ACUTE THROMBOSIS OF TRANSPLANT RENAL ARTERY

Resident: Stephen Dreyer, MD, MBA

Attendings: Timothy Whitehead, MD and Boris Karaman, MD

Program/Dept: University Hospitals Case Medical Center/ Case Western Reserve University

CHIEF COMPLAINT & HPI

Chief Complaint and/or reason for consultation

23 year old female with methylmalonic acidemia status post combined liver and kidney transplant 8 years ago presents with acute rise in creatinine.

History of Present Illness

Patient had undergone a combined liver and kidney transplant in 2006 for methylmalonic acidemia. The patients baseline serum creatinine was 1.3.

Patient was an inpatient in the epilepsy monitoring unit for evaluation of seizures when she experienced nausea and vomiting. A BMP was drawn which demonstrated an acute rise in BUN and creatinine to 37 and 5.95.

RELEVANT HISTORY

Past Medical History Methylmalonic acidemia secondary to cobalamin B deficiency

Past Surgical History Simultaneous liver-kidney transplant in 2006

Family & Social History Non contributory

Review of Systems Nausea and vomiting

Medications Prednisone Tacrolimus Mycophenolic acid

DIAGNOSTIC WORKUP

Physical Exam Mild generalized tenderness to abdominal palpation.

Laboratory Data Serum Creatinine of 5.95

BUN of 37

Platelets of 115,000

INR 1.1

Non-Invasive Imaging STAT renal transplant ultrasound

QUESTION SLIDE – DIAGNOSTIC WORKUP

What is the imaging modality of choice in evaluating renal transplants and their complications?

A: Contrast enhanced CT

B: Color Doppler ultrasound

C: MRI/MRA

D: Renal Scintigraphy

CORRECT!

What is the imaging modality of choice in evaluating renal transplants and their complications?

A: Contrast enhanced CT

B: Color Doppler ultrasound

Cheap

Noninvasive

Nonnephrotoxic

C: MRI/MRA

D: Renal Scintigraphy

CONTINUE WITH CASE

SORRY, THAT’S INCORRECT!

What is the imaging modality of choice in evaluating renal transplants and their complications?

A: Contrast enhanced CT

B: Color Doppler ultrasound

Cheap

Noninvasive

Nonnephrotoxic

C: MRI/MRA

D: Renal Scintigraphy

CONTINUE WITH CASE

RENAL TRANSPLANT ULTRASOUND

Power Doppler of renal transplant demonstrates no flow within the arcuate arteries.

Color Doppler demonstrates thrombus at the renal artery/aorta anastomosis.

DIAGNOSIS

Acute thrombosis of the transplant kidney renal artery

INTERVENTION

Initial abdominal aortogram demonstrated occlusion of the transplanted renal artery just distal to its origin.

No perfusion of the transplanted kidney was identified.

Occlusion of transplanted renal artery

No perfusion of renal transplant

INTERVENTION (CONT.)

Catheter directed thrombolysis was performed on the transplanted artery with tPA and abciximab.

Arteriogram performed through the infusion catheter demonstrated clearance of clot from the transplant artery, revealing a significant, short, smooth segmental stenosis in the distal third of the right transplant artery (arrow).

INTERVENTION (CONT.)

A: Balloon angioplasty was performed with a 6 mm balloon.

B: Post angioplasty arteriogram demonstrated residual stenosis so a 5 mm x 18 mm stent was placed across the stenosis.

C: Repeat arteriogram from transplant artery origin demonstrated homogenous perfusion of the transplant without significant perfusion defects.

A

B

C

CLINICAL FOLLOW UP

Ultrasound of the transplanted kidney preformed 24 hours post intervention demonstrates homogenous perfusion of the graft.

Patient’s creatinine continued to rise to 8.0 immediately post intervention requiring 2 sessions of dialysis but returned to baseline and has been stable for 3 months post intervention.

SUMMARY & TEACHING POINTS

Successful catheter directed thrombolysis and stenting of acute transplanted renal artery thrombosis with return to baseline kidney function.

Arterial thrombosis in a renal transplant is a major complication that usually leads to graft loss.

Thrombolysis may be an effective treatment to save renal transplants up to 24 hours after arterial occlusion.

The imaging modality of choice for the diagnosis renal artery thrombosis is color Doppler sonography.