To haemodialysis and back: saving a kidney graft by treatment of an arteriovenous fistula

Email: a.h.brantsma{at}int.umcg.nl

Sir,

With an incidence of around 16%, arteriovenous fistula (AVF) is a frequent complication of percutaneous renal biopsy (PRB) after kidney transplantation [1]. In only 0–5% of cases, however, an AVF causes clinical signs, such as systolic–diastolic murmur in the area of the graft, haematuria or hypertension [1–3]. A more serious consequence of AVF is a decline in renal function caused by shunting of part of the blood flow directly through the AVF into the venous system, bypassing the glomerular vessels. This leads to a shortage in circulation at the glomerular level in the flow area behind the AVF. The perfusion outside the flow area of the AVF will also be reduced since a substantial part of the blood flow in this region will be shunted towards the affected flow area. Due to this diminished blood flow the affected flow area will activate the renin–angiotensin system causing hypertension and sodium-retention [1,4,5].

Recently a 36-year-old male with end-stage renal failure due to type 1 diabetes received a simultaneous pancreas–kidney transplant in our clinic. Due to limited improvement of renal function (Figure 1) in total three PRBs were performed during follow-up, all taken from the upper pole. The first two biopsies showed signs compatible with cyclosporine and tacrolimus toxicity, respectively, but cessation of these drugs did not improve renal function. After the second PRB a systolic–diastolic murmur was heard above the graft and presence of an AVF was suspected. Colour-coded Doppler sonography (CCDS), however, did not support this diagnosis. Forty-five days after transplantation the patient had to return to haemodialysis and a third PRB was performed, showing signs of focal tubular necrosis. Clinically there was now hypertension and mild urinary sodium retention, both suspected to have a renovascular cause, which strengthened earlier suspicions of the existence of an AVF despite the negative CCDS. Subsequent angiography revealed two large AVFs with rapid venous outflow in the upper pole of the graft (Figure 2). Both AVFs were coiled using superselective transcatheter embolization, which resulted in disappearance of the murmur, improvement of renal function, normalization of blood pressure and urinary sodium-excretion. Currently, more than 1.5 years after transplantation, the patient has an excellent renal function with a creatinine clearance of 54 ml/min.



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Fig. 1. Digital angiographic images obtained during the embolization procedure in the patient. (a) Selective catheterization of the renal artery. The arrows indicate the two fistulas with both niduses. The two feeding arteries and venous outflow vessels are visible. (b) Image after superselective embolization of the first fistula. The arrow indicates the coil. (c) Results after superselective placement of both coils (arrows).

 


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Fig. 2. The course of serum creatinine levels after transplantation. Black arrows indicate the time of the percutaneous renal biopsies. White arrow indicates time of embolization procedure. Dashed line shows serum creatinine levels during haemodialysis.

 
This is to our knowledge the first report of successful treatment of a patient with ‘features of end stage renal failure’ after PRB-induced AVF. This case clearly shows that sometimes an AVF can cause serious problems and therefore requires treatment. However, due to the low incidence of symptomatic AVFs after PRB there is little attention to this phenomenon in clinical practice. With this case we want to stress the importance of considering AVF as a complication of a PRB in the differential diagnosis of poorly understood renal dysfunction after kidney transplantation.

Auke H. Brantsma1, Ted R. Prins2, Eltjo F. de Maar1, Jaap J. Homan van der Heide1, Rutger J. Ploeg3 and Willem J. van Son1

1 Department of Internal Medicine Division of Nephrology2 Department of Radiology3 Department of Surgery University Medical Center Groningen The Netherlands

Acknowledgments

No funding was received for the writing of this article.

Conflict of interest statement. None declared.

References

  1. Brandenburg VM, Frank RD, Riehl J. Color-coded duplex sonography study of arteriovenous fistulae and pseudoaneurysms complicating percutaneous renal allograft biopsy. Clin Nephrol 2002; 58: 398–404[ISI][Medline]
  2. Merkus JW, Zeebregts CJ, Hoitsma AJ, van Asten WN, Koene RA, Skotnicki SH. High incidence of arteriovenous fistula after biopsy of kidney allografts. Br J Surg 1993; 80: 310–312[ISI][Medline]
  3. Gainza FJ, Minguela I, Lopez-Vidaur I, Ruiz LM, Lampreabe I. Evaluation of complications due to percutaneous renal biopsy in allografts and native kidneys with color-coded Doppler sonography. Clin Nephrol 1995; 43: 303–308[ISI][Medline]
  4. Shimmura H, Ishikawa N, Tanabe K et al. Angiographic embolization in patients with renal allograft arteriovenous fistula. Transplant Proc 1998; 30: 2990–2992[CrossRef][ISI][Medline]
  5. Dorffner R, Thurnher S, Prokesch R et al. Embolization of iatrogenic vascular injuries of renal transplants: immediate and follow-up results. Cardiovasc Intervent Radiol 1998; 21: 129–134[CrossRef][ISI][Medline]




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