Interventional Management of Vascular Complications after Renal Transplantation

Abstract

Background Kidney transplantations are increasing due to demographic changes and are the treatment of choice for end-stage renal disease. Non-vascular and vascular complications may occur in the early phase after transplantation and at later stages. Overall postoperative complications after renal transplantations occur in approximately 12 % to 25 % of renal transplant patients. In these cases, minimally invasive therapeutic interventions are essential to ensure long-term graft function. This review article focuses on the most critical vascular complications after renal transplantation and highlights current recommendations for interventional treatment.

Method A literature search was performed in PubMed using the search terms “kidney transplantation”, “complications”, and “interventional treatment”. Furthermore, the 2022 annual report of the German Foundation for Organ Donation and the EAU guidelines for kidney transplantation (European Association of Urology) were considered.

Results and Conclusion Image-guided interventional techniques are favorable compared with surgical revision and should be used primarily for the treatment of vascular complications. The most common vascular complications after renal transplantation are arterial stenoses (3 %–12.5 %), followed by arterial and venous thromboses (0.1 %–8.2 %) and dissection (0.1 %). Less frequently, arteriovenous fistulas or pseudoaneurysms occur. In these cases, minimally invasive interventions show a low complication rate and good technical and clinical results. Diagnosis, treatment, and follow-up should be performed in an interdisciplinary approach at highly specialized centers to ensure the preservation of graft function. Surgical revision should be considered only after exhausting minimally invasive therapeutic strategies.

Key Points: 

• Vascular complications after renal transplantation occur in 3 % to 15 % of patients.

• Image-guided interventional procedures should be performed primarily to treat vascular complications of renal transplantation.

• Minimally invasive interventions have a low complication rate with good technical and clinical outcomes.

Citation Format

• Verloh N, Doppler M, Hagar MT et al. Interventional Management of Vascular Complications after Renal Transplantation. Fortschr Röntgenstr 2023; 195: 495 – 504

Key words

angiography - interventional procedures - renal angiography - transplantation

Publication History

Received: 19 July 2022

Accepted: 28 November 2022

Article published online:
02 March 2023

• References

• 1 Organtransplantation DS. Jahresbericht Organspende und Transplantation in Deutschland. Frankfurt am Main: Deutsche Stiftung Organtransplantation; 2021.
• 2 Wolfe RA, Ashby VB, Milford EL. et al. Comparison of mortality in all patients on dialysis, patients on dialysis awaiting transplantation, and recipients of a first cadaveric transplant. N Engl J Med 1999; 341: 1725-1730 DOI: 10.1056/NEJM199912023412303.
• 3 Tonelli M, Wiebe N, Knoll G. et al. Systematic review: kidney transplantation compared with dialysis in clinically relevant outcomes. Am J Transplant 2011; 11: 2093-2109 DOI: 10.1111/j.1600-6143.2011.03686.x.
• 4 Koch M, Weinmann-Menke J. Interdiziplinäre Zusammenarbeit nach Nierentransplantation (NTX). Nieren-und Hochdruckkrankheiten 2020; 49: 419
• 5 Breda A, Budde K, Figueiredo A. et al. EAU Guidelines on Renal Transplantation. EAU Guidelines on Renal Transplantation 2022; 19-23
• 6 Buttigieg J, Agius-Anastasi A, Sharma A. et al. Early urological complications after kidney transplantation: An overview. World J Transplant 2018; 8: 142-149 DOI: 10.5500/wjt.v8.i5.142.
• 7 Bhagat VJ, Gordon RL, Osorio RW. et al. Ureteral obstructions and leaks after renal transplantation: outcome of percutaneous antegrade ureteral stent placement in 44 patients. Radiology 1998; 209: 159-167 DOI: 10.1148/radiology.209.1.9769827.
• 8 Kaskarelis I, Koukoulaki M, Georgantas T. et al. Ureteral complications in renal transplant recipients successfully treated with interventional radiology. Transplant Proc 2008; 40: 3170-3172 DOI: 10.1016/j.transproceed.2008.08.040.
• 9 Irving HC, Kashi SH. Complications of renal transplantation and the role of interventional radiology. J Clin Ultrasound 1992; 20: 545-552
• 10 Iezzi R, la Torre MF, Santoro M. et al. Interventional radiological treatment of renal transplant complications: a pictorial review. Korean J Radiol 2015; 16: 593-603 DOI: 10.3348/kjr.2015.16.3.593.
• 11 Kolli KP, LaBerge JM. Interventional Management of Vascular Renal Transplant Complications. Tech Vasc Interv Radiol 2016; 19: 228-236 DOI: 10.1053/j.tvir.2016.06.008.
• 12 Orons PD, Zajko AB. Angiography and interventional aspects of renal transplantation. Radiol Clin North Am 1995; 33: 461-471
• 13 Kobayashi K, Censullo ML, Rossman LL. et al. Interventional radiologic management of renal transplant dysfunction: indications, limitations, and technical considerations. Radiographics 2007; 27: 1109-1130 DOI: 10.1148/rg.274065135.
• 14 Verghese PS. Pediatric kidney transplantation: a historical review. Pediatr Res 2017; 81: 259-264 DOI: 10.1038/pr.2016.207.
• 15 Olschewski P, Seehofer D, Ollinger R. et al. [Vascular reconstruction in visceral transplantation surgery]. Chirurg 2016; 87: 114-118 DOI: 10.1007/s00104-015-0108-7.
• 16 Taffel MT, Nikolaidis P. Expert Panel on Urologic I. et al. ACR Appropriateness Criteria((R)) Renal Transplant Dysfunction. J Am Coll Radiol 2017; 14: S272-S281 DOI: 10.1016/j.jacr.2017.02.034.
• 17 van der Molen AJ, Reimer P, Dekkers IA. et al. Post-contrast acute kidney injury – Part 1: Definition, clinical features, incidence, role of contrast medium and risk factors: Recommendations for updated ESUR Contrast Medium Safety Committee guidelines. Eur Radiol 2018; 28: 2845-2855 DOI: 10.1007/s00330-017-5246-5.
• 18 Cheungpasitporn W, Thongprayoon C, Mao MA. et al. Contrast-induced acute kidney injury in kidney transplant recipients: A systematic review and meta-analysis. World J Transplant 2017; 7: 81-87 DOI: 10.5500/wjt.v7.i1.81.
• 19 van der Molen AJ, Reimer P, Dekkers IA. et al. Post-contrast acute kidney injury. Part 2: risk stratification, role of hydration and other prophylactic measures, patients taking metformin and chronic dialysis patients: Recommendations for updated ESUR Contrast Medium Safety Committee guidelines. Eur Radiol 2018; 28: 2856-2869 DOI: 10.1007/s00330-017-5247-4.
• 20 van der Molen AJ, Reimer P, Dekkers IA. et al. Post-contrast acute kidney injury–Part 1: Definition, clinical features, incidence, role of contrast medium and risk factors. European radiology 2018; 28: 2845-2855
• 21 Lee J, Cho JY, Lee HJ. et al. Contrast-induced nephropathy in patients undergoing intravenous contrast-enhanced computed tomography in Korea: a multi-institutional study in 101487 patients. Korean J Radiol 2014; 15: 456-463 DOI: 10.3348/kjr.2014.15.4.456.
• 22 Nyman U, Almén T, Jacobsson B. et al. Are intravenous injections of contrast media really less nephrotoxic than intra-arterial injections?. European radiology 2012; 22: 1366-1371
• 23 Karlsberg RP, Dohad SY, Sheng R. et al. Contrast medium-induced acute kidney injury: comparison of intravenous and intraarterial administration of iodinated contrast medium. J Vasc Interv Radiol 2011; 22: 1159-1165 DOI: 10.1016/j.jvir.2011.03.020.
• 24 Kooiman J, Le Haen PA, Gezgin G. et al. Contrast-induced acute kidney injury and clinical outcomes after intra-arterial and intravenous contrast administration: risk comparison adjusted for patient characteristics by design. Am Heart J 2013; 165: 793-799 DOI: 10.1016/j.ahj.2013.02.013.
• 25 McDonald JS, Leake CB, McDonald RJ. et al. Acute Kidney Injury After Intravenous Versus Intra-Arterial Contrast Material Administration in a Paired Cohort. Invest Radiol 2016; 51: 804-809 DOI: 10.1097/RLI.0000000000000298.
• 26 Tong GE, Kumar S, Chong KC. et al. Risk of contrast-induced nephropathy for patients receiving intravenous vs. intra-arterial iodixanol administration. Abdom Radiol (NY) 2016; 41: 91-99 DOI: 10.1007/s00261-015-0611-9.
• 27 Mammen NI, Chacko N, Ganesh G. et al. Aspects of hypertension in renal allograft recipients. A study of 1000 live renal transplants. Br J Urol 1993; 71: 256-258 DOI: 10.1111/j.1464-410x.1993.tb15938.x.
• 28 Hurst FP, Abbott KC, Neff RT. et al. Incidence, predictors and outcomes of transplant renal artery stenosis after kidney transplantation: analysis of USRDS. American journal of nephrology 2009; 30: 459-467 DOI: 10.1159/000242431.
• 29 Patel NH, Jindal RM, Wilkin T. et al. Renal arterial stenosis in renal allografts: retrospective study of predisposing factors and outcome after percutaneous transluminal angioplasty. Radiology 2001; 219: 663-667 DOI: 10.1148/radiology.219.3.r01jn30663.
• 30 Fervenza FC, Lafayette RA, Alfrey EJ. et al. Renal artery stenosis in kidney transplants. American journal of kidney diseases 1998; 31: 142-148 DOI: 10.1053/ajkd.1998.v31.pm9428466.
• 31 Roberts JP, Ascher NL, Fryd DS. et al. Transplant renal artery stenosis. Transplantation 1989; 48: 580-583
• 32 Willicombe M, Sandhu B, Brookes P. et al. Postanastomotic transplant renal artery stenosis: association with de novo class II donor‐specific antibodies. American Journal of Transplantation 2014; 14: 133-143 DOI: 10.1111/ajt.12531.
• 33 Ghazanfar A, Tavakoli A, Augustine T. et al. Management of transplant renal artery stenosis and its impact on long-term allograft survival: a single-centre experience. Nephrology Dialysis Transplantation 2011; 26: 336-343 DOI: 10.1093/ndt/gfq393.
• 34 Seratnahaei A, Shah A, Bodiwala K. et al. Management of transplant renal artery stenosis. Angiology 2011; 62: 219-224 DOI: 10.1177/0003319710377076.
• 35 Nikolic B, Rose SC, Ortiz J. et al. Standards of reporting for interventional radiology treatment of renal and pancreatic transplantation complications. J Vasc Interv Radiol 2012; 23: 1547-1556 DOI: 10.1016/j.jvir.2012.09.009.
• 36 Rundback JH, Rizvi A, Tomasula J. Percutaneous treatment of transplant renal artery stenosis: techniques and results. Techniques in Vascular and Interventional Radiology 1999; 2: 91-97
• 37 Salvadori M, Di Maria L, Rosati A. et al. Efficacy and safety of Palmaz stent implantation in the treatment of renal artery stenosis in renal transplantation. Transplant Proc 2005; 37: 1047-1048 DOI: 10.1016/j.transproceed.2004.12.229.
• 38 Patel U, Kumar S, Johnson OW. et al. Long-term Graft and Patient Survival after Percutaneous Angioplasty or Arterial Stent Placement for Transplant Renal Artery Stenosis: A 21-year Matched Cohort Study. Radiology 2019; 290: 555-563 DOI: 10.1148/radiol.2018181320.
• 39 Chen LX, De Mattos A, Bang H. et al. Angioplasty vs stent in the treatment of transplant renal artery stenosis. Clin Transplant 2018; 32: e13217 DOI: 10.1111/ctr.13217.
• 40 Ngo A, Markar S, De Lijster M. et al. A systematic review of outcomes following percutaneous transluminal angioplasty and stenting in the treatment of transplant renal artery stenosis. Cardiovascular and interventional radiology 2015; 38: 1573-1588 DOI: 10.1007/s00270-015-1134-z.
• 41 Leertouwer T, Gussenhoven E, Bosch J. et al. Stent placement for renal arterial stenosis: where do we stand? A meta-analysis. Radiology 2000; DOI: 10.1148/radiology.216.1.r00jl0778.
• 42 Voiculescu A, Schmitz M, Hollenbeck M. et al. Management of arterial stenosis affecting kidney graft perfusion: a single‐centre study in 53 patients. American journal of transplantation 2005; 5: 1731-1738 DOI: 10.1111/j.1600-6143.2005.00927.x.
• 43 Macchini M, Mokrane T, Darcourt J. et al. Percutaneous transluminal angioplasty alone versus stent placement for the treatment of transplant renal artery stenosis. Diagn Interv Imaging 2019; 100: 493-502 DOI: 10.1016/j.diii.2019.03.010.
• 44 Chang H, Gelb BE, Stewart ZA. et al. Safety And Efficacy of Drug Eluting Stents for Treatment of Transplant Renal Artery Stenosis. Annals of Vascular Surgery 2022; DOI: 10.1016/j.avsg.2022.03.033.
• 45 Hoffmann R, Mintz GS. Coronary in-stent restenosis – predictors, treatment and prevention. Eur Heart J 2000; 21: 1739-1749 DOI: 10.1053/euhj.2000.2153.
• 46 Estrada CC, Musani M, Darras F. et al. 5 Years Experience With Drug Eluting and Bare Metal Stents as Primary Intervention in Transplant Renal Artery Stenosis. Transplant Direct 2017; 3: e128 DOI: 10.1097/TXD.0000000000000643.
• 47 Bruno S, Remuzzi G, Ruggenenti P. Transplant renal artery stenosis. J Am Soc Nephrol 2004; 15: 134-141 DOI: 10.1097/01.asn.0000099379.61001.f8.
• 48 Eufrasio P, Parada B, Moreira P. et al. Surgical complications in 2000 renal transplants. Transplant Proc 2011; 43: 142-144 DOI: 10.1016/j.transproceed.2010.12.009.
• 49 Grenier N, Claudon M, Trillaud H. et al. Noninvasive radiology of vascular complications in renal transplantation. European radiology 1997; 7: 385-391 DOI: 10.1007/s003300050171.
• 50 Maleux G, Messiaen T, Stockx L. et al. Transcatheter embolization of biopsy-related vascular injuries in renal allografts. Long-term technical, clinical and biochemical results. Acta Radiol 2003; 44: 13-17
• 51 Dimitroulis D, Bokos J, Zavos G. et al. Vascular complications in renal transplantation: a single-center experience in 1367 renal transplantations and review of the literature. In: Transplantation proceedings. Elsevier; 2009: 1609-1614
• 52 Domagala P, Kwiatkowski A, Wszola M. et al. Complications of transplantation of kidneys from expanded-criteria donors. In: Transplantation proceedings. Elsevier; 2009: 2970-2971
• 53 Wuthrich RP. Factor V Leiden mutation: potential thrombogenic role in renal vein, dialysis graft and transplant vascular thrombosis. Curr Opin Nephrol Hypertens 2001; 10: 409-414 DOI: 10.1097/00041552-200105000-00018.
• 54 Parajuli S, Lockridge JB, Langewisch ED. et al. Hypercoagulability in Kidney Transplant Recipients. Transplantation 2016; 100: 719-726 DOI: 10.1097/TP.0000000000000887.
• 55 Ojo AO, Hanson JA, Wolfe RA. et al. Dialysis modality and the risk of allograft thrombosis in adult renal transplant recipients. Kidney Int 1999; 55: 1952-1960 DOI: 10.1046/j.1523-1755.1999.00435.x.
• 56 Rouviere O, Berger P, Beziat C. et al. Acute thrombosis of renal transplant artery: graft salvage by means of intra-arterial fibrinolysis. Transplantation 2002; 73: 403-409 DOI: 10.1097/00007890-200202150-00014.
• 57 Giustacchini P, Pisanti F, Citterio F. et al. Renal vein thrombosis after renal transplantation: an important cause of graft loss. In: Transplantation proceedings. Elsevier; 2002: 2126-2127