Renal allograft venous thrombosis is salvageable

Unexpected success in early post-transplantation renal vein thrombosis: A case report and literature review

Background: Allograft renal vein thrombosis can cause graft loss during the early postoperative period. This diagnosis is sometimes elusive, requiring a strong suspicion. On the other hand, several authors have recognized risk factors for allograft renal vein thrombosis, but neither a preventive approach nor a treatment have been recommended for this complication. Case presentation: We present a case report of early allograft renal vein thrombosis, preceded by femoral common deep vein thrombosis in a recipient of a third kidney transplant. Despite femoral common deep vein thrombosis treatment with low-molecular-weight heparin and progressive improvement of renal function to a nadir serum creatinine of 0.51 mg/dL, the patient experienced a sudden episode of anuria on postoperative day 5. Doppler ultrasonography strongly suggested the diagnosis of allograft renal vein thrombosis. The patient underwent balloon catheter and aspiration venous thrombectomy, followed by unfractionated heparin perfusion. After 4 days of anuria and multiple blood transfusions, when allograft nephrectomy was contemplated, diuresis suddenly resumed. After 1 year of follow-up, the patient still has a normal renal function. Conclusion: This case report shows successful treatment of allograft renal vein thrombosis associated with deep vein thrombosis in the first week of transplantation, using balloon catheter and aspiration venous thrombectomy followed by perfusion of unfractionated heparin. The authors suggest this technique as a treatment option for transplant renal vein thrombosis. However, they reinforce the importance of individualized treatment and they remind that a delay may jeopardize the potential benefit of the procedure.

Endovascular intervention for iliac vein thrombosis after simultaneous kidney-pancreas transplant

May–Thurner syndrome (MTS) is an anatomic variant where the overlying right common iliac artery compresses and chronically obstructs the left common iliac vein, leading to thrombosis. Interventions for symptomatic MTS include endovascular thrombectomy and stenting. Occluding venous thrombus can be fatal to transplanted allografts. No guidelines exist for patients with MTS after simultaneous kidney-pancreas transplant. A 57-year-old female with ESRD and diabetes mellitus underwent a kidney-pancreas transplant. Post-operative imaging revealed a compressed left CIV with an occlusive thrombus threatening the renal graft. Thrombectomy with stent placement was performed, maintaining patency of both allograft venous outflows. Post-intervention the patient has demonstrated preserved kidney and pancreas allograft function through 1 year of follow-up. Interventions for MTS in patients after transplant are challenging given the complex allograft vascular reconstruction. We present a case which demonstrates that angiographic interventions for MTS can be safely performed after simultaneous kidney-pancreas transplant.

Iliofemoral deep venous thrombosis in kidney transplant patients can cause graft dysfunction

We present a series of kidney transplant dysfunction secondary to lower extremity deep venous thrombosis (DVT). A 70-year-old man underwent living unrelated kidney transplantation and presented 2 months postoperatively with acute kidney injury (AKI) secondary to external iliac vein thrombosis. Graft function improved after endovascular intervention. A 43-year-old man underwent living unrelated kidney transplantation and presented 3 years postoperatively with AKI secondary to external iliac vein thrombosis. Graft function recovered after thrombolysis. A 42-year-old woman underwent simultaneous pancreas and kidney transplantation. Four weeks postoperatively, she had AKI secondary to common femoral vein DVT. Her graft function improved after common iliac vein stenting. A 67-year-old man underwent living unrelated kidney transplantation and presented a week later with lower extremity DVT and AKI. His graft function improved with anticoagulation. Iliofemoral DVT can cause allograft dysfunction. The cause may be multifactorial. Endovascular intervention is safe and feasible when anticoagulation fails.

Successful salvage of allograft dysfunction triggered by transplant renal vein thrombosis immediately after kidney transplantation: a case report

Background

Transplant renal vein thrombosis (TRVT) is a severe vascular complication and is caused by various factors, including recipient factors, donor factors, immunosuppression regimens, and surgical techniques. Despite adequate interventions, including thrombolytic therapy or surgical thrombectomy, successful salvage of the allograft is often difficult. We observed a case of TRVT induced by compression of the renal vein immediately after intraoperative abdominal closure.

Case presentation

A 41-year-old male underwent ABO-compatible living kidney transplantation. The donor was his 45-year-old sister, and her right kidney was donated. The allograft had a single artery and vein. One of the preoperative recipient problems was obesity (body mass index, 33.4 kg/m²). Intraoperative Doppler ultrasonography (US) revealed sufficient blood flow throughout the allograft, and urine output was also observed. After surgery, hematuria was observed; the urine output decreased and serum creatinine levels increased to 7.0 mg/dL. Doppler US showed a decrease in diastolic flow and an elevated resistive index, which were similar findings to those noted in acute rejection. Although steroid pulse therapy was initiated, allograft dysfunction was worsening. On postoperative day 4, surgical exploration revealed TRVT; consequently, thrombectomy was performed. The urine output increased, and serum creatinine levels decreased to 1.8 mg/dL. The cause of TRVT development may be that the transplant renal vein was relatively short, due to the right kidney being compressed by surrounding tissues after abdominal closure, and that TRVT was gradually developing due to stagnant blood flow.

Conclusion

Although TRVT is induced by multiple factors, an accurate diagnosis is often difficult. Understanding these factors, including obesity, and considering TRVT as a cause of allograft dysfunction are important during the pre-, peri-, and postoperative periods. Knowledge of TRVT can lead to early and accurate diagnosis and intervention, resulting in better outcomes for the patients with allograft dysfunction.

Vascular thrombosis in pediatric kidney transplantation: Graft survival is possible with adequate management

OBJECTIVE

Vascular thrombosis (VT) in pediatric kidney transplantation (KT) is a dreaded event that leads to graft loss in almost 100% of cases. In recent years, VT has become the most common cause of early graft loss. The aim of this study was to analyze our experience in diagnosis and treatment of VT and the impact of a new management protocol on patient outcome.

METHODS

We conducted a retrospective study of 176 consecutive KT performed at our institution by the pediatric urology team between January 2000 and December 2015 and identified patients with VT. A protocol of prevention and early detection of VT was introduced in 2012.

RESULTS

Out of 176 KT, nine cases of VT were identified (5.1%). The mean recipient age was 5.1 years (SD 4.9 years) and mean weight was 22.28 kg (SD 15.6 kg). Diagnosis was intraoperative in two cases and within the first 24 h after surgery in the remaining seven. Immediate surgical exploration was performed after diagnosis in all. Of the five episodes that occurred before 2012, all developed complete graft ischemia requiring transplantectomy. However, in the four cases diagnosed after 2012, graft perfusion could be restored in three, and abdominal wall closure with a mesh and delayed sequentially closure under ultrasound guidance was performed. With a follow-up of 30, 25, and 20 months, the three recovered grafts are still functioning normally.

CONCLUSIONS

Increased awareness and the application of a protocol for prevention, detection and treatment of VT in pediatric KT can prevent graft loss. Immediate surgical intervention is mandatory after diagnosis. Avoiding compartment syndrome with delayed sequential closure may be useful to improve graft survival.

Transplant renal vein thrombosis in a recipient with aberrant venous anatomy

Renal vein thrombosis in a transplanted kidney is an uncommon but critical complication that can result in graft loss if management is delayed. A 31-year-old male with known atresia of the inferior vena cava who received a deceased donor renal transplant 7 years previously presented to hospital with severe graft site pain and a week of nausea, vomiting, and chills. Serum creatinine was markedly elevated from baseline. Sonographic examination revealed external iliac vein thrombosis with extension of the thrombus into the transplant renal vein. Urgent angiographic administration of tissue plasminogen activator and suction thrombectomy was performed, then followed by heparin and clopidogrel post procedure. Within 24 h, his serum creatinine improved, and within 2 weeks returned to his baseline. He was started on lifelong warfarin anti-coagulation to reduce the risk of rethrombosis secondary to his uncorrectable aberrant venous anatomy. Due to the turbulent and sometimes reversed flow in the major veins, lifelong anticoagulation should be strongly considered for such transplant patients with recipient aberrancy of the large veins.

A case report of venous thrombosis after kidney transplantation - We can save the graft? Time is the success factor

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Kidney graft vein thrombosis is a rare surgical complication.

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The reports of graft rescue are scarce.

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The diagnosis of vascular complications should be done as early as possible.

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The fundamental to the success is the time of diagnosis to intervention.

Introduction

Venous thrombosis is a serious surgical complication that frequently results in loss of kidney graft.

Case presentation

We report the case of a female patient recipient of a decease kidney transplant that in the tenth postoperative presented with hematuria, graft pain and oliguria. Ultrasound examination was suggestive of venous thrombosis with abnormal doppler waveform pattern and reversal of diastolic flow. She underwent emergency surgical intervention after 2 h of diagnosis. The vein thrombus was removed by perfusing the renal graft artery with 1000 ml of Euro-Collins solution. The patient evolves with recovery of renal function after 1 week of the procedure

Discussion

Similar reports of graft rescue in the vein thrombosis are scarce and that the time of diagnosis to intervention is a determining factor.

Conclusion

Rapid diagnosis of exactly 2 h combined with the early re-operation may be successful in preserving renal graft in cases of venous thrombosis.

Doppler Ultrasonography Findings During Recovery Period of Transplanted Kidney After Infarction and Necrosis Due to Renal Vein Thrombosis: A Case Report

A 47-year-old male patient underwent living-related renal transplant. On day 3 posttransplant, without evidence of associated clinical symptoms, the patient's serum creatinine levels had increased. The patient was given immunosuppressive medication, and a followup Doppler ultrasonography revealed hypoechoic areas in the inferior pole of the renal parenchyma. Eventually, on day 25, there was no perfusion in the superior and inferior poles of the transplanted kidney. No venous flow was shown in the middle segment, and only arterial vascularization with a high resistive index and negative diastolic phase was observed. Renal biopsy showed acute humoral rejection. This was interpreted as venous thrombosis secondary to acute humoral rejection. Tissue plasminogen activator infusion, plasmapheresis, and hemodialysis were administered. After 1.5 months, arterial flow returned to its normal pattern and the renal allograft recovered by gaining back its full vascularity at the end of month 8.

Renal paratransplant hernia revealed: a review of the literature

BACKGROUND

Renal paratransplant hernia (RPH) is an uncommon variant of internal hernias developed in renal transplant recipients. The aim of this review is to meticulously present and analyze all data coming mainly from case reports or short-case studies on this very uncommon surgical entity.

MATERIALS AND METHODS

The MEDLINE/PubMed database was searched for publications with the medical subject heading ''renal paratransplant hernia''. All the references from the identified articles were searched for relevant information. The end date of the literature search was set to March 2016.

RESULTS

Our search revealed five publications, three short clinical series (three cases each) and two case reports. The total number of cases retrieved was 11. RPH should be considered as an iatrogenic surgical complication. The incidence is around 0.45%.

CONCLUSIONS

RPH is a relatively uncommon but potentially fatal complication after renal transplantation, and its non-specific symptoms may lead to misdiagnosis. Physician awareness, prompt diagnosis, and early surgical intervention are critical. In addition, meticulous surgical technique during transplantation may help avoid this complication.

Salvage of grafts with vascular thrombosis during live donor renal allotransplantation: a critical analysis of successful outcome

OBJECTIVES

To report a high-volume institution experience with salvage techniques for vascular accidents during live donor renal allotransplantation.

METHODS

Between March 1976 and January 2011, 2208 recipients underwent live donor renal allotransplantation. A retrospective review of recipients with vascular accidents - renal artery thrombosis and renal vein thrombosis - was carried out. Salvage procedures were recorded and their outcomes were assessed.

RESULTS

A total of 23 (1%) vascular accidents occurred, including renal artery thrombosis and renal vein thrombosis in 19 (0.8%) and four (0.18%) recipients, respectively. All renal artery thrombosis patients were treated by open revascularization and the graft was salvaged in 12 patients (63%). Two renal vein thrombosis events were resolved by percutaneous catheter-directed thrombolytic therapy. Of the other two allografts, one was salvaged by thrombectomy and revascularization, and the other was lost. On univariable analysis, older recipients (P = 0.003), pretransplant hypertension (P =  0.001), more human leukocyte antigen mismatches (≥3; P = 0.036), shorter ischemia time (≤45 min; P = 0.004) and longer time to diagnosis (>3.5 days; P = 0.013) were significantly associated with non-salvage of the graft after vascular accidents. Nevertheless, none of these variables were significant on the multivariable analysis. Over a median follow up of 35 months, the median (range) serum creatinine was 2 mg/dL (range 0.8-8.8 mg/dL), and 11 (79%) recipients were living with functioning grafts.

CONCLUSIONS

Despite the devastating complications, vascular accidents are salvageable and revascularization is crucial for graft salvage. Angiographic percutaneous techniques are viable alternatives for renal vein thrombosis.

Successful Salvage of a Renal Allograft after Acute Renal Vein Thrombosis due to May-Thurner Syndrome

A 68-year-old Caucasian female with a past medical history of a deceased donor kidney transplant four months prior was admitted with a two-day history of anuria and acute kidney injury. A renal ultrasound demonstrated thrombus in the transplanted kidney's renal vein that extended into the left iliac vein as well as into the left femoral venous system. Catheter-guided tissue thrombolytics were infused directly into the clot. Within twelve hours of initiating thrombolytic infusion, there was brisk urine output. Interval venography demonstrated decreasing clot burden. At the time of discharge her creatinine was 0.78 mg/dL, similar to her baseline value prior to presentation. The patient was noted to have May-Thurner syndrome on intravascular ultrasound (IVUS). Angioplasty followed by stent placement was done. Unique to our case report was the timing of the presentation of renal vein thrombosis (four months after transplant) and the predisposing anatomy consistent with May-Thurner syndrome, which was diagnosed with IVUS and successfully treated with local thrombolytics.

Identification of risk factors for vascular thrombosis may reduce early renal graft loss: a review of recent literature

Renal graft survival has improved over the past years, mainly owing to better immunosuppression. Vascular thrombosis, though rare, therefore accounts for up to one third of early graft loss. We assess current literature on transplantation, identify thrombosis risk factors, and discuss means of avoiding thrombotic events and saving thrombosed grafts. The incidence of arterial thrombosis was reported to 0.2–7.5% and venous thrombosis 0.1–8.2%, with the highest incidence among children and infants, and the lowest in living donor reports. The most significant risk factors for developing thrombosis were donor-age below 6 or above 60 years, or recipient-age below 5-6 years, per- or postoperative hemodynamic instability, peritoneal dialysis, diabetic nephropathy, a history of thrombosis, deceased donor, or >24 hours cold ischemia. Multiple arteries were not a risk factor, and a right kidney graft was most often reported not to be. Given the thrombosed kidney graft is diagnosed in time, salvage is possible by urgent reoperation and thrombectomy. Despite meticulous attentions to reduce thrombotic risk factors, thrombosis cannot be entirely prevented and means to an early detection of this complication is desirable in order to save the kidneys through prompt reoperation. Microdialysis may be a new tool for this.

High venous pressure in the main renal vein causing development of peritransplant venous collaterals in renal transplant patients: a rare finding

We will show the sonographic appearance of peritransplant venous collaterals in renal transplants with renal venous hypertension. Three cases of renal transplants with pericapsular vessels were identified at our institution. Two cases were related to renal vein thrombosis. The third case had pericapsular vessels secondary to venous hypertension from arterialization of the transplant renal vein by a preexisting right thigh arteriovenous graft. The development of high venous pressures in renal transplants leading to the collaterals' venous drainage has been rarely described. This finding should be recognized as a rare complication of renal transplants but does not necessarily lead to transplant failure.

Using microdialysis for early detection of vascular thrombosis after kidney transplantation in an experimental porcine model

BACKGROUND

In kidney transplantation (KTx), vascular thrombosis has a major impact on morbidity and graft survival. The ischaemia, caused by thrombosis, can lead to interstitial metabolite changes. The aim of this experimental study was to create conditions in which the graft would be prone to vascular thrombosis following KTx and then to evaluate the role of microdialysis (MD) for its early detection.

METHODS

Sixteen randomized pigs in the control group received heparin and immunosuppressive drugs, while the case group received none. Based on histopathological evidence of vascular thrombosis, the case group was subdivided into mildly and severely congested subgroups. Using MD, we evaluated the interstitial concentrations of glucose, lactate to pyruvate ratio, glutamate and glycerol in the transplanted grafts during different phases of KTx.

RESULTS

Following reperfusion, we noted considerable changes. The severely congested subgroup showed a low and decreasing level of glucose. Only in this group did the lactate to pyruvate ratio continue to increase until the end of monitoring. The glycerol level increased continuously in the entire case group and this increase was most significant in the severely congested subgroup. In all of the study groups, glutamate concentration remained in a low steady state until the end of monitoring.

CONCLUSION

MD can be an appropriate method for early detection of vascular complications after KTx. Decreasing glucose levels, increased lactate to pyruvate ratio and increased glycerol levels are appropriate indicators for early detection of vascular thromboses following KTx. Particularly, the glycerol level could predict the necessity and urgency of intervention needed to ultimately save the transplanted kidney.

Renal paratransplant hernia: a surgical complication of kidney transplantation

INTRODUCTION

Renal paratransplant hernia is an uncommon and potentially fatal complication of renal transplantation. In this condition, bowel herniates through a defect in the peritoneum over the transplanted kidney and becomes trapped.

CASE REPORT

Six cases have been reported previously, and we herein report three cases encountered in 668 kidney recipients. Abdominal pain and distention with or without vomiting were the main symptoms, presenting within 4 days after surgery. Abdominal CT scan confirmed the presence of bowel obstruction and paratransplant hernia. All three patients underwent emergent laparotomy, and resection of necrotic bowel was required in one patient who died of multiple organ failure 1 week after laparotomy.

CONCLUSION

Renal paratransplant hernia is uncommon and potentially fatal, thus, prompt diagnosis and early surgical intervention are critical. Additionally, meticulous surgical technique during transplantation may help avoid this complication.

Microdialysis for detection of renal ischemia after experimental renal transplantation

PURPOSE

We designed an experimental renal transplantation model and evaluated microdialysis as a detector of induced postoperative ischemia, a feared complication that when caused by vascular thrombosis most often causes renal graft loss.

MATERIALS AND METHODS

Two microdialysis catheters were placed in the left kidney in 16 pigs, including 1 superficially in the renal cortex and 1 fixed on the renal capsule. Two-hour baseline measurements were made at steady state, after which the kidney was removed and subjected to warm and cold ischemia. It was subsequently re-anastomosed end to end in situ and reperfused for 5 hours. Pigs were then randomized into a total renal artery occlusion and a control group.

RESULTS

At baseline there were no changes in local metabolites (glucose, glutamate, glycerol and lactate) and no significant difference between the groups. Glycerol increased 4-fold in each group during cold ischemia but there were no pivotal alterations in other metabolites. After kidney reperfusion glycerol decreased and all metabolites were in steady state after 1 hour. At 30 minutes after postoperative ischemia was introduced there were significant increases in all kidneys in ischemia vs steady state reperfusion levels of cortical lactate, glutamate, glycerol and the lactate-to-glucose ratio (each rank sum test p <0.001). No metabolic changes were seen in controls.

CONCLUSIONS

Microdialysis detected significant metabolic changes after postoperative ischemia in pigs with experimental renal transplantation, while no metabolic changes were observed in controls. In the future microdialysis may become a valuable tool for postoperative observation of transplanted kidneys, most probably with major impact on early graft survival.

A rare cause of iliocaval thrombosis in kidney transplantation

INTRODUCTION

Renal vein thrombosis (RVT) has an incidence of 0.55% to 3.4% and accounts for as many as one-third of early allograft losses. Rarely, RVT may be a consequence of an extension of ipsilateral iliac vein thrombosis. We present a rare case of iliocaval thrombosis as a consequence of inferior vena cava compression by a large-for-size kidney transplant.

CASE REPORT

A 20-year-old woman with spina bifida and kidney failure received a living donor kidney from her 52-year-old father. On postoperative day 8, the patient had right lower quadrant abdominal pain associated with oliguria. Graft duplex ultrasonography examination revealed venous thrombosis arising in the right femoral vein and extending to the iliac vein. An urgent second laparotomy was performed, and the kidney was finally placed in the peritoneal cavity.

CONCLUSIONS

The eventuality of an inferior vena cava compression by a transplanted kidney should be considered in any recipient with sudden leg swelling and acute graft dysfunction. An early diagnosis and prompt intervention may reduce the progression to RVT and subsequent graft nephrectomy. When planning a kidney transplantation with a supposed size discrepancy between donor and recipient, positioning the kidney on the left side or in the peritoneal cavity may be preferred.

Late renal vein thrombosis associated with recurrence of membranous nephropathy in a renal allograft: a case report

Allograft renal vein thrombosis (RVT) is an uncommon but potentially catastrophic complication. Although it usually occurs in the early posttransplant period and is associated with surgical complications or vascular rejection, it may develop later, when it is generally related with a hypercoagulable state. Typical clinical presentation is sudden oligoanuric acute renal failure, and hematuria, with a painful and swollen renal allograft. Confirmation of the diagnosis requires Doppler ultrasound and computed tomography. Herein we have reported a successfully treated case of late RVT that developed in an allograft with recurrent membranous nephropathy associated with the nephrotic syndrome. The patient fully recovered renal graft function a few days after presentation, which was related to anticoagulant therapy. We demonstrated complete recanalization of the venous thrombosis.

Reversed diastolic flow in the renal transplant: perioperative implications versus transplants older than 1 month

OBJECTIVE

The purpose of our study was to evaluate the causes, waveform morphology, and clinical outcomes of high-resistance reversed diastolic flow in transplanted kidneys.

MATERIALS AND METHODS

To identify patients with reversed diastolic flow, we performed a review of 5,089 renal transplant Doppler sonograms obtained over a 10-year period. Waveform morphology was correlated with surgical-histologic findings and clinical outcomes.

RESULTS

Fifty-nine patients (33 male, 26 female; age range, 14-69 years) with reversed diastolic flow fell into three chronologic groups: acute group (six patients), transplant < 24 hours; perioperative group (34 patients), transplant < or = 30 days; and long-term group (19 patients), transplant > 30 days. Acute reversed diastolic flow was associated with higher likelihood of graft survival (p = 0.001, Fisher's exact test) compared with reversed diastolic flow discovered in the perioperative or long-term group. In the acute group, hematoma, acute tubular necrosis, renal vein thrombosis, and vascular kink produced reversed diastolic flow. The causes of reversed diastolic flow for the perioperative group were acute tubular necrosis, rejection, and renal vein thrombosis; for the long-term group, reasons for diastolic reversal were rejection, glomerulosclerosis, low cardiac output, and diabetic nephrosclerosis. The causes of reversed diastolic flow were not differentiated by waveform morphology.

CONCLUSION

The causes of reversed diastolic flow cannot be distinguished by waveform morphology. Patients with reversed diastolic flow < 24 hours after transplantation warrant emergent exploration because correction of treatable causes may lead to recovered function. Long-standing renal transplants with reversed diastolic flow are not likely salvageable.