić M, Smiljanić R, Muršić M, Duspara V, Lušić M, Perkov D, Hrabak-Paar M, Zidanić M, Skender M. RADIOLOGICAL IMAGING IN RENAL TRANSPLANTATION. Acta Clin Croat 2018; 57:694-712. [PMID: 31168207 PMCID: PMC6544089 DOI: 10.20471/acc.2018.57.04.12] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
SUMMARY – Radiological diagnostic methods have a significant role in the preoperative and postoperative care of patients after kidney transplantation. Improvement and innovations in technology, but also the growing experience of the radiologists who deal with kidney transplant patients as part of the transplant team lead to earlier detection of complications in the postoperative period, which are the leading cause of transplant failure. In this article, we describe, through diagnostic imaging examples, detailed evaluation of all possible complications that can occur after kidney transplantation, with evaluation of different possible diagnostic methods that can be used in the preoperative assessment and postoperative follow up and care of the transplanted patient. The goal of this article is to demonstrate and summarize in detail the possible complications of renal transplantation and how to best diagnostically approach them, with special reference to ultrasound which is the main imaging method for this group of conditions.
Collapse
Affiliation(s)
| | - Luka Novosel
- 1Department of Diagnostic and Interventional Radiology, Zagreb University Hospital Center, Zagreb, Croatia; 2School of Medicine, University of Zagreb, Zagreb, Croatia; 3Department of Diagnostic and Interventional Radiology, Sestre milosrdnice University Hospital Center, Zagreb, Croatia
| | - Melita Rupčić
- 1Department of Diagnostic and Interventional Radiology, Zagreb University Hospital Center, Zagreb, Croatia; 2School of Medicine, University of Zagreb, Zagreb, Croatia; 3Department of Diagnostic and Interventional Radiology, Sestre milosrdnice University Hospital Center, Zagreb, Croatia
| | - Ranko Smiljanić
- 1Department of Diagnostic and Interventional Radiology, Zagreb University Hospital Center, Zagreb, Croatia; 2School of Medicine, University of Zagreb, Zagreb, Croatia; 3Department of Diagnostic and Interventional Radiology, Sestre milosrdnice University Hospital Center, Zagreb, Croatia
| | - Miroslav Muršić
- 1Department of Diagnostic and Interventional Radiology, Zagreb University Hospital Center, Zagreb, Croatia; 2School of Medicine, University of Zagreb, Zagreb, Croatia; 3Department of Diagnostic and Interventional Radiology, Sestre milosrdnice University Hospital Center, Zagreb, Croatia
| | - Vlatko Duspara
- 1Department of Diagnostic and Interventional Radiology, Zagreb University Hospital Center, Zagreb, Croatia; 2School of Medicine, University of Zagreb, Zagreb, Croatia; 3Department of Diagnostic and Interventional Radiology, Sestre milosrdnice University Hospital Center, Zagreb, Croatia
| | - Mario Lušić
- 1Department of Diagnostic and Interventional Radiology, Zagreb University Hospital Center, Zagreb, Croatia; 2School of Medicine, University of Zagreb, Zagreb, Croatia; 3Department of Diagnostic and Interventional Radiology, Sestre milosrdnice University Hospital Center, Zagreb, Croatia
| | - Dražen Perkov
- 1Department of Diagnostic and Interventional Radiology, Zagreb University Hospital Center, Zagreb, Croatia; 2School of Medicine, University of Zagreb, Zagreb, Croatia; 3Department of Diagnostic and Interventional Radiology, Sestre milosrdnice University Hospital Center, Zagreb, Croatia
| | - Maja Hrabak-Paar
- 1Department of Diagnostic and Interventional Radiology, Zagreb University Hospital Center, Zagreb, Croatia; 2School of Medicine, University of Zagreb, Zagreb, Croatia; 3Department of Diagnostic and Interventional Radiology, Sestre milosrdnice University Hospital Center, Zagreb, Croatia
| | - Martina Zidanić
- 1Department of Diagnostic and Interventional Radiology, Zagreb University Hospital Center, Zagreb, Croatia; 2School of Medicine, University of Zagreb, Zagreb, Croatia; 3Department of Diagnostic and Interventional Radiology, Sestre milosrdnice University Hospital Center, Zagreb, Croatia
| | - Mateja Skender
- 1Department of Diagnostic and Interventional Radiology, Zagreb University Hospital Center, Zagreb, Croatia; 2School of Medicine, University of Zagreb, Zagreb, Croatia; 3Department of Diagnostic and Interventional Radiology, Sestre milosrdnice University Hospital Center, Zagreb, Croatia
| |
Collapse
|
|
4
|
Sobrino Díaz L, Mosquera Rey V, Rodríguez García M, Alonso Pérez M, Ridao Cano N, Díaz Corte C, Zanabili Al-Sibbai AA. Stenosis of the iliac artery after kidney transplantation as a cause of refractory hypertension and intermittent claudication. Nefrologia 2018; 38:325-327. [PMID: 29731012 DOI: 10.1016/j.nefro.2017.05.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Revised: 03/05/2017] [Accepted: 05/18/2017] [Indexed: 11/30/2022] Open
Affiliation(s)
- Lucía Sobrino Díaz
- Área de Gestión Clínica de Nefrología, Hospital Universitario Central de Asturias, Oviedo, Asturias, España.
| | - Vicente Mosquera Rey
- Servicio de Angiología y Cirugía Vascular, Hospital Universitario Central de Asturias, Oviedo, Asturias, España
| | - Minerva Rodríguez García
- Área de Gestión Clínica de Nefrología, Hospital Universitario Central de Asturias, Oviedo, Asturias, España
| | - Manuel Alonso Pérez
- Servicio de Angiología y Cirugía Vascular, Hospital Universitario Central de Asturias, Oviedo, Asturias, España
| | - Natalia Ridao Cano
- Área de Gestión Clínica de Nefrología, Hospital Universitario Central de Asturias, Oviedo, Asturias, España
| | | | | |
Collapse
|
|
5
|
Kim DY, Jung HD, Lee JH, Kim HS, Lee DY, Oh JS, Kim SM, Sin YH, Kim JK, Huh K, Park JH, Jung GS. Successful Balloon Angioplasty with Low-pressure Balloon on Early Transplant Renal Artery Stenosis at Postoperative Day 7. KOREAN JOURNAL OF TRANSPLANTATION 2016. [DOI: 10.4285/jkstn.2016.30.2.103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Doo Youp Kim
- Department of Nephrology, Bong Seng Memorial Hospital, Busan, Korea
| | - Hyun Do Jung
- Department of Nephrology, Bong Seng Memorial Hospital, Busan, Korea
| | - Jin Ho Lee
- Department of Nephrology, Bong Seng Memorial Hospital, Busan, Korea
| | - Han Sae Kim
- Department of Nephrology, Bong Seng Memorial Hospital, Busan, Korea
| | - Dong Yeol Lee
- Department of Nephrology, Bong Seng Memorial Hospital, Busan, Korea
| | - Joon Seok Oh
- Department of Nephrology, Bong Seng Memorial Hospital, Busan, Korea
| | - Seong Min Kim
- Department of Nephrology, Bong Seng Memorial Hospital, Busan, Korea
| | - Yong Hun Sin
- Department of Nephrology, Bong Seng Memorial Hospital, Busan, Korea
| | - Joong Kyung Kim
- Department of Nephrology, Bong Seng Memorial Hospital, Busan, Korea
| | - Kill Huh
- Department of General Surgery, Bong Seng Memorial Hospital, Busan, Korea
| | - Jong Hyun Park
- Department of General Surgery, Bong Seng Memorial Hospital, Busan, Korea
| | - Gyu Sik Jung
- Department of Radiology, Kosin University Gospel Hospital, Busan, Korea
| |
Collapse
|
|
6
|
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.
Collapse
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
| |
Collapse
|
|
7
|
Kim HY, Yun JH, Kim DH, Lee JH, Oh JS, Kim SM, Sin YH, Kim JK, Kim YJ. Treatment of Renal Transplant Recipients with Concurrent Acute Cellular Rejection and Transplant Renal Artery Stenosis. KOREAN JOURNAL OF TRANSPLANTATION 2015. [DOI: 10.4285/jkstn.2015.29.3.160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Hee Yeoun Kim
- Department of Internal Medicine, Bong Seng Memorial Hospital, Busan, Korea
| | - Jeong Hee Yun
- Department of Internal Medicine, Bong Seng Memorial Hospital, Busan, Korea
| | - Dong Han Kim
- Department of Internal Medicine, Bong Seng Memorial Hospital, Busan, Korea
| | - Jin Ho Lee
- Department of Internal Medicine, Bong Seng Memorial Hospital, Busan, Korea
| | - Joon Seok Oh
- Department of Internal Medicine, Bong Seng Memorial Hospital, Busan, Korea
| | - Seong Min Kim
- Department of Internal Medicine, Bong Seng Memorial Hospital, Busan, Korea
| | - Yong Hun Sin
- Department of Internal Medicine, Bong Seng Memorial Hospital, Busan, Korea
| | - Joong Kyung Kim
- Department of Internal Medicine, Bong Seng Memorial Hospital, Busan, Korea
| | - Yong Jin Kim
- Department of Pathology, Yeungnam University College of Medicine, Daegu, Korea
| |
Collapse
|
|
8
|
Koukoulaki M, Brountzos E, Loukopoulos I, Pomoni M, Antypa E, Vougas V, Drakopoulos S. Successful endovascular treatment of transplant intrarenal artery stenosis in renal transplant recipients: Two case reports. World J Transplant 2015; 5:68-72. [PMID: 26131408 PMCID: PMC4478601 DOI: 10.5500/wjt.v5.i2.68] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Revised: 11/30/2014] [Accepted: 03/20/2015] [Indexed: 02/05/2023] Open
Abstract
Transplant renal artery stenosis (TRAS) is a relatively rare complication after renal transplantation. The site of the surgical anastomosis is most commonly involved, but sites both proximal and distal to the anastomosis may occur, as well. Angioplasty is the gold standard for the treatment of the stenosis, especially for intrarenal lesions. We report two cases of intrarenal TRAS and successful management with angioplasty without stent placement. Both patients were male, 44 and 55 years old respectively, and they presented with elevated blood pressure or serum creatinine within three months after transplantation. Subsequently, they have undergone angioplasty balloon dilatation with normalization of blood pressure and serum creatinine returning to baseline level. Percutaneous transluminal balloon renal angioplasty is a safe and effective method for the treatment of the intrarenal TRAS.
Collapse
|
|
9
|
Rossi AP, Vella JP. Hypertension, living kidney donors, and transplantation: where are we today? Adv Chronic Kidney Dis 2015; 22:154-64. [PMID: 25704353 DOI: 10.1053/j.ackd.2015.01.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Accepted: 01/05/2015] [Indexed: 02/08/2023]
Abstract
Hypertension is a prevalent problem in kidney transplant recipients that is known to be a "traditional" risk factor for atherosclerotic cardiovascular disease leading to premature allograft failure and death. Donor, peritransplant, and recipient factors affect hypertension risk. Blood pressure control after transplantation is inversely associated with glomerular filtration rate (GFR). Calcineurin inhibitors, the most commonly used class of immunosuppressives, cause endothelial dysfunction, increase vascular tone, and sodium retention via the renin-angiotensin-aldosterone system resulting in systemic hypertension. Steroid withdrawal seems to have little impact on blood pressure control. Newer agents like belatacept appear to be associated with less hypertension. Transplant renal artery stenosis is an important, potentially treatable cause of hypertension. Dihydropyridine calcium channel blockers mitigate calcineurin inhibitor nephrotoxicity and may be associated with improved estimated GFR. Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers are not recommended in the first 3 to 6 months given their effects on reduced estimated GFR, anemia, and hyperkalemia. The use of ß-blockers may be associated with improved patient survival, even for patients without cardiovascular disease. Living donation may increase blood pressure by 5 mm Hg or more. Some transplant centers accept Caucasian living donors with well-controlled hypertension on a single agent if they agree to close follow-up.
Collapse
|
|
10
|
Granata A, Di Nicolò P, Scarfia VR, Insalaco M, Lentini P, Veroux M, Fatuzzo P, Fiorini F. Renal transplantation parenchymal complications: what Doppler ultrasound can and cannot do. J Ultrasound 2014; 18:109-16. [PMID: 26191098 DOI: 10.1007/s40477-014-0118-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Accepted: 07/06/2014] [Indexed: 12/13/2022] Open
Abstract
Kidney transplantation is the treatment of choice in end-stage renal disease, given the better quality of life of transplanted patients when compared with patients on maintenance dialysis. In spite of surgical improvements and new immunosuppressive regimens, parts of transplanted grafts still develop chronic dysfunction. Ultrasonography, both in B-mode and with Doppler ultrasound, is an important diagnostic tool in case of clinical conditions which might impair kidney function. Even though ultrasonography is considered fundamental in the diagnosis of vascular and surgical complications of the transplanted kidney, its role is not fully understood in case of parenchymal complications of the graft. The specificity of Doppler is low both in case of acute complications, such as acute tubular necrosis, drugs toxicity and acute rejection, and in case of chronic conditions, such as chronic allograft nephropathy. Single determinations of resistance indices present low diagnostic accuracy, which is higher in case of successive measurements performed during the follow-up of the graft. Modern techniques such as tissue pulsatility index, maximal fractional area and contrast-enhanced ultrasound increase ultrasonography diagnostic power in case of parenchymal complications of the transplanted kidney.
Collapse
Affiliation(s)
- Antonio Granata
- Nephrology and Dialysis Unit, "San Giovanni di Dio" Hospital, Agrigento, Italy ; Via F. Paradiso n°78/a, 95024 Acireale, CT Italy
| | - Pierpaolo Di Nicolò
- Nephrology and Dialysis Unit, "Santa Maria della Scaletta" Hospital, Imola, Bo Italy
| | - Viviana R Scarfia
- Nephrology and Dialysis Unit, "San Giovanni di Dio" Hospital, Agrigento, Italy
| | - Monica Insalaco
- Nephrology and Dialysis Unit, "San Giovanni di Dio" Hospital, Agrigento, Italy
| | - Paolo Lentini
- Nephrology and Dialysis Unit, "San Bassiano" Hospital, Bassano del Grappa, Italy
| | - Massimiliano Veroux
- Vascular Surgery and Organ Transplant Unit, University Hospital of Catania, Catania, Italy
| | - Pasquale Fatuzzo
- Nephrology and Dialysis Unit, University Hospital of Catania, Catania, Italy
| | - Fulvio Fiorini
- Nephrology and Dialysis Unit, "Santa Maria della Consolazione" Hospital, Rovigo, Italy
| |
Collapse
|
|
11
|
Pinho A, Sampaio S, Pestana M. Accelerated atherosclerosis after renal transplantation: an unsuspected cause of uncontrolled hypertension. Int J Nephrol Renovasc Dis 2014; 7:295-6. [PMID: 25053893 PMCID: PMC4105269 DOI: 10.2147/ijnrd.s69358] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Ana Pinho
- Department of Nephrology, Faro Hospital, Faro, Portugal ; Department of Nephrology, Hospital São João, Porto, Portugal
| | - Susana Sampaio
- Department of Nephrology, Hospital São João, Porto, Portugal
| | - Manuel Pestana
- Department of Nephrology, Hospital São João, Porto, Portugal ; Medical School and Nephrology Research and Development Unit, University of Porto, Porto, Portugal
| |
Collapse
|
|
12
|
Granata A, Clementi S, Londrino F, Romano G, Veroux M, Fiorini F, Fatuzzo P. Renal transplant vascular complications: the role of Doppler ultrasound. J Ultrasound 2014; 18:101-7. [PMID: 26191097 DOI: 10.1007/s40477-014-0085-6] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Accepted: 03/14/2014] [Indexed: 12/15/2022] Open
Abstract
Improvements in the care of kidney transplant recipients and advances in immunosuppressive therapy have reduced the incidence of graft rejection. As a result, other types of kidney transplant complications, such as surgical, urologic, parenchymal, and vascular complications, have become more common. Although vascular complications account for only 5-10 % of all post-transplant complications, they are a frequent cause of graft loss. Ultrasonography, both in B-mode and with Doppler ultrasound, is a fundamental tool in the differential diagnosis of renal allograft dysfunction. Doppler ultrasound is highly specific in cases of transplanted renal artery stenosis, pseudoaneurysms, arteriovenous fistulas, and thrombosis with complete or partial artery or vein occlusion. A single measurements of color Doppler indexes display high diagnostic accuracy and in particular cases are more useful during the post-transplantation follow-up period. More recent techniques, such as contrast-enhanced ultrasound, undoubtedly increase the accuracy of ultrasonography in the diagnosis of vascular complications involving the transplanted kidney.
Collapse
Affiliation(s)
- Antonio Granata
- Nephrology and Dialysis Unit, "St. Giovanni di Dio" Hospital, Agrigento, Italy ; Via F. Paradiso n°78/a, 95024 Acireale (CT), Italy
| | - Silvia Clementi
- Medical Oncology Unit, Humanitas, Centro Catanese di Oncologia, Catania, Italy
| | | | - Giulia Romano
- Internal Medicine Unit, AOU "Vittorio Emanuele, Policlinico", Catania, Italy
| | - Massimiliano Veroux
- Vascular Surgery and Organ Transplant Unit, University Hospital of Catania, Catania, Italy
| | - Fulvio Fiorini
- Nephrology and Dialysis Unit, "Santa Maria della Consolazione" Hospital, Rovigo, Italy
| | - Pasquale Fatuzzo
- Cattedra di Nefrologia, Scuola di Specializzazione in Nefrologia, University Hospital of Catania, Catania, Italy
| |
Collapse
|
|
13
|
Ghirardo G, De Franceschi M, Vidal E, Vidoni A, Ramondo G, Benetti E, Motta R, Ferraro A, Zanon GF, Miotto D, Murer L. Transplant renal artery stenosis in children: risk factors and outcome after endovascular treatment. Pediatr Nephrol 2014; 29:461-7. [PMID: 24305958 DOI: 10.1007/s00467-013-2681-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Revised: 10/17/2013] [Accepted: 10/25/2013] [Indexed: 01/04/2023]
Abstract
BACKGROUND Transplant renal artery stenosis (TRAS) is an increasingly recognised cause of post-transplant hypertension. METHODS We retrospectively analysed 216 paediatric renal recipients transplanted between 2001 and 2011 to assess TRAS prevalence and percutaneous transluminal angioplasty (PTA) efficacy. To assess risk factors, we compared children with TRAS with a propensity score-matched cohort of recipients without TRAS. RESULTS Of the 216 paediatric patients who were transplanted in the study period, 44 were hypertensive (prevalence 20.3 %) and ten presented with TRAS (prevalence 4.6 %, median age at transplantation 14 years, range 6.78-17.36 years). Hypertensive patients without TRAS were prescribed one to two anti-hypertensive agents, whereas patients with TRAS required one to five medications. In the TRAS group, one recipient presented with vascular complications during surgery, and in three patients the graft had vascular abnormalities. TRAS was detected by Doppler ultrasonography (US) performed due to hypertension in nine of the patients with TRAS, but in the tenth case the TRAS was clinically silent and detected by routine Doppler-US screening. TRAS diagnosis was refined using angio-computed tomography or angio-magnetic resonance imaging. All patients underwent PTA without complications. Significant improvement after PTA was observed in the standard deviation scores for blood pressure [3.2 ± 1.4 (pre-PTA) vs. 1.04 ± 0.8 (post-PTA); p = 0.0006) and graft function [creatinine clearance: 69 ± 17.08 (pre-PTA) vs. 80.7 ± 21.5 ml/min/1.73 m(2) (post-PTA); p = 0.006] We observed no significant differences between the two cohorts for cold ischaemia time, recipient/donor weight ratio, delayed graft function, cytomegalovirus infections and acute rejection episodes. CONCLUSIONS Our study reports a low but significant TRAS prevalence among the paediatric patients who were transplanted at our centre in the study period and confirms that PTA is an effective and safe therapeutic option in paediatric renal transplant recipients. Known risk factors do not appear to be related to the development of TRAS.
Collapse
Affiliation(s)
- Giulia Ghirardo
- Pediatric Nephrology, Dialysis and Transplant Unit, Department of Pediatrics, University Hospital of Padua, Via Giustiniani 2, 35128, Padova, Italy,
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
|
14
|
O'Neill WC. Renal relevant radiology: use of ultrasound in kidney disease and nephrology procedures. Clin J Am Soc Nephrol 2014; 9:373-81. [PMID: 24458082 DOI: 10.2215/cjn.03170313] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Ultrasound is commonly used in nephrology for diagnostic studies of the kidneys and lower urinary tract and to guide percutaneous procedures, such as insertion of hemodialysis catheters and kidney biopsy. Nephrologists must, therefore, have a thorough understanding of renal anatomy and the sonographic appearance of normal kidneys and lower urinary tract, and they must be able to recognize common abnormalities. Proper interpretation requires correlation with the clinical scenario. With the advent of affordable, portable scanners, sonography has become a procedure that can be performed by nephrologists, and both training and certification in renal ultrasonography are available.
Collapse
Affiliation(s)
- W Charles O'Neill
- Renal Division, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| |
Collapse
|
|
15
|
Nixon JN, Biyyam DR, Stanescu L, Phillips GS, Finn LS, Parisi MT. Imaging of Pediatric Renal Transplants and Their Complications: A Pictorial Review. Radiographics 2013; 33:1227-51. [DOI: 10.1148/rg.335125150] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
|
|
16
|
Dores H, Campante Teles R, Nogueira A, Almeida M, Messias H, Diogo Barata J, Mendes M. Percutaneous thrombus aspiration in renal artery stenosis after renal transplantation. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2012. [DOI: 10.1016/j.repce.2012.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
|
|
17
|
Dores H, Campante Teles R, Nogueira A, Almeida M, Messias H, Barata JD, Mendes M. [Percutaneous thrombus aspiration in renal artery stenosis after renal transplantation]. Rev Port Cardiol 2012; 31:803-8. [PMID: 23141785 DOI: 10.1016/j.repc.2012.04.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2011] [Accepted: 04/24/2012] [Indexed: 11/30/2022] Open
Abstract
We describe the case of a patient with chronic renal failure under hemodialysis for five years who, after renal transplantation, developed acute renal failure and hypertension refractory to medical therapy. Given the clinical and imaging (renal ultrasound and computed tomography) suspicion of renal artery graft thrombosis, invasive angiography was performed, which confirmed the diagnosis. The therapeutic approach consisted of percutaneous thrombus aspiration and subsequent balloon angioplasty of the entire artery, followed by stent implantation in a second procedure. The clinical course was uneventful with improvement of renal function and normalization of blood pressure. The case highlights the importance of percutaneous intervention in the management of patients with vascular complications after transplantation, with successful application of a procedure normally used in the setting of acute myocardial infarction - percutaneous thrombus aspiration and implantation of a drug-eluting vascular stent.
Collapse
Affiliation(s)
- Hélder Dores
- Serviço de Cardiologia, Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Lisboa, Portugal.
| | | | | | | | | | | | | |
Collapse
|
|
18
|
Bou Matar R, Warshaw B, Hymes L, Greenbaum LA. Routine transplant Doppler ultrasonography following pediatric kidney transplant. Pediatr Transplant 2012; 16:607-12. [PMID: 22554083 DOI: 10.1111/j.1399-3046.2012.01712.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The utility and cost-effectiveness of routine transplant renal DU as a screening test in the immediate postoperative period following pediatric renal transplantation has not been systematically evaluated. Our center's transplant protocol includes a routine DU on postoperative day 3, unless an earlier DU was obtained for a specific indication. We retrospectively evaluated 113 consecutive pediatric renal transplant recipients. Indication for DU (routine vs. non-routine), timing, results, and graft outcome data were collected. We determined whether the DU result affected patient management. Eighty routine DU examinations were evaluated. Thirty (37.5%) of the 80 routine DUs had abnormalities. Most abnormalities were minor and did not require intervention. One patient with a dysfunctional bladder had mild hydronephrosis; this led to a decision to increase the frequency of bladder catheterization. This was the only intervention based upon the routine DUs. Twenty percent of routine DUs revealed abnormalities that led to a follow-up study, but none of these studies led to an intervention. The incremental cost of each DU exceeded $1080 and the incremental cost-effectiveness ratio for a documented change in management exceeded $86, 400. Our results suggest that routine post-transplant DU is not cost-effective in pediatric renal allograft recipients.
Collapse
|
|
19
|
Marini M, Fernandez-Rivera C, Cao I, Gulias D, Alonso A, Lopez-Muñiz A, Gonzalez-Martinez P. Treatment of Transplant Renal Artery Stenosis by Percutaneous Transluminal Angioplasty and/or Stenting: Study in 63 Patients in a Single Institution. Transplant Proc 2011; 43:2205-7. [PMID: 21839234 DOI: 10.1016/j.transproceed.2011.06.049] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
|
|
20
|
Ureteral fistulae after kidney transplantation: experience with 224 cases. ACTA CHIRURGICA IUGOSLAVICA 2011; 58:89-94. [PMID: 21630552 DOI: 10.2298/aci1101089b] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Ureteral fistulae after kidney transplantation represent major early urological complications with reported incidence from 1.2% to 12% in large series. The aim of the study is to establish the incidence, types and ureteral fistula related morbidity and lethality rates, by donor type. From 1995. to 2001, a total of 224 kidney transplantations (171 from living and 53 from cadaveric donor) have been performed at the Institute of Urology and Nephrology in Belgrade. Mean patients age was 36,67 years (11-64; SD = 10.69). Ureteral fistulae appeared only after living donor transplantation in a total of five patients (2.2%) (p > 0.05). In all patients open fistula repair was performed. Two patients had recidive ureteral fistula after primary and after secondary open repair. Following the third open repair one patient had lethal outcome. Ureteral fistulae after kidney transplantation still remain challenging urological problem with considerable morbidity and lethality rates.
Collapse
|
|
21
|
Mangray M, Vella JP. Hypertension after kidney transplant. Am J Kidney Dis 2011; 57:331-41. [PMID: 21251543 DOI: 10.1053/j.ajkd.2010.10.048] [Citation(s) in RCA: 99] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2010] [Accepted: 10/27/2010] [Indexed: 12/13/2022]
Abstract
Hypertension in kidney transplant recipients is a major "traditional" risk factor for atherosclerotic cardiovascular disease. Importantly, atherosclerotic cardiovascular disease is the leading cause of premature death and a major factor in death-censored graft failure in transplant recipients. The blood pressure achieved after transplant is related inversely to postoperative glomerular filtration rate (GFR), with many patients experiencing a significant improvement in blood pressure control with fewer medications within months of surgery. However, the benefits of improved GFR and fluid status may be affected by the immunosuppression regimen. Immunosuppressive agents affect hypertension through a variety of mechanisms, including catechol- and endothelin-induced vasoconstriction, abrogation of nitric oxide-induced vasodilatation, and sodium retention. Most notable is the role of calcineurin inhibitors in promoting hypertension, cyclosporine more so than tacrolimus. Additionally, the combination of calcineurin- and mammalian target of rapamycin (mTOR)-inhibitor therapy is synergistically nephrotoxic and promotes hypertension, whereas steroid withdrawal and minimization strategies seem to have little or no impact on hypertension. Other important causes of hypertension after transplant, beyond a progressive decrease in GFR, include transplant renal artery stenosis and sequelae of antibody-mediated rejection. Calcium channel blockers may be the most useful medication for mitigating calcineurin inhibitor-induced vasoconstriction, and use of such agents may be associated with improvements in GFR. Use of inhibitors of the renin-angiotensin system, such as angiotensin-converting enzyme inhibitors and angiotensin receptor blockers, remains an attractive strategy for many transplant recipients, although some recipients may have significant adverse effects associated with these medications, including decreased GFR, hyperkalemia, and anemia. In conclusion, hypertension control affects both patient and long-term transplant survival, and its best management requires careful analysis of causes and close monitoring of therapies.
Collapse
|
|
22
|
Brabrand K, Holdaas H, Gűnther A, Midtvedt K. Spontaneous regression of initially elevated peak systolic velocity in renal transplant artery. Transpl Int 2011; 24:555-9. [DOI: 10.1111/j.1432-2277.2011.01233.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
|
23
|
Ghazanfar A, Tavakoli A, Augustine T, Pararajasingam R, Riad H, Chalmers N. Management of transplant renal artery stenosis and its impact on long-term allograft survival: a single-centre experience. Nephrol Dial Transplant 2010; 26:336-43. [PMID: 20601365 DOI: 10.1093/ndt/gfq393] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Transplant renal artery stenosis (TRAS) is a recognized complication resulting in post-transplant hypertension associated with allograft dysfunction. It is a commonly missed but potentially treatable complication that may present from months to years after transplant surgery. In this retrospective study, we compared management strategies and outcomes of TRAS from 1990 to 2005. METHODS Case notes of transplant recipients with TRAS demonstrated by angiography were reviewed. Angiography and was carried out when there was a clinical or Doppler ultrasound suspicion of TRAS. The clinical diagnosis of TRAS was based on uncontrolled refractory/new-onset hypertension and/or unexplained graft dysfunction in the absence of another diagnosis, such as rejection, obstruction or infection. The two-tailed Student t-test was used to analyse the differences between mean arterial pressure, serum creatinine, and estimated glomerular filtration rate before and after the intervention. RESULTS Sixty-seven patients with angiogram-confirmed TRAS were included. Forty-four, 9 and 14 patients were managed with primary percutaneous transluminal renal angioplasty (PTRA), surgical intervention and conservative treatment, respectively. Uncontrolled hypertension was the most common presentation noted in 74.62%. Post-anastamotic single stenosis was the commonest occurrence (n = 53). Angioplasty had the highest 1- and 5-year graft survival rate of 91% and 86%, respectively. The worst prognosis was noted in patients treated with secondary PTRA after failed surgery or secondary surgery after failed primary PTRA. CONCLUSIONS TRAS is a recognized complication resulting in loss of renal allografts. Early Doppler ultrasound is a good primary diagnostic tool. Early intervention is associated with a good long-term graft function.
Collapse
Affiliation(s)
- Abbas Ghazanfar
- Department of Transplant Surgery, Manchester Royal Infirmary, UK.
| | | | | | | | | | | |
Collapse
|
|
24
|
Gosmanova EO, Wu S, O'Neill WC. Application of ultrasound in nephrology practice. Adv Chronic Kidney Dis 2009; 16:396-404. [PMID: 19695508 DOI: 10.1053/j.ackd.2009.07.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Ultrasonography plays critical roles in many aspects of nephrology practice. Applications include the evaluation of the kidneys and urinary tract, guidance for the percutaneous kidney biopsy and temporary hemodialysis access placement, and vascular ultrasound of upper extremities related to the permanent hemodialysis access. The simplicity of technique and the limited spectrum of pathological changes coupled with portability, low cost, and safety make sonography the modality of choice for kidney and vascular imaging. This review summarizes the indications for kidney and vascular ultrasound and describes the most commonly encountered findings. Although many ultrasound findings are nonspecific, their diagnostic use is greatly enhanced by knowledge of the clinical presentation. Therefore, it is essential for nephrologists to possess skills in performing and interpreting ultrasound studies in order to improve the care of patients with kidney diseases.
Collapse
|
|
25
|
Krejčí K, Zadražil J, Tichý T, Al-Jabry S, Horčička V, Štrebl P, Bachleda P. Sonographic findings in borderline changes and subclinical acute renal allograft rejection. Eur J Radiol 2009; 71:288-95. [DOI: 10.1016/j.ejrad.2008.04.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2007] [Revised: 02/01/2008] [Accepted: 04/21/2008] [Indexed: 02/05/2023]
|
|
26
|
Gunther A, Foss A, Holdaas H, Brabrand K, Hartmann A, Line PD, Midtvedt K. Increased peak systolic velocity in the renal artery of paediatric kidneys transplanted to adult recipients. Nephrol Dial Transplant 2008; 23:4041-4043. [PMID: 18586763 DOI: 10.1093/ndt/gfn358] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2025] Open
Abstract
BACKGROUND Paediatric kidneys transplanted to adult recipients increase in size after transplantation. It is unknown if the renal artery diameter increases concomitantly with the kidney. This study was performed to assess if peak systolic velocity (PSV) in the renal arteries of paediatric kidneys transplanted to adult recipients is comparable to PSV in the renal arteries of adult kidneys transplanted to adult recipients. Subjects and methods. Fifteen adult patients with paediatric renal transplants were examined with ultrasound Doppler and compared with a control group of adult recipients with adult transplants. MR angiography (MRA) or intra-arterial angiography (IA) was performed in patients with elevated PSV. MRA renal diameters of the paediatric transplants were compared with adult transplants. RESULTS The mean maximum PSV of the paediatric kidneys was 2.0 m/s (0.9-3.8), almost twice compared with the adult grafts transplanted to adult recipients, 1.1 m/s (0.7-1.6), P < 0.001. Seven paediatric transplants had a PSV >1.8 m/s, but only two had significant stenosis on MRA/IA. All patients had excellent blood pressure and renal function. The mean diameter of the paediatric renal arteries was 4.1 mm (3.4-6.0), whereas the mean for the adult renal arteries was 5.6 mm (4.8-6.9), P = 0.02. CONCLUSION Adult recipients of paediatric kidneys have significantly higher maximum PSV in the renal artery compared to adult recipients of adult grafts. The significantly smaller renal artery diameter might explain the high PSV. A PSV >1.8 m/s by itself does not necessarily indicate transplant renal artery stenosis in paediatric kidneys transplanted to adult recipients, but should be related to clinical findings.
Collapse
Affiliation(s)
- Anne Gunther
- Department of Radiology, Rikshospitalet University Hospital, N-0027 Oslo, Norway.
| | | | | | | | | | | | | |
Collapse
|
|
27
|
|
|
28
|
Gao J, Ng A, Shih G, Goldstein M, Kapur S, Wang J, Min RJ. Intrarenal color duplex ultrasonography: a window to vascular complications of renal transplants. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2007; 26:1403-18. [PMID: 17901143 DOI: 10.7863/jum.2007.26.10.1403] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
OBJECTIVE We analyze and discuss the importance of intrarenal color duplex ultrasonography (CDUS) in the diagnosis and differential diagnosis of vascular complications in renal transplants. METHODS We retrospectively reviewed results of CDUS, especially intrarenal CDUS, in 102 consecutive inpatients with vascular complications of renal transplants from January 1, 2000, to December 31, 2006. Correlations between CDUS and magnetic resonance angiography, digital subtraction angiography, surgical findings, and clinical diagnoses were studied. RESULTS Abnormal findings on intrarenal CDUS clearly represent vascular complications primarily located at the main renal vessels and intrarenal vessels. In our study, there were 5 cases of false-negative intrarenal arteriovenous fistulas, 1 case of false-positive transplant renal vein thrombosis, and 2 cases of false-negative transplant renal artery stenosis. The accuracy of detecting vascular complications of renal transplants with CDUS was 92% (94/102). CONCLUSIONS Intrarenal CDUS is a noninvasive, accurate diagnostic tool that can be administrated portably and is easily repeatable, thereby making it not only a highly valuable imaging technique but also the method of choice in screening and diagnosing vascular complications of renal transplants.
Collapse
Affiliation(s)
- Jing Gao
- Department of Radiology, New York Presbyterian Hospital-Weill Cornell Medical Center, 525 E 68th St, Starr 8A 27, New York, NY 10021, USA.
| | | | | | | | | | | | | |
Collapse
|
|
29
|
Abstract
Hypertension is common after renal transplant and is associated with adverse graft and patient outcomes. A thorough understanding of the unique factors that operate in renal transplant recipients is essential for the proper evaluation and management of this disorder. In this review, the authors outline the pathogenesis, diagnostic workup, and treatment of hypertension after renal transplant.
Collapse
Affiliation(s)
- Fasika Tedla
- From SUNY Downstate Medical Center, Brooklyn, NY
| | - Rick Hayashi
- From SUNY Downstate Medical Center, Brooklyn, NY
| | | | | |
Collapse
|
|
30
|
Ardalan MR, Tarzamani MK, Shoja MM. A Correlation Between Direct and Indirect Doppler Ultrasonographic Measures in Transplant Renal Artery Stenosis. Transplant Proc 2007; 39:1436-8. [PMID: 17580156 DOI: 10.1016/j.transproceed.2007.02.062] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2005] [Revised: 11/02/2006] [Accepted: 02/05/2007] [Indexed: 11/17/2022]
Abstract
Screening for transplant renal artery stenosis (TRAS) with Doppler ultrasonography (DUS) is increasingly used in the era of kidney transplantation. Direct Doppler study of the stenotic site is a time- consuming and difficult method that requires an angle of interrogation parallel to the vessel. The aim of this study was to assess the correlation between the direct-PSVs (peak systolic velocity at the stenotic site), PSVs/PSVi (PSVi, peak systolic velocity of the adjacent iliac artery)-and indirect-intrarenal arterial resistive index (RI), perfusion index (PI), acceleration time (AT)-DUS findings in the kidney transplant recipients with TRAS. We performed 26 DUS studies of both intrarenal and main renal arteries in 19 TRAS patients (who had PSVs > 150 cm/s, PSVs/PSVi > 2). The mean values of PSVs and PSVs/PSVi were 212 +/- 44.19 cm/s and 2.77 +/- 0.77, respectively. The mean intrarenal RI, PI, and AT were 0.48 +/- 0.065, 0.70 +/- 0.12, and 177.8 +/- 54.6 msec, respectively. A significant negative correlation was found between PSVs and intrarenal RI (Pearson correlation coefficient (r) = -0.4, two-tailed P = .043). No correlation was found between intrarenal PI or AT and the direct DUS findings (P > .05). With a cutoff level of 0.55 for intrarenal resistive index, the sensitivity of this parameter to detect proximal renal arterial stenosis was about 85%. Conclusively, PSVs and intrarenal RI were negatively correlated. Intrarenal resistive index can be used as an screening measure for detection of TRAS.
Collapse
Affiliation(s)
- M R Ardalan
- Department of Nephrology, Dialysis and Transplantation, Tabriz University of Medical Sciences (TUMS), Tabriz, Iran.
| | | | | |
Collapse
|
|
31
|
Abstract
B-mode sonography is an extremely useful and cost-effective method to eliminate urinary obstruction as a cause of acute renal failure and should be performed on all patients in whom obstruction is likely or in whom the cause of renal failure is not apparent. The threshold should be reduced in patients with solitary kidneys and sonography is probably indicated in all transplant patients. Sonography has very little utility in the management of other patients with acute renal failure. Although sonographic changes do occur in acute tubular necrosis, they are difficult to detect in the absence of baseline studies and are nonspecific.
Collapse
Affiliation(s)
- W Charles O'Neill
- Department of Medicine, Renal Division, Emory University School of Medicine, Atlanta, Ga 30322, USA.
| |
Collapse
|
|
32
|
Ardalan MR, Tarzamni MK. Renal Allograft Hemodynamic and Diameter Changes After Living Donor Transplantation. Transplant Proc 2006; 38:388-9. [PMID: 16549127 DOI: 10.1016/j.transproceed.2005.12.092] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Renal ultrasound is a valuable tool to measure allograft diameters and hemodynamic changes, some of which may help us to predict ongoing rejection. Longitudinal (L) and horizontal (H) diameters, and resistive index (RI) of intrarenal arteries of kidneys were measured before transplantation in the donor site, as well as 1 week after transplantation in the recipient site (7.5 MHz probe). We excluded patients with acute rejection, delayed graft function, perinephric collection, suspected allograft artery stenosis, or serum creatinine >2 mg/dL. Finally, allograft measurements were compared with the donor parameters. The mean values of L and H diameters in 32 normal allografts were: L 119 +/- 10.4 mm; H 54 +/- 8.4 mm; L/H ratio 2.25 +/- 0.27; RI 0.57 +/- 0.55. The mean values of these measurements when the kidney was in the donor body were: L 110 +/- 9.4 mm; H 44.3 +/- 5.4 mm; L/H ratio 2.97 +/- 0.25; RI 0.61 +/- 0.040. Both L and H diameters were increased significantly after transplantation, but the L/H ratio and RI were decreased significantly (P < .05). The presumed physiologic explanations for these findings in allograft are increased blood flow, decreased intrarenal arterial resistance, stress relaxation, and lack of sympathetic innervation.
Collapse
Affiliation(s)
- M R Ardalan
- Renal Transplantation Unit, Imam University Hospital, Tabriz Medical University, Tabriz, Iran.
| | | |
Collapse
|
|
33
|
Polak WG, Jezior D, Garcarek J, Chudoba P, Patrzałek D, Boratyńska M, Szyber P, Klinger M. Incidence and Outcome of Transplant Renal Artery Stenosis: Single Center Experience. Transplant Proc 2006; 38:131-2. [PMID: 16504683 DOI: 10.1016/j.transproceed.2005.11.097] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Since the incidence of transplant renal artery stenosis (TRAS) in renal allografts varies from 1% to 23%, we sought to examine its incidence, to analyze treatment options, and to ascertain its outcomes. Retrospective analysis of 793 kidney allograft recipients transplanted between 1996 and 2004 revealed an incidence of 0.9% (n = 7). Time from kidney transplantation to the first symptoms varied from 1 week to 3 years (median, 4 months). Three patients experiences refractory hypertension and six patients developed allograft dysfunction. Screening color Doppler ultrasonography showed hemodynamic changes in six patients with the definitive diagnosis confirmed by angiography in all patients. One patient with an anastomotic stenosis was treated with a surgical operation and six patients, percutaneous transluminal angioplasty (PTA), with stenting in three cases. Both surgical as well as PTA treatment were successful in all but one patient, who underwent PTA alone, developed chronic renal insufficiency necessitating hemodialysis and finally lost his allograft. In the other patients all symptoms resolved after treatment and the patients are doing well with functioning allografts. Although TRAS was an uncommon complication, if recognized promptly it could be treated by surgery or PTA with a high success rate.
Collapse
Affiliation(s)
- W G Polak
- Department of Vascular, General and Transplant Surgery, Wroclaw Medical University, ul. Poniatowskiego 2, 50-326 Wroclaw, Poland.
| | | | | | | | | | | | | | | |
Collapse
|
|
34
|
Audard V, Matignon M, Hemery F, Snanoudj R, Desgranges P, Anglade MC, Kobeiter H, Durrbach A, Charpentier B, Lang P, Grimbert P. Risk factors and long-term outcome of transplant renal artery stenosis in adult recipients after treatment by percutaneous transluminal angioplasty. Am J Transplant 2006; 6:95-9. [PMID: 16433762 DOI: 10.1111/j.1600-6143.2005.01136.x] [Citation(s) in RCA: 118] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Transplant renal artery stenosis (TRAS) is a common complication of kidney transplantation but attempts to identify predisposing risk factors for TRAS have yielded conflicting results. In order to determine the predisposing factors for transplant (TRAS), we retrospectively reviewed the records of 29 renal allograft recipients with TRAS treated with percutaneous transluminal angioplasty (PTA). The TRAS group was compared with a case-control group of 58 patients. Predisposing factors for TRAS included CMV infection (41.4% vs. 12.1% p = 0.0018) and initial delayed graft function (DGF) (48.3% vs. 15.5% p = 0.0018), respectively in the TRAS and the control group. Acute rejection occurred more frequently in patients from the TRAS group (48.3%) compared with the control group (27.6%), although the difference was not significant (p = 0.06). In a multivariate analysis, only CMV infection (p = 0.005) and DGF (p = 0.009) appear to be significantly and independently associated with TRAS. The long-term graft survival was significantly higher in the control group, compared with the TRAS group (p = 0.03). Our study suggests that CMV infection and DGF are two reliable risk factors for TRAS. Despite treatment by PTA with primary successful results, TRAS significantly affects long-term graft outcome.
Collapse
Affiliation(s)
- V Audard
- Department of Nephrology and Transplantation and Université Paris XII, Henri Mondor Hospital, Créteil, France
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
|
35
|
Voiculescu A, Schmitz M, Hollenbeck M, Braasch S, Luther B, Sandmann W, Jung G, Mödder U, Grabensee B. Management of arterial stenosis affecting kidney graft perfusion: a single-centre study in 53 patients. Am J Transplant 2005; 5:1731-8. [PMID: 15943633 DOI: 10.1111/j.1600-6143.2005.00927.x] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
We assessed clinical and duplex sonographic (CDS) findings, and outcome in patients with stenosis of the transplant renal artery (TRAS) or the aorto-iliac segment proximal to the graft (Prox-TRAS) treated with dilatation (PTA), stenting (PTAS) and surgery. From 1988 to 2002, of 1189 patients with renal transplantations, 117 underwent angiography. Fifty-three patients with TRAS (n = 37)/Prox-TRAS (n = 16) were found (4.4%). Clinical presentation included deterioration of hypertension (144 +/- 15/84 +/- 9, 157 +/- 22/90 +/- 10 mmHg; p < 0.001), increase of creatinine (1.7 +/- 0.9, 2.5 +/- 1.3 mg/dL; p = 0.01) and renal failure (n = 12). CDS indicated insufficient perfusion and differentiated between TRAS and Prox-TRAS. From renal transplantation (RTX) until the detection of stenosis pulsatility indices (PI) decreased from 1.2 +/- 0.46 to 0.98 +/- 0.29; (p = 0.001). Fifty-two patients underwent invasive treatment (21 PTA, 10 PTAS and 21 surgery) after which hypertension and creatinine significantly improved. PI increased. Restenosis occurred in 16 (52%) cases of the interventional (PTA 62% and PTAS 30%) and in 3 (14%) of the surgical group (p = 0.011). Hypertension and graft dysfunction due to perfusion problems are rare. Clinical findings are nonspecific but CDS findings are helpful to select patients for angiography. Invasive treatment leads to clinical improvement. Surgery yields better results than PTA, but additional stenting will probably improve the outcome of angioplasty.
Collapse
Affiliation(s)
- Adina Voiculescu
- Department of Nephrology, Heinrich-Heine-University, Düsseldorf, Germany.
| | | | | | | | | | | | | | | | | |
Collapse
|
|
36
|
Elster EA, Hale DA, Mannon RB, Cendales LC, Kleiner D, Swanson SJ, Kirk AD. Surgical transplant physical examination: correlation of renal resistance index and biopsy-proven chronic allograft nephropathy. J Am Coll Surg 2005; 200:552-6. [PMID: 15804469 DOI: 10.1016/j.jamcollsurg.2004.12.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2004] [Revised: 12/01/2004] [Accepted: 12/08/2004] [Indexed: 10/25/2022]
Abstract
BACKGROUND Chronic allograft nephropathy (CAN) remains the leading cause of late renal allograft loss that is minimally responsive to therapy once graft dysfunction is clinically evident. A screening test capable of identifying individuals at high risk for CAN would be a valuable adjunct to patient care, but to be cost effective, should be administered during routine evaluations by transplantation clinicians. STUDY DESIGN We have compared the resistive index (RI) as measured by Doppler ultrasonography with subsequent biopsy findings on 91 renal allograft recipients who had a subsequent protocol-directed biopsy at least 3 months after renal transplant. All ultrasonography was performed by the transplantation surgical staff without involving the radiology department or a separate appointment time. RESULTS Twenty-one patients had RI >/= 80 (average 621 days posttransplantation). Among these individuals, the subsequent incidence of CAN was 38%. Length of time between initial assessment of increased RI and biopsy-proved CAN averaged 233 days. The remaining 70 patients with RI < 80 had an incidence of CAN of 11.4% (p = 0.018). There were minimal complications from these biopsies. Sensitivity and specificity of an elevated RI in predicting CAN were 50% and 83%, respectively. The negative predicted value of an elevated RI in determination of CAN was 89%. CONCLUSIONS These results suggest that elevated RI is an early predictor of histologically relevant CAN, possibly a result of burgeoning vasculopathy. The technical expertise required to make this appraisal is well within the capabilities of transplantation surgeons and trainees. Early evidence of CAN may allow for a targeted change in therapy before clinically significant injury. Ultrasonography should become a routine part of a transplantation clinic evaluation.
Collapse
Affiliation(s)
- Eric A Elster
- Transplantation Branch, National Institute of Diabetes, Digestive and Kidney Diseases, National Institutes of Health, Department of Health and Human Services, Bethesda, MD 20892, USA
| | | | | | | | | | | | | |
Collapse
|
|
37
|
Abstract
Renal US is one of several imaging modalities available to the EP in the evaluation of patients with acute urologic disorders. It offers excellent anatomic detail without exposure to radiation or contrast agents but is limited in its assessment of renal function. It is an important alternative to helical CT scanning for evaluating renal colic, especially in children and pregnant women. It has an important role in excluding bilateral renal obstruction as the cause of acute renal failure. It is likely that Doppler renal US also will take on a prominent role in the evaluation of renal vascular disorders. It already has become the standard of care in the management of renal transplant patients. Bedside emergency renal US performed and interpreted by EPs with limited training and experience is increasing in use and gaining acceptance. At present, the primary role of renal US is to identify hydronephrosis in patients with renal colic or acute renal failure but, in the future, its role likely will expand as technology advances and its use increases. In many patients, bedside renal US may obviate the need for further diagnostic workup and speed the diagnosis and treatment of an emergency patient.
Collapse
Affiliation(s)
- Vicki E Noble
- Department of Emergency Medicine, Massachusetts General Hospital, Boston 02114, USA
| | | |
Collapse
|
|
38
|
Buturović-Ponikvar J, Ponikvar R. High-grade renal transplant artery stenosis after suboptimal angioplasty: favourable long-term outcome. Transplant Proc 2003; 35:2891-3. [PMID: 14697930 DOI: 10.1016/j.transproceed.2003.10.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The purpose of our report is to present the long-term outcomes of three renal transplant recipients with high-grade stenosis and suboptimal percutaneous angioplasty (PTA) because of technical difficulties. Two men and one woman of age 67, 53, and 54 years, who maintained functional cadaveric graft for 17, 9, and 13 years, and had diagnosed significant renal transplant artery stenosis at 2, 1, and 2 years after renal transplantation, respectively, were studied. Stenoses were diagnosed angiographically in the first patient and by Doppler in other two patients, then confirmed by angiography. All three patients had difficult-to-treat hypertension with deterioration of graft function in the presence of or after introducing ACE-inhibitor therapy. PTA was performed in all patients with suboptimal or unsuccessful results as assessed by angiography or control Doppler examination--the residual stenosis was significant and practically unchanged. Surgery was not performed because of high risk, so patients were further treated conservatively. Hypertension was treated avoiding ACE inhibitors. Twelve, 7, and 7 years after angioplasty the serum creatinine is stable in all patients, even decreased compared to pre-PTA and early post-PTA levels, namely, 134, 102, and 75 micromol/L, respectively. Control Doppler examinations revealed a residual stenotic jet in all patients, with slightly decreased peak systolic velocity over time, indicating a slightly decreased grade of stenosis. These observations suggest that renal transplant artery stenosis, even of high grade, can be stable, or even regress with time with excellent long-term graft survival. Randomized studies comparing conservative treatment versus revascularization are warranted.
Collapse
Affiliation(s)
- J Buturović-Ponikvar
- Department of Nephrology, University Medical Center Ljubljana, 1525 Ljubljana, Slovenia.
| | | |
Collapse
|
|
39
|
Asif A, Leclercq B, Merrill D, Bourgoignie JJ, Roth D. Arteriovenous fistula creation: should US nephrologists get involved? Am J Kidney Dis 2003; 42:1293-300. [PMID: 14655204 DOI: 10.1053/j.ajkd.2003.08.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
|
40
|
Bruno S, Ferrari S, Remuzzi G, Ruggenenti P. Doppler ultrasonography in posttransplant renal artery stenosis: a reliable tool for assessing effectiveness of revascularization? Transplantation 2003; 76:147-53. [PMID: 12865801 DOI: 10.1097/01.tp.0000071849.78031.13] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Renal artery stenosis is usually treated by angioplasty and stenting, but the effectiveness of graft perfusion is difficult to establish on clinical grounds. METHODS We compared changes in Doppler ultrasound parameters such as resistive index and peak systolic velocity with concomitant changes in renal vascular resistances, renal blood velocity, and wall shear stress measured before and 1 month after percutaneous transluminal angioplasty and stenting in 12 renal transplant patients with renal artery stenosis. RESULTS After revascularization, peak systolic velocity and resistive index normalized in all patients. Changes in peak systolic velocity (-72%; P<0.001 vs. basal) were positively correlated (P<0.0001; r=0.87) with those in renal blood velocity (-88%; P<0.01 vs. basal) and with those (P<0.0005; r=0.80) in wall shear stress (-97%; P<0.005). Changes in resistive index (+21%; P<0.005) were negatively correlated (P=0.009; r=0.51) with those in renal vascular resistances (-40%; P<0.01). Changes in Doppler parameters (resistive index and peak systolic velocity) reflected those in renal vascular resistances and renal blood velocity with 100% sensitivity and specificity. CONCLUSIONS Doppler ultrasound is a reliable, noninvasive, and easily available tool for identifying subjects who may benefit from kidney graft revascularization and to assess the effectiveness of the procedure.
Collapse
Affiliation(s)
- Simona Bruno
- Laboratory of Advanced Drug Development, Clinical Research Centre for Rare Diseases "Aldo e Cele Daccò" the Mario Negri Institute for Pharmacological Research, Ranica (Bergamo), Italy
| | | | | | | |
Collapse
|
|
41
|
Gill JS, Tonelli M, Mix CH, Pereira BJG. The change in allograft function among long-term kidney transplant recipients. J Am Soc Nephrol 2003; 14:1636-42. [PMID: 12761266 DOI: 10.1097/01.asn.0000070621.06264.86] [Citation(s) in RCA: 85] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Long-term kidney allograft survival continues to remain an elusive goal. Kidney transplant recipients are believed to be at high risk for loss of allograft function, and new, potentially non-nephrotoxic immunosuppressive medications are advocated to improve long-term allograft survival. To evaluate the efficacy of such therapeutic interventions, information regarding the change in GFR among kidney transplant recipients with long-term allograft survival is needed. We studied 40,963 transplant recipients between 1987 and 1996 with allograft survival of at least 2 yr in the United States Renal Data System. Linear regression methods were applied to serial GFR estimates after transplantation. The baseline mean GFR at 6 mo after transplantation was 49.6 +/- 15.4 ml/min per 1.73 m(2). During the mean follow-up of 5.7 +/- 2.3 yr, the mean +/- standard error of the change in GFR was -1.66 +/- 6.51 ml/min per 1.73 m(2) per year (median, -0.94 L/min per 1.73 m(2) per year). A total of 12,583 (30%) of patients had improvement in GFR, 8133 (20%) patients had no change in GFR, and 20,247 (50%) patients had decline in GFR. It is concluded that, although most patients had significant impairment of GFR at baseline, the decline in GFR was slow and many patients had either no change or improvement in GFR. Strategies to improve long-term kidney allograft survival that increase baseline allograft function may be more effective than strategies to slow the decline in GFR.
Collapse
Affiliation(s)
- John S Gill
- Division of Nephrology, St. Paul's Hospital, Vancouver, British Columbia, Canada
| | | | | | | |
Collapse
|
|
42
|
|
|
43
|
Abstract
The fragmented care of nephrology patients that results from referral to a radiologist for renal ultrasound (US) and biopsy, a surgeon for dialysis access placement, and an interventional radiologist for dialysis catheter placement and vascular access procedures often leads to delays in the treatment of these patients. Many specialists perform and interpret sonograms particular to their specialty rather than relying on technicians for performance and radiologists for interpretation, and nephrologists recently have begun to embrace this technology as an aid in the diagnosis and treatment of their patients. By combining an understanding of the pathophysiology of renal disease with the ability to perform clinical correlation and apply the laboratory data, the nephrologist is ideally suited to perform and interpret renal US and US guidance for percutaneous renal biopsies. Additionally, patients requiring peritoneal dialysis (PD) access have traditionally been referred to a general surgeon for catheter placement, which incurs additional delay in therapy and loss of decision-making control by the referring nephrologist. Recent data has emphasized that the peritoneal dialysis access procedure can be performed safely and effectively by a nephrologist trained in PD access procedures. Nephrologists also successfully perform tunneled hemodialysis catheter placement and vascular access procedures on an outpatient basis. The medical needs of patients with renal disease can be safely and efficiently delivered by a nephrologist trained in interventional nephrology (IN). This growing area of expertise will minimize delays, reduce cost, and allow physicians with training in the management of end-stage renal disease (ESRD) patients to be involved in the procedural aspects of their patients' care. An aggressive approach to the development of IN training programs at academic centers is warranted.
Collapse
Affiliation(s)
- Arif Asif
- Division of Nephrology, Department of Medicine, University of Miami, School of Medicine, Miami, Florida 33136, USA.
| | | | | | | | | |
Collapse
|