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.