Fibromuscular dysplasia in a living donor: early post-operative allograft artery stenosis with successful venous interposition
Heiner H. Wolters1,,
Thorsten Vowinkel1,
Marc Schult1,
Stefan Heidenreich2,
Norbert Senninger1 and
Karl-Heinz Dietl1
1 Department of General Surgery of Universitätskliniküm Münster and
2 Department of Inner Medicine-D and Nephrology of Universitätskliniküm Münster, Münster, Germany
Keywords: fibromuscular dysplasia; living donation; renal artery stenosis; transplantation
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Introduction
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The still existing disparity between organ shortage and recipients waiting has led to a rising quantity of living donors. With a growing number of potential donors anatomic varieties such as both-sided polar arteries or fibromuscular dyplasia (FMD) are more often seen in the clinical routine, which may cause complications and therefore need a differentiated surgical therapy.
Allograft renal artery stenosis (RAS) is the most frequent of vascular complications in the first months after renal transplantation, with an incidence ranging from 1 to 12%. Hypertension, progressive deterioration of allograft function and angiotensin converting enzyme inhibitors-induced renal failure are the most common manifestations [1]. We report a case of early allograft dysfunction after living donation caused by a stenosis of the renal transplant artery due to FMD after a series of 39 kidney transplantations after living donation were carried out in our department between 1995 and 1999. In this series, two cases of FMD of the renal artery were detected in two donors. After grafting, a stenosis of the renal transplant artery in the early post-operative course prompted a venous interposition in one of the two FMD-graft recipients. Operative procedure resulted in immediate improvement of renal allograft function.
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Case
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Among 39 living donor renal transplantations performed between 1995 and 1999, a 35-year-old man with end-stage renal disease due to glomerulonephritis underwent renal transplantation after living donation in April 1999. The donor was his 70-year-old mother with an uneventful medical history, especially no history of hypertension and a totally normal kidney function showing a normal creatinine-clearance of 100 ml/min. Compulsory angiography of donor renal arteries showed a mild FMD (Figure 1
). As the mother insisted on donation, the transplantation was carried out with a total cold ischaemia time of 150 min, a first warm ischaemia time of 40 s and a second warm ischaemia time of 25 min. Intraoperatively the FMD could be recognized as mild so that the single renal artery was sutured to the external iliac artery in an end-to-side fashion. The venous anastomosis was carried out to the external iliac vein and ureter was anastomosed to the bladder in standard technique. Initial immunosuppressive regimen included prednisolone, mycophenolat mofetil, and cyclosporin.
The kidney graft showed good function in the early post-operative course. From the fifth post-operative day, however, serum creatinine was rising from its lowest level of 2.2 to 4.0 mg/dl. Colour-coded flow Doppler ultrasound on this day revealed haemodynamic disturbances suggesting a renal artery stenosis. Selective graft angiography on the sixth post-operative day illustrated a stenosis of the renal artery (Figure 2
) so that operative revision and venous interposition was performed. Subsequently graft function improved quickly and creatinine dropped from a maximum of 4.61.9 mg/dl within 5 days. The patient was discharged after an uneventful follow-up after 22 days with normal blood pressure. In addition to the immunosuppressive treatment, aspirin was given in a dosage of 100 mg/day starting with day of venous interposition.
All other grafts after living donation between 1995 and 1999 (n=38) showed good function in the early post-operative course following living donation. The average creatinine level was 1.3±0.5 mg/dl after 12 months (n=26) and 1.6±0.4 mg/dl after 24 months (n=16). Extended vascular surgery (venous interposition) in case of FMD in the reported case did not harm the graft, which showed excellent function in follow-up (creatinine at 6 months: 1.7 mg/dl). Hypertension, which sometimes is reported in case of FMD in elderly patients, did not occur during follow-up in donor or in recipient in our case.
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Discussion
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Renal allograft artery stenosis is a serious post-transplantation complication, which may induce arterial thrombosis and graft loss. FMD, which has been reported to be detected in about 3.310.9% of potential living kidney donors [13] is believed to be even more common among women older than 50 [4]. For pre-operative detection, selective angiography of the kidneys is still the best method and should be performed whenever there is doubt about FMD [5]. However, even if FMD is detected it should be no contraindication for performing living donation as long as the donor is free of any hypertensive drug medication. The risk of hypertension for both donor and recipient, however, must be discussed in these cases extensively beforehand with the donor and recipient. As spontaneous dissection of graft artery in FMD has been recently described [6,7], FMD has to be judged as a risk factor for this event. Under these circumstances early warning signs such as rising serum creatinine levels or rising blood pressure should immediately lead to further diagnostic tests: if Doppler ultrasound cannot indisputably rule out stenosis of the graft artery, an angiography has to be performed.
In case of proven graft artery stenosis, different possibilities of reconstruction are possible: a successful treatment with intravascular stent insertion after cadaveric transplantation has recently been reported [7]. In our patient, transplant arteriography allowed immediate diagnosis and successful revascularization with venous interposition. The risk of renal artery dissection following percutaneous transluminal angioplasty has been reported [8]. In our opinion this procedure is unacceptable for grafts from living donors since vascular surgery can offer a wide field of safe options. Another point not to be neglected is that open surgery can exclude other rare reasons for graft deterioration such as kidney torsion, which may mimic artery stenosis especially in early post-operative course. We follow the belief that if living donation is accepted in case of FMD an elaborate vascular surgery, namely venous interposition, should be done to ensure an optimal transplant outcome.
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Notes
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Correspondence and offprint requests to: Heiner H. Wolters, MD, Klinik für Allegemeine Chirurgie, Westf.-Wilhelms Universität, Waldeyerstr. 1, D-48149 Münster, Germany. Email: wolterh{at}uni\|[hyphen]\|muenster.de 
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Received for publication: 2.12.00
Accepted in revised form: 1. 8.01