Abstract: PUB534
Anuria in Transplant Renal Artery Stenosis (TRAS) with Pseudoaneurysm: A Rare Presentation of an Uncommon Co-occurrence
Session Information
Category: Transplantation
- 2102 Transplantation: Clinical
Authors
- Kumar, Joy, Kasturba Medical College Manipal, Manipal, Karnataka, India
- Mishra, Tanisha, Kasturba Medical College Manipal, Manipal, Karnataka, India
- Nagaraju, Shankar Prasad, Kasturba Medical College Manipal, Manipal, Karnataka, India
- Prabhu, Attur Ravindra, Kasturba Medical College Manipal, Manipal, Karnataka, India
- Rangaswamy, Dharshan, Kasturba Medical College Manipal, Manipal, Karnataka, India
Introduction
TRAS and pseudoaneurysm are notorious post-transplant vascular complications with reported incidence of 1-23% and 1% respectively. Decline in graft function, worsening or resistant hypertension with volume overload and flash pulmonary edema in severe cases due to RAAS activation is commonly seen. However, anuria is a rare but alarming manifestation.
Case Description
A 54-year-old male was evaluated for acute onset dyspnea and anuria. Hypoxia with bilateral coarse crepitations due to pulmonary edema was evident on CXR. BP was elevated to 210/110 mmHg. Acute increase in Cr to 4.26 mg/dl as compared to his post-transplant baseline Cr range of 0.7-0.9 mg/dl signaled graft dysfunction. Post cadaveric renal transplantation, he had achieved good graft function and urine output with nadir Cr of 0.67 mg/dl and received induction anti-thymocyte globulin along with triple immunosuppression maintenance. No improvement in urine output was seen after initial stabilization in the ED with O2, intravenous diuretics and nitroglycerin infusion support. Hemodialysis was started while transplant renal artery doppler was suggestive of TRAS with low velocity (30cm/sec) parvus tardus waveform at the hilum. A graft renal artery angiography diagnosed TRAS with pseudoaneurysm. Therapeutic angioplasty with stenting led to improvement in renal function, urine output and blood pressure recordings. Dialysis was stopped. The patient was discharged with serum Cr of 0.97 mg/dl.
Discussion
Acute onset anuria is an uncommon yet emergent sign in post transplant patients requiring urgent investigation and management to prevent graft loss and mortality. While post-renal obstruction is the usual etiology, evaluation for renal and prerenal vascular compromise causing anuria is important. A high index of suspicion is crucial to evaluate for TRAS in the background of graft dysfunction and worsening hypertension post transplantation while ruling out graft rejection, post transplant infections, calcineurin nephrotoxicity and post renal obstruction. Stenting has shown improved outcomes in management of TRAS and pseudoaneurysm.