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Saudi Journal of Kidney Diseases and Transplantation
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CASE REPORT  
Year : 2013  |  Volume : 24  |  Issue : 5  |  Page : 965-968
A kink in transplantation: A rare cause of early graft dysfunction


1 Department of Surgery, All India Institute of Medical Sciences, New Delhi, India
2 Department of Nephrology, Pushpawati Singhania Research Institute, New Delhi, India

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Date of Web Publication12-Sep-2013
 

   Abstract 

Kink of the transplant renal artery is a rare yet correctable cause of early graft dysfunction. We describe a 35-year-old male patient with end-stage renal disease who underwent live, related renal transplantation with end-to-side anastomosis of the graft vessels with the external iliac vessels. He had oliguria and uncontrolled hypertension in the post-operative course and was found to have a parvus tardus waveform on Doppler ultrasound and an acute angled kink of the renal artery on angiography. After failure of initial attempts at per cutaneous transluminal renal angioplasty, the patient was re-explored and the graft renal artery was anastomosed with the internal iliac artery. The patient had a steady recovery and was discharged with a good renal function. A kinking of the renal artery should be excluded when early graft dysfunction is associated with a parvus tardus waveform.

How to cite this article:
Reddy VK, Guleria S, Abdullah SM, Bansal R. A kink in transplantation: A rare cause of early graft dysfunction. Saudi J Kidney Dis Transpl 2013;24:965-8

How to cite this URL:
Reddy VK, Guleria S, Abdullah SM, Bansal R. A kink in transplantation: A rare cause of early graft dysfunction. Saudi J Kidney Dis Transpl [serial online] 2013 [cited 2019 Nov 15];24:965-8. Available from: http://www.sjkdt.org/text.asp?2013/24/5/965/118103

   Introduction Top


Transplant renal transplant artery stenosis (TRAS) occurs in up to 23% of recipients, [1] which can lead to a poor graft survival and a worse overall survival rate. [2] A kinking of the renal artery is an uncommon yet correctable cause of graft dysfunction leading to graft loss, if overlooked. [3] The restricted space within the transplant bed and the displacement of the graft have been postulated to be the cause, [4] especially when the right kidney of the donor is used as the shorter renal vein leads to an arterial kink. [5] We describe a case of early graft dysfunction due to a kink in the renal artery, managed by re-anastomosis after a failed attempt at endovascular treatment.


   Case Report Top


The present case is about a 35-year-old male patient of end-stage renal disease due to hypertensive nephropathy who underwent a live, related renal transplantation at a private center. His native urine output was approximately 500 mL in 24 h. The left kidney of his mother was transplanted into his right iliac fossa and the graft renal vessels were anastomosed end-to-side with the external iliac vessels. Uretero neocystostomy was made over a double J catheter. Intraoperative Doppler ultrasonography showed normal flow in the anastomosed vessels. The patient was on a triple-drug immunosuppression regimen of cyclosporine 6 mg/kg, aiming for a cyclosporine peak level of 1.2-1.5 μg/mL, mycophenolate mofetil 1 gm twice a day orally and prednisolone 20 mg once daily orally. Induction immunosuppression was given using injection Daclizumab. Post-operatively, the patient had a urine output of 150 mL/day, which progressed to anuria, and the patient developed accelerated hypertension by the third post-operative day. A duplex ultrasonography was performed that showed tardus parvus waveform in the intrarenal arteries. The normal spectral waveform from an intrarenal artery has a sharp systolic rise, a gradual reduction in the velocity of flow in later systole and a low-velocity forward flow through the diastole. In parvus tardus, a small amplitude waveform with a prolonged systolic rise is indicative of a proximal stenosis. A Day 4 kidney biopsy showed acute tubular necrosis (ATN). A magnetic resonance angiography (MRA) was performed on Day 5 [Figure 1], which showed kinking of the graft renal artery 5 mm distal to the anastomosis. On the sixth post-operative day, the patient was referred to our institute with a daily urine output of 600 mL, a serum creatinine of 8.2 mg/dL and a blood pressure of 200/130 mmHg in spite of being on five anti-hypertensives. A repeat duplex Doppler ultrasonography was consistent with the previous ultrasound findings [Figure 2]. A digital subtraction angiography (DSA) was carried out the next day after admission with an intent to localize and treat the kink endo vascularly using Visipaque (GE Health Care, New Jersey, NJ, USA), an iso-osmolar and non-ionic contrast, in view of the deranged renal function. The DSA showed narrowing at the site of arterial anastomosis with an acute angled bend just distal to the anastomotic site. The DSA did reveal a compromise in the blood flow to the cortex. We endeavoured to perform a percutaneous trans-luminal stenting of the kink, but any attempt to cross the lesion using the wire caused the selectively hooked catheter to disengage. The procedure was abandoned and the patient was then taken up for surgery. At re-exploration, the transplant kidney looked pink and perfused, but there was a kink in the graft renal artery. The internal iliac artery was mobilized and the arterial anastomosis was taken down. The original venous and ureteric anastomosis were not dismantled. The kidney was perfused in situ with cold Ringer's solution. This was done to minimize the warm ischemia insult. Ringers solution used was iso-osmolar and had no potassium.
Figure 1: Magnetic resonance angiography of the transplant renal vessels showing an acute angled kink of the transplant renal artery 5 mm distal to the anastomosis.

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Figure 2: Doppler ultrasonography of the intrarenal vessels showing tardus parvus flow pattern suggesting significant stenosis upstream.

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Commercial organ perfusions, like Euro-collins solution, are rich in potassium and should not be used for in situ perfusion. It was then reanastomosed in an end-to-end fashion with the internal iliac artery. The urine output on the day following the surgery was 500 mL. The post-operative renal Doppler on Day 3 showed normal flow in the graft renal vessels. He required three more dialyses in the post-operative period and a graft biopsy was performed on Day 6 after the second surgery showed features of resolving ATN. He was discharged on Day 14 after the second surgery with a rapidly declining creatinine of 2.1 mg/dL. He has been on close follow-up now for more than four months and, when last seen, had a serum creatinine of 1.4 mg/dL.


   Discussion Top


Transplant renal artery kinking is a rare cause of early graft dysfunction. Hemodynamic mechanisms act in the pathophysiology of a stenosis at the end-to-side anastomosis due to an overacute angle of take off between the graft renal artery and the recipient iliac artery or due to a redundant renal artery leading to a kink and turbulent flow. [6] The definition of a significant kink is subjective, although, typically, an arterial orientation of more than 45 degree on the angiographic view that demonstrated the renal artery is considered significant. [4] There have been only three case reports of kinked renal artery that have been successfully managed. [3],[7],[8] One of these cases was managed surgically and one was managed by endovascular means. The third case did not have a significant pressure gradient on Doppler ultrasonography and was managed conservatively. A kinked renal artery usually manifests as early graft dysfunction, along with difficult to treat hypertension. [9] The diagnosis is made by the findings of elevated peak systolic flow at the kink and a parvus tardus waveform in the intrarenal vessels on duplex Doppler ultrasonography. MRA and DSA are valuable adjuncts in localizing the site of the stenosis.

Kinks usually lead to some degree of stenosis. According to Butorovic et al, [9] some renal transplant artery stenosis without significant kinking remain stable in the majority of patients and can be treated conservatively provided there is no graft dysfunction. However, renal artery kinking usually presents with early graft dysfunction, necessitating timely intervention. Percutaneous transluminal renal angioplasty (PTRA) has an immediate success rate of 20-94% in transplant renal artery stenosis [1] and is the intervention of first choice for stenosis that are short, linear and distal to the anastomosis. [10] PTRA has been tried to relieve renal artery kinks, [8] but, in our case, the kink was just distal to the anastomotic line, and it has been suggested that stenosis and kinks at the anastomotic line have a low rate of success and a high risk of complications with PTRA and, therefore, these should be treated surgically. [11],[12] The use of the internal iliac artery for reconstruction is a useful salvage technique.

In conclusion, our case illustrates that transplant renal artery kinking is a rare cause of early graft dysfunction. A tardus parvus waveform on a Doppler ultrasound should arouse a high index of suspicion. These can be managed by endovascular means. Rarely is recourse to surgery required, which was successful as in our case.


   Acknowledgment Top


The authors acknowledge the help of Dr. Priya Jagia and Dr. Sanjeev Sharma, Department of Cardiac Radiology, All India Institute of Medical Sciences, and Dr. Sanjeev Saxena, Department of Nephrology, Pushpavati Singhania Research Institute, New Delhi, in the development of this manuscript.

 
   References Top

1.Hagen G, Wadstrom J, Magnusson M, Magnusson A. Outcome after percutaneous transluminal angioplasty of arterial stenosis in renal transplant patients. Acta Radiol 2009;50:270-5.  Back to cited text no. 1
    
2.Peregrin JH, Burgelova M. Restoration of failed renal graft function after successful angioplasty of pressure-resistant renal artery stenosis using a cutting balloon: A case report. Cardiovasc Intervent Radiol 2009;32:548-53.  Back to cited text no. 2
    
3.Frauchiger B, Bock A, Spoendlin M, et al. Early renal transplant dysfunction due to arterial kinking stenosis. Nephrol Dial Transplant 1994;9:76-9.  Back to cited text no. 3
[PUBMED]    
4.Chua GC, Snowden S, Patel U. Kinks of the transplant renal artery without accompanying intra-arterial pressure gradient do not require correction: Five-year outcome study. Cardiovasc Intervent Radiol 2004;27:643-50.  Back to cited text no. 4
[PUBMED]    
5.Fabian MA, Herrin MK, Baxter J, Ackermann JR. Extension of the right renal vein in cadaveric renal transplants with use of the vena cava and the TA-30 V3 surgical stapler. Surg Gynecol Obstet 1991;173:233-4.  Back to cited text no. 5
[PUBMED]    
6.Fervenza FC, Lafayette RA, Alfrey EJ, Petersen J. Renal artery stenosis in kidney transplants. Am J Kidney Dis 1998;31:142-8.  Back to cited text no. 6
[PUBMED]    
7.Krumme B, Pisarski P, Blum U, Kirste G, Schollmeyer P. Unusual cause of early graft dysfunction after kidney transplantation. Am J Nephrol 1998;18:237-9.  Back to cited text no. 7
[PUBMED]    
8.Miah M, Madaan S, Kessel DJ, Newstead CG, Guleria S. Transplant renal artery kinking: A rare cause of early graft dysfunction. Nephrol Dial Transplant 2004;19:1930-1.  Back to cited text no. 8
[PUBMED]    
9.Buturovic-Ponikvar J. Renal transplant artery stenosis. Nephrol Dial Transplant 2003;18 Suppl 5:v74-7.  Back to cited text no. 9
    
10.Benoit G, Moukarzel M, Hiesse C, Verdelli G, Charpentier B, Fries D. Transplant renal artery stenosis: Experience and comparative results between surgery and angioplasty. Transpl Int 1990;3:137-40.  Back to cited text no. 10
    
11.Shames BD, Odorico JS, D'Alessandro AM, Pirsch JD, Sollinger HW. Surgical repair of transplant renal artery stenosis with preserved cadaveric iliac artery grafts. Ann Surg 2003;237:116-22.  Back to cited text no. 11
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12.Sutherland RS, Spees EK, Jones JW, Fink DW. Renal artery stenosis after renal transplantation: The impact of the hypogastric artery anastomosis. J Urol 1993;149:980-5.  Back to cited text no. 12
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Correspondence Address:
Sandeep Guleria
Department of Surgical Disciplines, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029
India
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DOI: 10.4103/1319-2442.118103

PMID: 24029262

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    Abstract
   Introduction
   Case Report
   Discussion
   Acknowledgment
    References
    Article Figures
 

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