Limits...
Biopsy Induced Arteriovenous Fistula and Venous Stenosis in a Renal Transplant.

Allam SR, Sankarapandian B, Memon IA, Nef PC, Livingston TS, Rofaiel G - Case Rep Nephrol (2015)

Bottom Line: Percutaneous stenting appears to be safe and effective treatment for this condition.BK viremia improved from 36464 copies/mL to 15398 copies/mL.Serum creatinine improved to 1.5 mg/dL after.

View Article: PubMed Central - PubMed

Affiliation: Tarrant Nephrology Associates, 1001 Pennsylvania Avenue, Fort Worth, TX 76104, USA ; Division of Transplant Nephrology, Fort Worth Transplant Institute, Plaza Medical Center, 900 Eighth Avenue, Fort Worth, TX 76104, USA.

ABSTRACT
Renal transplant vein stenosis is a rare cause of allograft dysfunction. Percutaneous stenting appears to be safe and effective treatment for this condition. A 56-year-old Caucasian female with end stage renal disease received a deceased donor renal transplant. After transplant, her serum creatinine improved to a nadir of 1.2 mg/dL. During the third posttransplant month, her serum creatinine increased to 2.2 mg/dL. Renal transplant biopsy showed BK nephropathy. Mycophenolate was discontinued. Over the next 2 months, her serum creatinine crept up to 6.2 mg/dL. BK viremia improved from 36464 copies/mL to 15398 copies/mL. A renal transplant ultrasound showed lower pole arteriovenous fistula and abnormal waveforms in the renal vein. Carbon dioxide (CO2) angiography demonstrated severe stenosis of the transplant renal vein. Successful coil occlusion of fistula was performed along with angioplasty and deployment of stent in the renal transplant vein. Serum creatinine improved to 1.5 mg/dL after.

No MeSH data available.


Related in: MedlinePlus

CO2 angiogram obtained after placement of stent in renal transplant vein showed no residual stenosis.
© Copyright Policy - open-access
Related In: Results  -  Collection


getmorefigures.php?uid=PMC4561942&req=5

fig2: CO2 angiogram obtained after placement of stent in renal transplant vein showed no residual stenosis.

Mentions: Over the next month, her serum creatinine increased to 3.1 to 3.5 mg/dL range. During her fifth posttransplant month office visit, she reported progressive oliguria and lower extremity edema. She was noted to be fluid overloaded on exam. Serum creatinine further increased to 6.2 mg/dL. Random urine protein by creatinine ratio showed nephrotic range proteinuria with a ratio of 4.5, which was a significant increase from 1.1 a month prior. She was hospitalized at that point and was dialyzed on two consecutive days for fluid overload. Blood BK PCR actually improved to 15398 copies/mL. A renal transplant ultrasound showed lower pole arteriovenous fistula, increased velocities, and abnormal waveforms in the renal vein. Given dialysis dependent allograft dysfunction despite improvement in BK viremia and abnormal findings of the ultrasound, we proceeded with interventional radiological procedures. Common iliac angiography with CO2 demonstrated patent common and external iliac arteries. There was a widely patent end-to-side renal artery anastomosis. Arteriovenous fistula was demonstrated in the lower pole of the transplant kidney with early filling of the renal vein. There was severe stenosis of the main renal vein. Successful coil occlusion of fistula was performed using a 3 mm × 50 mm microcoil. Then, renal venography using CO2 was performed that confirmed a high-grade stenosis of the renal vein for a length of approximately 30 mm (Figure 1). Angioplasty was initially performed with 8 mm × 4 cm balloon followed by 10 mm × 4 cm balloon. Repeat venography again demonstrated moderately severe stenosis of the renal vein. Then, 8 mm × 30 mm self-expanding stent was deployed across the renal vein stenosis. Repeat venography demonstrated no significant residual stenosis (Figure 2). Percutaneous renal transplant biopsy performed at the same time showed moderate to severe acute tubular injury with mild interstitial infiltrate consisting of lymphocytes and plasma cells. There was mild arteriosclerosis, interstitial fibrosis, and tubular atrophy (about 10%). There was positive tubular epithelial nuclear staining for SV40. In addition, there was extensive interstitial edema, likely a consequence of significant venous outflow obstruction. Her urine output significantly improved after renal vein stenting and dialysis was discontinued after a total of three dialysis sessions. Serum creatinine eventually stabilized around 1.5 mg/dL range. Patient was given oral anticoagulation combined with antiplatelet therapy Aspirin 81 mg daily for 6 months after the procedure followed by long-term administration of Aspirin 325 mg daily.


Biopsy Induced Arteriovenous Fistula and Venous Stenosis in a Renal Transplant.

Allam SR, Sankarapandian B, Memon IA, Nef PC, Livingston TS, Rofaiel G - Case Rep Nephrol (2015)

CO2 angiogram obtained after placement of stent in renal transplant vein showed no residual stenosis.
© Copyright Policy - open-access
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC4561942&req=5

fig2: CO2 angiogram obtained after placement of stent in renal transplant vein showed no residual stenosis.
Mentions: Over the next month, her serum creatinine increased to 3.1 to 3.5 mg/dL range. During her fifth posttransplant month office visit, she reported progressive oliguria and lower extremity edema. She was noted to be fluid overloaded on exam. Serum creatinine further increased to 6.2 mg/dL. Random urine protein by creatinine ratio showed nephrotic range proteinuria with a ratio of 4.5, which was a significant increase from 1.1 a month prior. She was hospitalized at that point and was dialyzed on two consecutive days for fluid overload. Blood BK PCR actually improved to 15398 copies/mL. A renal transplant ultrasound showed lower pole arteriovenous fistula, increased velocities, and abnormal waveforms in the renal vein. Given dialysis dependent allograft dysfunction despite improvement in BK viremia and abnormal findings of the ultrasound, we proceeded with interventional radiological procedures. Common iliac angiography with CO2 demonstrated patent common and external iliac arteries. There was a widely patent end-to-side renal artery anastomosis. Arteriovenous fistula was demonstrated in the lower pole of the transplant kidney with early filling of the renal vein. There was severe stenosis of the main renal vein. Successful coil occlusion of fistula was performed using a 3 mm × 50 mm microcoil. Then, renal venography using CO2 was performed that confirmed a high-grade stenosis of the renal vein for a length of approximately 30 mm (Figure 1). Angioplasty was initially performed with 8 mm × 4 cm balloon followed by 10 mm × 4 cm balloon. Repeat venography again demonstrated moderately severe stenosis of the renal vein. Then, 8 mm × 30 mm self-expanding stent was deployed across the renal vein stenosis. Repeat venography demonstrated no significant residual stenosis (Figure 2). Percutaneous renal transplant biopsy performed at the same time showed moderate to severe acute tubular injury with mild interstitial infiltrate consisting of lymphocytes and plasma cells. There was mild arteriosclerosis, interstitial fibrosis, and tubular atrophy (about 10%). There was positive tubular epithelial nuclear staining for SV40. In addition, there was extensive interstitial edema, likely a consequence of significant venous outflow obstruction. Her urine output significantly improved after renal vein stenting and dialysis was discontinued after a total of three dialysis sessions. Serum creatinine eventually stabilized around 1.5 mg/dL range. Patient was given oral anticoagulation combined with antiplatelet therapy Aspirin 81 mg daily for 6 months after the procedure followed by long-term administration of Aspirin 325 mg daily.

Bottom Line: Percutaneous stenting appears to be safe and effective treatment for this condition.BK viremia improved from 36464 copies/mL to 15398 copies/mL.Serum creatinine improved to 1.5 mg/dL after.

View Article: PubMed Central - PubMed

Affiliation: Tarrant Nephrology Associates, 1001 Pennsylvania Avenue, Fort Worth, TX 76104, USA ; Division of Transplant Nephrology, Fort Worth Transplant Institute, Plaza Medical Center, 900 Eighth Avenue, Fort Worth, TX 76104, USA.

ABSTRACT
Renal transplant vein stenosis is a rare cause of allograft dysfunction. Percutaneous stenting appears to be safe and effective treatment for this condition. A 56-year-old Caucasian female with end stage renal disease received a deceased donor renal transplant. After transplant, her serum creatinine improved to a nadir of 1.2 mg/dL. During the third posttransplant month, her serum creatinine increased to 2.2 mg/dL. Renal transplant biopsy showed BK nephropathy. Mycophenolate was discontinued. Over the next 2 months, her serum creatinine crept up to 6.2 mg/dL. BK viremia improved from 36464 copies/mL to 15398 copies/mL. A renal transplant ultrasound showed lower pole arteriovenous fistula and abnormal waveforms in the renal vein. Carbon dioxide (CO2) angiography demonstrated severe stenosis of the transplant renal vein. Successful coil occlusion of fistula was performed along with angioplasty and deployment of stent in the renal transplant vein. Serum creatinine improved to 1.5 mg/dL after.

No MeSH data available.


Related in: MedlinePlus