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Successful Endovascular Management of Resistant Hypertension Post Kidney Transplant: A Case Report

RATIONALE: Transplant renal artery stenosis (TRAS) is a well-recognized and potentially reversible cause of resistant hypertension post transplantation and can affect 1% to 23% of recipients. Stenosis of the iliac segment proximal to the transplant renal artery (proximal TRAS) causing dysfunction of...

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Autores principales: Madken, Mohit, Gotra, Akshat, Qazi, Shakeel, Fairhead, Todd, Burns, Kevin D.
Formato: Online Artículo Texto
Lenguaje:English
Publicado: SAGE Publications 2022
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9493670/
https://www.ncbi.nlm.nih.gov/pubmed/36160314
http://dx.doi.org/10.1177/20543581221119896
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author Madken, Mohit
Gotra, Akshat
Qazi, Shakeel
Fairhead, Todd
Burns, Kevin D.
author_facet Madken, Mohit
Gotra, Akshat
Qazi, Shakeel
Fairhead, Todd
Burns, Kevin D.
author_sort Madken, Mohit
collection PubMed
description RATIONALE: Transplant renal artery stenosis (TRAS) is a well-recognized and potentially reversible cause of resistant hypertension post transplantation and can affect 1% to 23% of recipients. Stenosis of the iliac segment proximal to the transplant renal artery (proximal TRAS) causing dysfunction of the transplanted kidney is less common with reported incidence of 2% to 3%. Presentation typically occurs between 3 months and 2 years post transplant but may happen at any time. Noninvasive investigations such as Doppler ultrasound, computed tomography (CT) angiogram, and magnetic resonance angiogram are useful in initial evaluation, but definitive diagnosis of hemodynamically significant stenosis often requires formal angiogram. Transplant renal artery stenosis should be suspected in any kidney transplant recipient with worsening hypertension and/or deterioration in kidney function which is otherwise unexplained. We present the case of a kidney transplant recipient with resistant hypertension and impaired graft function, secondary to severe impairment of graft blood flow from proximal iliac system occlusion. PRESENTING CONCERNS OF THE PATIENT: A 74-year-old female 15 years post live donor kidney transplant presented with graft dysfunction (serum Cr 229 μmol/L) and resistant hypertension, requiring use of 8 antihypertensive medications. On physical examination, blood pressure was 160/92 mm Hg with no tenderness over the renal graft in the right lower abdominal quadrant and no audible bruit in kidney allograft area. DIAGNOSIS: Transplant Doppler ultrasound showed reversal of flow in the right external iliac artery suggestive of ipsilateral proximal iliac occlusion. Pre-procedure CT demonstrated severe atherosclerotic burden within the aorta and bilateral iliac systems. The anastomosed right renal artery appeared patent. INTERVENTIONS: Conventional angiogram showed occlusion of the right common and proximal external iliac arteries with retrograde perfusion of the transplant kidney via the contralateral left iliac system and aorta. Subintimal recanalization of the right iliac system was performed with angioplasty and kissing stent placement at the aortic bifurcation with stents extending into the proximal right external iliac artery. Post deployment angiogram demonstrated renewed patency of the right iliac system, with restoration of antegrade perfusion to the transplant kidney. OUTCOMES: The patient’s blood pressure decreased significantly after the procedure, with improvement in graft function. After 6 months, the patient continued to have optimally controlled blood pressure (on 3 medications) and stable graft function (serum Cr 74 μmol/L). TEACHING POINTS: Our case describes proximal TRAS and the contribution of renal hypoperfusion to hypertension and impaired graft function, with the potential for reversibility.
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spelling pubmed-94936702022-09-23 Successful Endovascular Management of Resistant Hypertension Post Kidney Transplant: A Case Report Madken, Mohit Gotra, Akshat Qazi, Shakeel Fairhead, Todd Burns, Kevin D. Can J Kidney Health Dis Educational Case Report RATIONALE: Transplant renal artery stenosis (TRAS) is a well-recognized and potentially reversible cause of resistant hypertension post transplantation and can affect 1% to 23% of recipients. Stenosis of the iliac segment proximal to the transplant renal artery (proximal TRAS) causing dysfunction of the transplanted kidney is less common with reported incidence of 2% to 3%. Presentation typically occurs between 3 months and 2 years post transplant but may happen at any time. Noninvasive investigations such as Doppler ultrasound, computed tomography (CT) angiogram, and magnetic resonance angiogram are useful in initial evaluation, but definitive diagnosis of hemodynamically significant stenosis often requires formal angiogram. Transplant renal artery stenosis should be suspected in any kidney transplant recipient with worsening hypertension and/or deterioration in kidney function which is otherwise unexplained. We present the case of a kidney transplant recipient with resistant hypertension and impaired graft function, secondary to severe impairment of graft blood flow from proximal iliac system occlusion. PRESENTING CONCERNS OF THE PATIENT: A 74-year-old female 15 years post live donor kidney transplant presented with graft dysfunction (serum Cr 229 μmol/L) and resistant hypertension, requiring use of 8 antihypertensive medications. On physical examination, blood pressure was 160/92 mm Hg with no tenderness over the renal graft in the right lower abdominal quadrant and no audible bruit in kidney allograft area. DIAGNOSIS: Transplant Doppler ultrasound showed reversal of flow in the right external iliac artery suggestive of ipsilateral proximal iliac occlusion. Pre-procedure CT demonstrated severe atherosclerotic burden within the aorta and bilateral iliac systems. The anastomosed right renal artery appeared patent. INTERVENTIONS: Conventional angiogram showed occlusion of the right common and proximal external iliac arteries with retrograde perfusion of the transplant kidney via the contralateral left iliac system and aorta. Subintimal recanalization of the right iliac system was performed with angioplasty and kissing stent placement at the aortic bifurcation with stents extending into the proximal right external iliac artery. Post deployment angiogram demonstrated renewed patency of the right iliac system, with restoration of antegrade perfusion to the transplant kidney. OUTCOMES: The patient’s blood pressure decreased significantly after the procedure, with improvement in graft function. After 6 months, the patient continued to have optimally controlled blood pressure (on 3 medications) and stable graft function (serum Cr 74 μmol/L). TEACHING POINTS: Our case describes proximal TRAS and the contribution of renal hypoperfusion to hypertension and impaired graft function, with the potential for reversibility. SAGE Publications 2022-09-20 /pmc/articles/PMC9493670/ /pubmed/36160314 http://dx.doi.org/10.1177/20543581221119896 Text en © The Author(s) 2022 https://creativecommons.org/licenses/by-nc/4.0/This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License (https://creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage).
spellingShingle Educational Case Report
Madken, Mohit
Gotra, Akshat
Qazi, Shakeel
Fairhead, Todd
Burns, Kevin D.
Successful Endovascular Management of Resistant Hypertension Post Kidney Transplant: A Case Report
title Successful Endovascular Management of Resistant Hypertension Post Kidney Transplant: A Case Report
title_full Successful Endovascular Management of Resistant Hypertension Post Kidney Transplant: A Case Report
title_fullStr Successful Endovascular Management of Resistant Hypertension Post Kidney Transplant: A Case Report
title_full_unstemmed Successful Endovascular Management of Resistant Hypertension Post Kidney Transplant: A Case Report
title_short Successful Endovascular Management of Resistant Hypertension Post Kidney Transplant: A Case Report
title_sort successful endovascular management of resistant hypertension post kidney transplant: a case report
topic Educational Case Report
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9493670/
https://www.ncbi.nlm.nih.gov/pubmed/36160314
http://dx.doi.org/10.1177/20543581221119896
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