Outcomes of endovascular treatment of renal arterial stenosis in transplanted kidneys

ABSTRACT Objective To evaluate the effectiveness and outcomes of endovascular treatment of TRAS with PTA. Materials and Methods We searched our prospectively collected database looking at cases of TRAS between January 2005-December 2011. CCT was the gold-standart for diagnosis of TRAS. Parameters analysed comprised technical aspects, arterial blood pressure variation, and renal function. A minimum follow-up of 24 months was considered. Results Of the 2221 renal transplants performed in the selected period, 22 (0.9%) patients were identified with TRAS. Fourteen (63.6%) were male and mean age was 377±14.8years (12-69). Kidney graft was from deceased donnors in 20 (80%) cases. On doppler evaluation, mean blood flow speed after transplantation, at TRAS diagnosis and after TAP was 210.6±99.5, 417±122.7 and 182.5±81.6mL/sec, respectively (p<0.001). For SBP and DBP, there was a significant difference between between pre-intervention and all post-treatment time points (p<0.001). After 1 month of the procedure, there was stabilization of the Cr level with a significant difference between mean Cr levels along time (p<0.001). After a mean follow-up of 16±4.2 (3-24) months, overall success rate was 100%. Conclusions Endovascular treatment with PTA/stenting is a safe and effective option for managing TRAS, ensuring the functionality of the graft and normalization of blood pressure and renal function.

Adipose tissue derived mesenchymal stem cell transplantation in the treatment of ischemia/reperfusion induced acute kidney injury in rats. Application route and therapeutic window

Abstract Purpose: To evaluate renal repair in rats who had renal infarction induced by the obstruction of blood flow in the renal artery and were treated with transplantation of adipose tissue derived mesenchymal stem cell Methods: 16-week-old Wistar rats (n=72) were used, submitted to celiotomy and had of the renal artery and vein clipped for 24 hours. The animals were randomly assigned to 10 experimental homogeneous groups, corresponding to the treatments with phosphate-buffered saline (PBS) or adipose tissue derived mesenchymal stem cell (ADSC), duration of application (24 or 48 hours), and site of transplantation (lateral vein of the tail or intrarenal). After the treatments were performed, at 8 and 31 days, four animals in each group were subjected to left nephrectomy for histological studies. Results: Histologically, a higher amount of cell debris and tubules devoid of the epithelium and a higher degree of necrosis were observed in the groups treated with PBS, as opposed to a low degree of necrosis and higher tubular vascularization in the groups treated with ADSC, particularly in the group treated with intrarenal ADSC 48 hours after injury. Conclusion: The transplantation of ADSC positively contributed to the replacement of necrotic tissue by renal tubular cells, vascularization of the renal parenchyma, and restoration of the organ function.

Evaluation of the efficacy and safety of endovascular management for transplant renal artery stenosis

OBJECTIVES: To evaluate the safety and efficacy of endovascular intervention with angioplasty and stent placement in patients with transplant renal artery stenosis. METHODS: All patients diagnosed with transplant renal artery stenosis and graft dysfunction or resistant systemic hypertension who underwent endovascular treatment with stenting from February 2011 to April 2016 were included in this study. The primary endpoint was clinical success, and the secondary endpoints were technical success, complication rate and stent patency. RESULTS: Twenty-four patients with transplant renal artery stenosis underwent endovascular treatment, and three of them required reinterventions, resulting in a total of 27 procedures. The clinical success rate was 100%. All graft dysfunction patients showed decreased serum creatinine levels and improved estimated glomerular filtration rates and creatinine levels. Patients with high blood pressure also showed improved control of systemic blood pressure and decreased use of antihypertensive drugs. The technical success rate of the procedure was 97%. Primary patency and assisted primary patency rates at one year were 90.5% and 100%, respectively. The mean follow-up time of patients was 794.04 days after angioplasty. CONCLUSION: Angioplasty with stent placement for the treatment of transplant renal artery stenosis is a safe and effective technique with good results in both the short and long term.

Caso exitoso de bypass aorto renal un mes después de oclusión de ambas arterias renales y hemodiálisis / Case successful renal bypass graft one month after occlusion of both renal arteries and hemodialysis

Objetivo: Informar la posibilidad de restituir la función renal por medio de bypass aorto-renal luego de la oclusión de ambas arterias renales y sin evidencia de flujo de tributarias tras un período de un mes de anuria y hemodiálisis. Métodos: Presentamos un caso de rescate de función renal por medio de cirugía de bypass aorto renal derecho con vena safena mayor luego de 30 días de anuria y dependencia de hemodiálisis en un paciente de 72 años a causa de oclusión bilateral de arterias renales. Resultados: Inmediatamente después del bypass aorto-renal se evidenció una diuresis de 1000cc/24hr; suspendiéndose la hemodiálisis luego de 06 sesiones después de la cirugía. Conclusión: La función renal puede rescatarse con revascularización subaguda luego de oclusión arterial renal sin evidencia angiografica de circulación colateral incluso un mes después de presentada la insuficiencia renal dependiente de hemodiálisis.

Objective: To communicate the possibility to restore renal function by means of aorto-renal bypass after bilateral occlusion of renal arteries and without proof of any tributary flow one month after onset of anuria and hemodialysis. Methods: We present a case of renal function rescue by means of great saphenous vein aorto-renal bypass after 30 days of anuria and hemodialysis in a 72 year-old man with bilateral occlusion of renal arteries. Results: 1000cc/24hr of urine was accounted for immediately after surgery, and hemodialysis was no longer necessary after 06 sessions post-surgery. Conclusion: Renal function can be restored with sub-acute revascularization after bilateral occlusion of renal arteries even one month after onset of anuria and hemodialysis.

Hypertension due to angiodysplasia.

Renovascular hypertension is non essential hypertension, wherein anatomically evident arterial occlusive disease and increased blood pressures are related as cause and effect. The hypertension is due to renal ischemia. Angiodysplasia is an uncommon angiopathy associated with heterogeneous histological changes that may affect the carotid circulation and the visceral and peripheral arteries.

Doença arterial renovascular: desafio terapêutico e seguimento a longo prazo / Arterial renovascular disease: therapeutic challenge and long term follow-up

Objetivo: Demonstrar dois casos de pacientes portadores de doença renovascular complicada tratados com sucesso através de cirurgia convencional. Método: Relato de dois casos de hipertensão renovascular tratados cirurgicamente. Resultados: Controle da hipertensão e melhora da função renal em ambos os casos tratados. Conclusão: Os dois casos apresentados são exemplos de como intervenções cirúrgicas com técnica adequada podem atenuar a hipertensão renovascular, remover o risco do edema agudo de pulmão, evitar o óbito iminente e postergar a entrada do paciente em programa de hemodiálise (AU)

Objective: Report two cases of complicated renovascular hypertension successfully treated with open surgery. Methods: Two case of renovascular hypertension surgically treated are herein reported. Results: There was improvement on hypertension control and renal function in both cases. Conclusions: Both cases reported are examples of how a correct surgery can attenuate renovascular hypertension, remove the risk of acute pulmonary edema, prevent death and delay hemodialysis (AU)

Combined epidural anesthesia & general anesthesia for aorto-renal bypass: two case reports.

Aorto-renal bypass surgery is associated with significant hemodynamic alterations as well as other comorbidities due to necessity of aortic cross-clamping and release during vascular anastomosis. Combined epidural and general anesthesia for the aorto-renal bypass surgeries provides not only hemodynamic stability during aortic cross-clamping but is also associated with increased graft blood flow, graft survival and decreased morbidity and mortality in intraoperative and postoperative period. Two cases of aorto-renal bypass are presented, for which combined epidural and general anesthesia techniques were applied.

Treatment of Fraley’s syndrome by upper-pole nephrectomy

CONTEXT: Fraley’s syndrome is characterized by vascular compression on the superior infundibulum with secondary dilatation of the upper pole calyx, mostly located on the right side. CASE REPORT: We present the case of a 22-year-old woman with vascular compression of the upper-pole infundibulocalyceal system (Fraley’s syndrome). The patient had a history of frequent hospitalizations for emergency care due to lumbar pain over the past twelve months. The diagnosis was obtained following renal arteriography. Since the surgical treatment by means of upper-pole nephrectomy, the patient has not had any further symptoms.

CONTEXTO: A síndrome de Fraley é caracterizada por impressão vascular do infundíbulo superior com dilatação secundária do pólo caliceal superior. É geralmente localizada no lado direito. RELATO DE CASO: Nós apresentamos o caso de uma mulher com 22 anos de idade com compressão vascular do sistema infundibulocaliceal do pólo superior (síndrome de Fraley). A paciente trazia história de hospitalizações freqüentes em emergências nos últimos 12 meses devido a cólicas renais. O diagnóstico foi obtido após arteriografia renal. Depois do tratamento cirúrgico por meio de nefrectomia polar superior, a paciente não apresentou mais sintomas.

Trombosis de la arteria renal después de suspender la terapia anticoagulante en una trasplantada renal con trombofilia: Caso Clínico / Renal artery thrombosis after withdrawal from anticoagulation therapy in a kidney transplant recipient with thrombophilia: Report of one case

Kidney graft loss because arterial thrombosis is not common and is related to risk factors such as recurrent vascular hemodialysis access thrombosis, collagen-vascular disease, repeated miscarriage, diabetes mellitus and thrombophilia. Patients having this last disorder have an increased risk of repeated thrombosis in successive transplants unless they receive anticoagulation therapy. We report a 51 year-old diabetic woman who had a history of recurrent vascular hemodialysis access thrombosis (both native and prosthetic) while on dialysis and received a cadaveric donor kidney. One month after transplantation she had axillary vein thrombosis complicated with pulmonary embolism and received anticoagulants for six months. Just days after stopping the anticoagulation, she became suddenly anuric due to renal artery thrombosis and complete graft infarction. The coagulation study showed moderate hyperhomocysteinemia and a significant protein C deficiency (39 percent). Days after nephrectomy she suffered a femoral vein thrombosis and anticoagulation was prescribed for life.

Ectopía ureteral de segmento superior de duplicación ureteral drenando a la uretra (Reporte de un caso) / Ectopic ureter segment segment superior of ureter duplication draining to uretra (Report of a case)

Reportamos un caso muy raro de un uretero ectópico con un megaureter drenado en la uretra con obstrucción distal en una mujer joven que se presentó con un absceso perirenal.

Increased arterial distensibility and renovascular hypertension in Goldenhar syndrome

Relatamos a associação de hipertensão renovascular por estenose de artéria renal e a Sindrome de Goldenhar (variante da displasia oculoauriculovertebral) em uma paciente do sexo feminino de 13 anos de idade. Este é o primeiro relato de tratamento por angioplastia. Além disso, detectamos por métodos não invasivos um aumento da distensibilidade arterial, a despeito da hipertensão arterial. A similaridade destes achados com outras doenças genéticas sugere que as alterações vasculares presentes podem estar relacionadas à Síndrome de Goldenhar.

Encefalopatia hipertensiva associada a estado de mal epiléptico de repetição: relato de caso / Hypertensive encephalopathy associated to repetitive seizures: case report

Criança de cinco anos, feminina, branca, com história de oito internamentos nos últimos dois meses por crises convulsivas caracterizadas por vômitos, perda de consciência e clonias em hemicorpo direito. No exame físico, verificou-se hipertensão arterial grave (270/140 mmHg). Os estudos de neuroimagem (tomografia computadorizada e ressonância magnética) revelaram extensas áreas hipodensas, sugerindo edema cerebral. A arteriografia renal mostrou estenose da artéria renal direita, determinando a etiologia da hipertensão arterial. Com o controle da hipertensão, após a nefrectomia, houve reversão completa dos sintomas, assim como das anomalias de imagem.

Frequência de estenose de artéria renal em 676 transplantes renais / Frequency of stenosis of renal the artery in 676 renal transplants

O transplante renal é um tratamento seguro e efetivo para os pacientes portadores de falência renal e em regime de diálise. Apesar de bem padronizada, a cirurgia pode apresentar complicaçoes urológicas, clínicas e vasculares sendo a estenose de artéria renal a complicaçao vascular mais comum. Objetivo. Verificar a freqüência de estenose de artéria renal nos pacientes submetidos a transplante renal, no período de fevereiro de 1985 a dezembro de 1994, na Unidade de Transplante Renal do Hospital Sao Paulo, da Universidade Federal de Sao Paulo - UNIFESP - Escola Paulista de Medicina, comparando-se as anastomoses arteriais término-terminal e término-lateral. Casuística e Método. Foram analisados, retrospectivamente, 676 prontuários de pacientes submetidos a trnasplante renal, com idade mediana de 34 anos. O teste exato de Fischer foi aplicado para comparar os grupos etários, étnicos e sexo em relaçao a presença de estenose, sendo calculado os limites inferior e superior para a porcentagem de casos com estenose. Resultados. A estenose de artéria renal foi encontrada em 11 pacientes (1,63 por cento). Destes, 0,74 por cento foram submetidos a anastomose arterial término-terminal e 0,89 por cento término-lateral. Todos os casos ocorreram em transplantes realizados com rim de doador cadáver. Conclusao. A freqüência de estenose de artéria renal foi baixa, verificada apenas em receptores de rins de doador cadáver, nao diferindo de modo significante em relaçao ao tipo de anastomose realizada,e e nao sofrendo interferência quanto à idade, ao sexo e ao grupo étnico dos pacientes transplantados.

Angioplastia renal transluminal percutánea: experiencia en tres enfermos / Study of three patients with renal angioplasty

El presente trabajo tiene como objetivo, demostrar nuestra experiencia inicial con el empleo de la angioplastia renal transluminal percutánea (ATP), como alternativa terapéutica no quirúrgica para el tratamiento de la hipertensión arterial de origen renovascular; se describe la técnica de dilatación con catéteres con balón, presentándose los resultados en tres pacientes con estenosis de la arteria renal de diferente etiología, los cuales presentaron una mejoría clínica evidente. Se comenta la utilidad de esta técnica en este trabajo preliminar realizado en una unidad del Instituto Mexicano del Seguro Social del sureste del país

Revascularizacion renal y recuperacion de la funcion en pacientes en dialisis / Kidney revascularization and recuperation of the function in patients in dialysis

Se realizó una revisión bibliográfica sobre la recuperación de la función con la reperfusión del riñon isquémico en dializados por ese motivo, encontrándose solamente 57 pacientes, número exiguo pues se estima que la nefropatía isquémica es la causa de insuficiencia en el 5 por ciento al 15 por ciento de los dializados, y la posibilidad de revertirla está bien estabelecida. La etiología más frecuente fue la arteriosclerosis; predominó en enfermos mayores de 60 años, con arteriosclerosis en otros territorios, que empeoraron su hipertensión arterial y/o presentaron episodios de induficiencia renal y/o cardíaca aguda, a veces de difícil tratamiento sin la revascularización. Se recuperaron riñoes con tiempos variables de isquemia preoperatoria, (días a 13 meses de diálisis, promedio 30,5 días), con riñones menores de 9 u 8 cm y aun de 7 cm, flujo renal ausente, curvas planas o ausencia de nefrograma en estudios radioisotópicos o sin colaterales ni lecho distal en la arteriografía. La oclusión arterial total fue más frecuente que la estenosis. Treinta y cinco por ciento de los pacientes revascularizados recuperaron la función en forma inmediata, 52 por ciento requirió transitoria, y sólo el 12.2 por ciento no se recuperó. La hipertensión mejoró o se controló con 1 o 2 drogas. Los buenos resultados se mantuvieron durante períodos prolongados. Con una selección clínica adecuada, la revascularización puede mejorar rápidamente la función renal de enfermos dializados por nefropatía isquémica, mejorando substancialmente el pronóstico y la calidad de vida de muchos de ellos.