Dr Jack Rycen1,2, Dr Dev Jegatheesan1,2, Dr Gilbert Pavilion1
1Princess Alexandra Hospital, Brisbane, Australia, 2University of Queensland, Brisbane, Australia
Biography:
Dr Jack Rycen is a Nephrology Advanced Trainee in his second year of training at the Princess Alexandra Hospital and Queensland Kidney and Transplant Service.
Background:
Transplant renal vein stenosis (TRVS) is a rare and potentially under-recognised vascular complication occurring after kidney transplantation. Without treatment, impairment of venous outflow and resultant venous hypertension can lead to progressive allograft dysfunction and loss. We present a the case of TRVS that was successfully treated with angioplasty and stenting.
Case Report:
A 60-year-old man with Alport’s syndrome was admitted with acutely deteriorating kidney function (serum creatinine 199 to 396 umol/L) 4 months following his 4th deceased donor kidney transplant. Urinalysis demonstrated 500 erythrocytes with no bacterial growth; serum BK virus, CMV and donor specific antibodies were not detected and a thrombophilia screen was negative. Non-contrast CT demonstrated markedly swollen transplant kidney parenchyma with no hydronephrosis, and Doppler US demonstrated generalised increased parenchymal resistive indices (range 0.79 to 0.86). Kidney biopsy demonstrated mild acute tubular injury with borderline acute T cell-mediated rejection, treated with 3 days of IV methylprednisolone. Due to persistent concerns of a co-existent renovascular pathology, higher resolution US and a CT angiogram were performed and demonstrated severe stenosis of the transplant renal vein. Following a difficult angioplasty, owing to tortuosity of the transplant renal vein, an 8 mm x 40 mm Absolute Pro self-expanding stent (Abbott) was successfully deployed with post-dilation using a 7 mm x 20 mm Viatric balloon with prescription of 6 weeks of dual antiplatelet therapy. Day 1 US demonstrated normalisation of parenchymal resistive indices and serum creatinine promptly returned to baseline (171 umol/L) within 2 weeks post-procedure.
Conclusion:
Diagnosis of TRVS requires a high level of clinical suspicion. In our patient, angioplasty and stenting resulted in both an immediate and sustained improvement in allograft function.