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Saudi Journal of Kidney Diseases and Transplantation
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Table of Contents   
LETTER TO THE EDITOR  
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 2019 May 25];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

1.
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
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Correspondence Address:
Dr. Desai Madhav
Department of Nephrology, Narayana Medical College, Nellore, Andhra Pradesh
India
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DOI: 10.4103/1319-2442.164591

PMID: 26354578

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