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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2015  |  Volume : 26  |  Issue : 5  |  Page : 1000-1005
Candida-associated pseudo-aneurysm of the transplant renal artery presenting as malignant hypertension and managed successfully without nephrectomy

1 Department of Nephrology, Narayana Medical College, Nellore, Andhra Pradesh, India
2 Department of Urology, Narayana Medical College, Nellore, Andhra Pradesh, India
3 Department of Radiology, Narayana Medical College, Nellore, Andhra Pradesh, India

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Date of Web Publication7-Sep-2015

How to cite this article:
Madhav D, Kumar P, Mohan C, Vijay, Mahesh U, Anusha, Suneetha, Suryaprakash. Candida-associated pseudo-aneurysm of the transplant renal artery presenting as malignant hypertension and managed successfully without nephrectomy. Saudi J Kidney Dis Transpl 2015;26:1000-5

How to cite this URL:
Madhav D, Kumar P, Mohan C, Vijay, Mahesh U, Anusha, Suneetha, Suryaprakash. Candida-associated pseudo-aneurysm of the transplant renal artery presenting as malignant hypertension and managed successfully without nephrectomy. Saudi J Kidney Dis Transpl [serial online] 2015 [cited 2020 Aug 3];26:1000-5. Available from: http://www.sjkdt.org/text.asp?2015/26/5/1000/164591
To the Editor,

Vascular complications after renal transplantation (RT) are serious surgical complications that can result in loss of the transplant kidney. Pseudo-aneurysm of the transplant renal artery (PA-TRA) is potentially life-threatening as its sudden rupture can lead to shock and death. Nephrectomy is usually required in the management of pseudo-aneurysm. Herein, we report a rare case of PA-TRA that presented as malignant hypertension. It was caused by Candida albicans (CA) and the aneurysm was successful resected without nephrectomy.

A 23-year-old male underwent RT in June 2013, with his mother being the kidney donor. His native kidney disease was chronic interstitial nephritis. He received intravenous methyl prednisolone for three consecutive days followed by oral prednisolone along with tacrolimus and mycophenolate sodium. Induction therapy was not given. Immediate graft function was good and he was discharged with serum creatinine of 0.9 mg/dL. Donor kidney harvesting was performed by the laparoscopic method. Donor renal artery was anastamosed to the right internal iliac artery of the recipient by end-to-end anastamosis. The recipient had no intraor post-operative complications. New-onset diabetes mellitus was diagnosed on the third post-operative day. One week after RT, the patient developed urinary tract infection with Klebsiella pneumonia, which required treatment with meropenem. About 25 days after RT, he presented with malignant hypertension (blood pressure was 190/130 mm Hg and papilledema was present) that required multiple anti-hypertensive medications, including arterial dilators. He was normotensive before this episode. The serum creatinine was normal at that time and there was no fluid overload. No bruit was heard over the transplant kidney (TxK). Blood tacrolimus levels were within normal limits. Doppler of the TRA did not suggest renal artery stenosis. Three days later, he developed a decrease in urine output and elevated serum creatinine. Urine and blood cultures were sterile. The serum creatinine had gradually increased to 2.5 mg/dL. Repeat Doppler of the graft renal artery showed altered waveform with decreased velocities seen in the intra-renal arteries. A computerized tomography (CT) angiogram showed fusiform out-pouching measuring 14 mm × 8 mm arising from the TRA at the preanastamotic site [Figure 1]. Re-exploration of the abdomen confirmed the PA-TRA with thrombosis within its lumen. Excision of the aneurysm was performed and the renal artery was re-anastomosed to the external iliac artery. Post-operative Doppler showed improved blood flow to the TxK. Open graft renal biopsy showed acute tubular necrosis. Histopathologic examination of the excised aneurysm did not reveal any fungal elements, but its culture grew CA. He was treated with voriconazole. After resection of the pseudo-aneurysm, hypertension subsided. Urine output improved gradually after one week and serum creatinine declined to 1.2 mg/dL. He did not require dialysis support. During follow-up, a magnetic resonance (MR) angiogram [Figure 2] showed improvement in blood flow to the TxK. Pseudoaneurysm of the TRA varies in presentation from asymptomatic to life-threatening rupture. Other presentations are fever, anemia and compression of the surrounding structures, graft dysfunction and, rarely, lumbosacral plexopathy. The causes of hypertension in pseudo-aneurysm are arterial stenosis, thromboembolism, branch artery compression and steal syndrome. [1] In this study, the patient presented with malignant hypertension probably due to the development of thrombus in the pseudo-aneurysm and decreased blood flow to the TxK that might have increased the renin levels. PA-TRA presents as early as nine days and may be delayed for up to six years after transplantation [Table 1], [Table 2] and [Table 3]. [1],[2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21]
Figure 1: Computerized tomography angiogram (arrow) shows pseudo-aneurysm of the transplant renal artery.

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Figure 2: Magnetic resonance angiogram (arrow) shows absent (ligated) internal iliac artery and no pseudo-aneurysm.

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Table 1: Literature on pseudo-aneurysm of transplant renal artery caused by Candida.

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Table 2: Literature on pseudo-aneurysm of transplant renal artery caused by other organisms.

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Table 3: Literature on pseudo-aneurysm of transplant renal artery managed "without" nephrectomy.

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The pseudo-aneurysm is caused by defective suture technique, suture rupture, vessel wall ischemia or infection, instrumental injury during perfusion and dissection of the vasa vasorum. Pre-existing aneurysms can become secondarily infected. The infections that pro-because of compromised blood flow to the kidney and more experience with surgical methods. A few earlier cases of PA-RTA caused by Candidiasis with TxK salvage have been reported [Table 3]. [1],[4],[16],[17],[18],[19],[20],[21] When compared with other patients in whom the transplant kidneys were saved (including infectious and noninfectious causes), our patient presented very early (25 days) after surgery and the mode of presentation was also different, i.e. malignant hypertension. Acute tubular necrosis due to ischemia was the cause of graft dysfunction in our patient. In other studies, the kidney donor was deceased or living-unrelated, while in the present study the donor was the mother. The risk factor for Candidiasis in spite of receiving lower immune-suppression in this patient may be prior use of antibiotics.

Pseudo-aneurysm of the renal artery is a rare cause of renal dysfunction. It may present as malignant hypertension. Pseudo-aneurysm associated with Candida infection is treatable without nephrectomy and mortality.

Conflict of interest: None declared.

   References Top

Hegde UN, Rajapurkar MM, Gang SD, Lele SS. Percutaneous endovascular management of recurrent aneurysm of transplant renal artery anastomosed to internal iliac artery. Indian J Urol 2008;24:411-3.  Back to cited text no. 1
[PUBMED]  Medknow Journal  
Potti A, Danielson B, Sen K. "True" mycotic aneurysm of a renal artery allograft. Am J Kidney Dis 1998;31:E3.  Back to cited text no. 2
Laouad I, Buchler M, Noel C, et al. Renal artery aneurysm secondary to Candida albicans in four kidney allograft recipients. Transplant Proc 2005;37:2834-6.  Back to cited text no. 3
Kountidou CS, Stier K, Niehues SM, et al. Successful repair of post-transplant mycotic aneurysm of iliac artery with renal graft preservation: A case report. Urology 2012;80:1151-3.  Back to cited text no. 4
Taksin L, Mallick S, Frachet O, et al. Mycotic aneurysm and renal transplant. A case report. Prog Urol 2009;19:149-52.  Back to cited text no. 5
Bracale UM, Santangelo M, Carbone F, et al. Anastomotic pseudoaneurysm complicating renal transplantation: Treatment options. Eur J Vasc Endovasc Surg 2010;39:565-8.  Back to cited text no. 6
Bozkurt D, Arda B, Sen S, et al. Arterial mycotic aneurysm rupture of two kidney cadaveric renal transplantation recipients secondary to Enterococci and Candida. Turk Nephrol Dial Transplant 2010;19:52-4.  Back to cited text no. 7
Albano L, Bretagne S, Mamzer-Bruneel MF, et al. Evidence that graft-site candidiasis after kidney transplantation is acquired during organ recovery: A multicenter study in France, for the French mycosis study group. Clin Infect Dis 2009;48:194-202.  Back to cited text no. 8
Ram Reddy C, Ram R, Swarnalatha G, et al. "True" mycotic aneurysm of the anastomotic site of the renal allograft artery. Exp Clin Transplant 2012;10:398-402.  Back to cited text no. 9
Garrido J, Lerma JL, Heras M, et al. Pseudoaneurysm of the iliac artery secondary to Aspergillus infection in two recipients of kidney transplants from the same donor. Am J Kidney Dis 2003;41:488-92.  Back to cited text no. 10
Wang R, Wu J, Wang Y, Huang H, He Q, Chen J. Aspergillus infection limited to the anastomosed artery following renal transplantation: A report of 4 cases. Transpl Infect Dis 2009;11:363-6.  Back to cited text no. 11
Fujikata S, Tanji N, Iseda T, Ohoka H, Yokoyama M. Mycotic aneurysm of the renal transplant artery. Int J Urol 2006;13:820-3.  Back to cited text no. 12
Fadhil RA, Al-Thani H, Al-Maslamani Y, Ali O. Trichosporon fungal arteritis causing rupture of vascular anastamosis after comercial kidney transplantation. Transplant Proc 2011;43:657-9.  Back to cited text no. 13
Srivastava A, Kumar J, Sharma S, Abhishek, Ansari MS, Kapoor R. Vascular complication in live related renal transplant: An experience of 1945 cases. Indian J Urol 2013;29:42-7.  Back to cited text no. 14
[PUBMED]  Medknow Journal  
Leonardou P, Gioldasi S, Zavos G, Pappas P. Mycotic pseudoaneurysms complicating renal transplantation: A case series and review of literature. J Med Case Rep 2012;6:59.  Back to cited text no. 15
Burkey SH, Vazquez MA, Valentine RJ. De novo renal artery aneurysm presenting 6 years after transplantation: A complication of recurrent arterial stenosis? J Vasc Surg 2000;32:388-91.  Back to cited text no. 16
Siu YP, Tong MK, Leung KT, et al. Renal artery pseudoaneurysm following renal transplantation and treatment by percutaneous thrombin injection. Hong Kong Med J 2006;12:80-1.  Back to cited text no. 17
Al-Wahaibi KN, Aquil S, Al-Sukaiti R, Al-Riyami D, Al-Busaidi Q. Transplant renal artery false aneurysm: Case report and lite-rature review. Oman Med J 2010;25:306-10.  Back to cited text no. 18
Buimer MG, van Hamersvelt HW, Adam van der Vliet J. Anastomotic pseudoaneurysm after renal transplantation; a new hybrid approach with graft salvage. Transpl Int 2012;25:e86-8.  Back to cited text no. 19
Taghavi M, Shojaee Fard A, Mehrsai R, Shadman M. Late onset anastomotic pseudoaneurysm of renal allograft artery: Case report, diagnosis, and treatment. Transplant Proc 2005;37:4297-9.  Back to cited text no. 20
Asztalos L, Olvasztó S, Fedor R, Szabó L, Balázs G, Lukács G. Renal artery aneurysm at the anastomosis after kidney transplantation. Transplant Proc 2006;38:2915-8.  Back to cited text no. 21

Correspondence Address:
Dr. Desai Madhav
Department of Nephrology, Narayana Medical College, Nellore, Andhra Pradesh
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DOI: 10.4103/1319-2442.164591

PMID: 26354578

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  [Table 1], [Table 2], [Table 3]


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