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Interventional Radiology
Procedures
Posttransplant Procedures
Transplant Kidney Procedures
Transplant Kidney Procedures
Brandt C. Wible, MD; Lee S. Cummings, MD; Matthew B. Wilkinson, MD, PhD
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KEY FACTS

  • Terminology

    • Preprocedure

      • Procedure

        • Outcomes

          TERMINOLOGY

          • Definitions

            • Transplant renal artery stenosis (TRAS): Hemodynamically significant narrowing of donor renal artery; often juxtaanastomotic in location; incidence of 3-12%
              • Clinical manifestations
                • Refractory hypertension
                • Renal insufficiency (e.g., creatinine > 1.3-1.6)
              • Causes
                • Early: Arterial kinking
                • Late: Anastomotic stenosis, intimal hyperplasia
                • Less common: Extrinsic compression by perigraft fibrosis
            • Proximal pseudostenosis of transplant renal artery (pseudo-TRAS)
              • Actually due to inflow aortoiliac atherosclerosis
                • Stenosis proximal to transplant artery
                • Incidence up to 2.4%; increases with age
            • Renal graft thrombosis: Acute thrombotic occlusion of transplant renal artery/vein (incidence 2-4%)
              • Transplant renal artery thrombosis
                • Etiologies
                  • Technical surgical anastomotic issue
                  • Rejection
                • 80% occur in 1st month
                  • Most common cause of graft loss in 1st week
                • Surgical therapy generally preferred
                  • Repair of surgical-technical issue may be possible
                  • Fresh anastomosis poses high bleed risk with endovascular treatment methods
                  • Explant of kidney may be necessary
              • Transplant renal vein thrombosis
                • Etiologies
                  • Iliofemoral deep vein thrombosis (DVT)
                  • Compression by perigraft collection
                • Treated with anticoagulation &/or surgery
            • Arteriovenous fistula (AVF)/pseudoaneurysm (PSA)
              • AVF: Abnormal arteriovenous communication
                • Typically occurs after transplant biopsy
                • Involves injury to both artery and vein
                • Clinical features
                  • Gross hematuria, renal insufficiency, hypertension, high-output cardiac failure/bruit
                • May be asymptomatic; may spontaneously resolve
                  • Endovascular therapy if symptomatic/enlarging
              • PSA: Contained leak from injured artery with connection to sac-like blood collection contained in perivascular space
                • Incidence: 1-18% after biopsy
                • Clinical feature: Hematuria
                • AVF and PSA may coexist
                • Endovascular therapy if symptomatic/enlarging
                  • Transcatheter coil embolization
            • Urinary obstruction/leak
              • Incidence: 3-10%
                • Often within 6 months of transplantation
              • Etiologies
                • Anuric patients: Chronically contracted bladder difficult to fill and expand initially
                • Obstructing calculus
                • Ureteral extrinsic compression or kinking
                • Distal ureteral ischemia (ureteral vascular supply arises from renal hilum)
              • Can diagnose leak by creatinine level in urinoma
                • High infection risk if immunocompromised
                • May require both percutaneous nephrostomy (PCN) and urinoma drain for treatment
            • Perigraft fluid collection
              • Occurs in up to 50% of patients
                • 15-20% clinically significant due to
                  • Pain
                  • Transplant dysfunction from vascular/ureteral compression
              • Early postoperative etiologies
                • Hematoma (early postoperative period)
                • Abscess (1st several postoperative weeks)
                • Urinoma (higher creatinine vs. serum creatinine)
              • Etiology persisting > 1st month
                • Lymphocele (protein, urea nitrogen, creatinine similar to serum levels)
            • Chronic rejection a.k.a. graft intolerance syndrome
              • Syndrome due to graft rejection
                • Fever, flu-like syndrome, local pain
              • Consider percutaneous/transcatheter ablation of renal transplant with ethanol
                • Prior to nephrectomy to reduce bleeding
            • Deceased-donor renal transplant
              • Procure renal artery with portion of aorta; anastomosed end-to-side to recipient common/external iliac artery (CIA/EIA)
              • 82% 5-year survival rate
            • Living-donor renal transplant
              • Procure renal artery without aorta; anastomosed end-to-side to recipient EIA, or end-to-end to recipient internal iliac artery (IIA)
              • 90% 5-year survival rate

          PREPROCEDURE

          • Indications

            • Contraindications

              • Preprocedure Imaging

                • Getting Started

                  PROCEDURE

                  • Patient Position/Location

                    • Procedure Steps

                      • Findings and Reporting

                        • Alternative Procedures/Therapies

                          POST PROCEDURE

                          • Things to Do

                            • Postprocedure Imaging

                              OUTCOMES

                              • Problems

                                • Complications

                                  • Expected Outcomes

                                    Selected References

                                    1. Banas B et al: Long-term kidney transplant outcomes: role of prolonged-release tacrolimus. Transplant Proc. 52(1):102-10, 2020
                                    2. Cao C et al: Temporary covered metallic ureteral stent placement for ureteral strictures following kidney transplantation: experience in 8 patients. J Vasc Interv Radiol. 31(11):1795-800, 2020
                                    3. Voora S et al: Management of kidney transplant recipients by general nephrologists: core curriculum 2019. Am J Kidney Dis. 73(6):866-79, 2019
                                    4. Coussement J et al: Antibiotics for asymptomatic bacteriuria in kidney transplant recipients. Cochrane Database Syst Rev. 2:CD011357, 2018
                                    5. Copelan A et al: Iatrogenic-related transplant injuries: the role of the interventional radiologist. Semin Intervent Radiol. 32(2):133-55, 2015
                                    6. Iezzi R et al: Interventional radiological treatment of renal transplant complications: a pictorial review. Korean J Radiol. 16(3):593-603, 2015
                                    7. Ngo AT et al: A systematic review of outcomes following percutaneous transluminal angioplasty and stenting in the treatment of transplant renal artery stenosis. Cardiovasc Intervent Radiol. 38(6):1573-88, 2015
                                    8. Galazka Z et al: Is severe atherosclerosis in the aortoiliac region a contraindication for kidney transplantation? Transplant Proc. 43(8):2908-10, 2011
                                    9. Marini M et al: Treatment of transplant renal artery stenosis by percutaneous transluminal angioplasty and/or stenting: study in 63 patients in a single institution. Transplant Proc. 43(6):2205-7, 2011
                                    10. Nankivell BJ et al: Diagnosis and prevention of chronic kidney allograft loss. Lancet. 378(9800):1428-37, 2011
                                    11. Pawlicki J et al: Risk factors for early hemorrhagic and thrombotic complications after kidney transplantation. Transplant Proc. 43(8):3013-7, 2011
                                    12. Hedegard W et al: Management of vascular and nonvascular complications after renal transplantation. Tech Vasc Interv Radiol. 12(4):240-62, 2009
                                    13. Saad WE et al: Percutaneous nephrostomy: native and transplanted kidneys. Tech Vasc Interv Radiol. 12(3):172-92, 2009
                                    14. Kobayashi K et al: Interventional radiologic management of renal transplant dysfunction: indications, limitations, and technical considerations. Radiographics. 27(4):1109-30, 2007
                                    15. Beecroft JR et al: Transplant renal artery stenosis: outcome after percutaneous intervention. J Vasc Interv Radiol. 15(12):1407-13, 2004
                                    16. Surlan M et al: The role of interventional radiology in management of patients with end-stage renal disease. Eur J Radiol. 46(2):96-114, 2003
                                    17. Patel NH et al: Renal arterial stenosis in renal allografts: retrospective study of predisposing factors and outcome after percutaneous transluminal angioplasty. Radiology. 219(3):663-7, 2001
                                    18. Perini S et al: Transcatheter embolization of biopsy-related vascular injury in the transplant kidney: immediate and long-term outcome. J Vasc Interv Radiol. 9(6):1011-9, 1998
                                    19. Kuzuhara K et al: Ethanol ablation of lymphocele after renal transplantation: a minimally invasive approach. Transplant Proc. 29(1-2):147-50, 1997
                                    20. Lorenzo V et al: Ablation of irreversibly rejected renal allograft by embolization with absolute ethanol: a new clinical application. Am J Kidney Dis. 22(4):592-5, 1993
                                    Related Anatomy
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                                    Related Differential Diagnoses
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                                    References
                                    Tables

                                    Tables

                                    KEY FACTS

                                    • Terminology

                                      • Preprocedure

                                        • Procedure

                                          • Outcomes

                                            TERMINOLOGY

                                            • Definitions

                                              • Transplant renal artery stenosis (TRAS): Hemodynamically significant narrowing of donor renal artery; often juxtaanastomotic in location; incidence of 3-12%
                                                • Clinical manifestations
                                                  • Refractory hypertension
                                                  • Renal insufficiency (e.g., creatinine > 1.3-1.6)
                                                • Causes
                                                  • Early: Arterial kinking
                                                  • Late: Anastomotic stenosis, intimal hyperplasia
                                                  • Less common: Extrinsic compression by perigraft fibrosis
                                              • Proximal pseudostenosis of transplant renal artery (pseudo-TRAS)
                                                • Actually due to inflow aortoiliac atherosclerosis
                                                  • Stenosis proximal to transplant artery
                                                  • Incidence up to 2.4%; increases with age
                                              • Renal graft thrombosis: Acute thrombotic occlusion of transplant renal artery/vein (incidence 2-4%)
                                                • Transplant renal artery thrombosis
                                                  • Etiologies
                                                    • Technical surgical anastomotic issue
                                                    • Rejection
                                                  • 80% occur in 1st month
                                                    • Most common cause of graft loss in 1st week
                                                  • Surgical therapy generally preferred
                                                    • Repair of surgical-technical issue may be possible
                                                    • Fresh anastomosis poses high bleed risk with endovascular treatment methods
                                                    • Explant of kidney may be necessary
                                                • Transplant renal vein thrombosis
                                                  • Etiologies
                                                    • Iliofemoral deep vein thrombosis (DVT)
                                                    • Compression by perigraft collection
                                                  • Treated with anticoagulation &/or surgery
                                              • Arteriovenous fistula (AVF)/pseudoaneurysm (PSA)
                                                • AVF: Abnormal arteriovenous communication
                                                  • Typically occurs after transplant biopsy
                                                  • Involves injury to both artery and vein
                                                  • Clinical features
                                                    • Gross hematuria, renal insufficiency, hypertension, high-output cardiac failure/bruit
                                                  • May be asymptomatic; may spontaneously resolve
                                                    • Endovascular therapy if symptomatic/enlarging
                                                • PSA: Contained leak from injured artery with connection to sac-like blood collection contained in perivascular space
                                                  • Incidence: 1-18% after biopsy
                                                  • Clinical feature: Hematuria
                                                  • AVF and PSA may coexist
                                                  • Endovascular therapy if symptomatic/enlarging
                                                    • Transcatheter coil embolization
                                              • Urinary obstruction/leak
                                                • Incidence: 3-10%
                                                  • Often within 6 months of transplantation
                                                • Etiologies
                                                  • Anuric patients: Chronically contracted bladder difficult to fill and expand initially
                                                  • Obstructing calculus
                                                  • Ureteral extrinsic compression or kinking
                                                  • Distal ureteral ischemia (ureteral vascular supply arises from renal hilum)
                                                • Can diagnose leak by creatinine level in urinoma
                                                  • High infection risk if immunocompromised
                                                  • May require both percutaneous nephrostomy (PCN) and urinoma drain for treatment
                                              • Perigraft fluid collection
                                                • Occurs in up to 50% of patients
                                                  • 15-20% clinically significant due to
                                                    • Pain
                                                    • Transplant dysfunction from vascular/ureteral compression
                                                • Early postoperative etiologies
                                                  • Hematoma (early postoperative period)
                                                  • Abscess (1st several postoperative weeks)
                                                  • Urinoma (higher creatinine vs. serum creatinine)
                                                • Etiology persisting > 1st month
                                                  • Lymphocele (protein, urea nitrogen, creatinine similar to serum levels)
                                              • Chronic rejection a.k.a. graft intolerance syndrome
                                                • Syndrome due to graft rejection
                                                  • Fever, flu-like syndrome, local pain
                                                • Consider percutaneous/transcatheter ablation of renal transplant with ethanol
                                                  • Prior to nephrectomy to reduce bleeding
                                              • Deceased-donor renal transplant
                                                • Procure renal artery with portion of aorta; anastomosed end-to-side to recipient common/external iliac artery (CIA/EIA)
                                                • 82% 5-year survival rate
                                              • Living-donor renal transplant
                                                • Procure renal artery without aorta; anastomosed end-to-side to recipient EIA, or end-to-end to recipient internal iliac artery (IIA)
                                                • 90% 5-year survival rate

                                            PREPROCEDURE

                                            • Indications

                                              • Contraindications

                                                • Preprocedure Imaging

                                                  • Getting Started

                                                    PROCEDURE

                                                    • Patient Position/Location

                                                      • Procedure Steps

                                                        • Findings and Reporting

                                                          • Alternative Procedures/Therapies

                                                            POST PROCEDURE

                                                            • Things to Do

                                                              • Postprocedure Imaging

                                                                OUTCOMES

                                                                • Problems

                                                                  • Complications

                                                                    • Expected Outcomes

                                                                      Selected References

                                                                      1. Banas B et al: Long-term kidney transplant outcomes: role of prolonged-release tacrolimus. Transplant Proc. 52(1):102-10, 2020
                                                                      2. Cao C et al: Temporary covered metallic ureteral stent placement for ureteral strictures following kidney transplantation: experience in 8 patients. J Vasc Interv Radiol. 31(11):1795-800, 2020
                                                                      3. Voora S et al: Management of kidney transplant recipients by general nephrologists: core curriculum 2019. Am J Kidney Dis. 73(6):866-79, 2019
                                                                      4. Coussement J et al: Antibiotics for asymptomatic bacteriuria in kidney transplant recipients. Cochrane Database Syst Rev. 2:CD011357, 2018
                                                                      5. Copelan A et al: Iatrogenic-related transplant injuries: the role of the interventional radiologist. Semin Intervent Radiol. 32(2):133-55, 2015
                                                                      6. Iezzi R et al: Interventional radiological treatment of renal transplant complications: a pictorial review. Korean J Radiol. 16(3):593-603, 2015
                                                                      7. Ngo AT et al: A systematic review of outcomes following percutaneous transluminal angioplasty and stenting in the treatment of transplant renal artery stenosis. Cardiovasc Intervent Radiol. 38(6):1573-88, 2015
                                                                      8. Galazka Z et al: Is severe atherosclerosis in the aortoiliac region a contraindication for kidney transplantation? Transplant Proc. 43(8):2908-10, 2011
                                                                      9. Marini M et al: Treatment of transplant renal artery stenosis by percutaneous transluminal angioplasty and/or stenting: study in 63 patients in a single institution. Transplant Proc. 43(6):2205-7, 2011
                                                                      10. Nankivell BJ et al: Diagnosis and prevention of chronic kidney allograft loss. Lancet. 378(9800):1428-37, 2011
                                                                      11. Pawlicki J et al: Risk factors for early hemorrhagic and thrombotic complications after kidney transplantation. Transplant Proc. 43(8):3013-7, 2011
                                                                      12. Hedegard W et al: Management of vascular and nonvascular complications after renal transplantation. Tech Vasc Interv Radiol. 12(4):240-62, 2009
                                                                      13. Saad WE et al: Percutaneous nephrostomy: native and transplanted kidneys. Tech Vasc Interv Radiol. 12(3):172-92, 2009
                                                                      14. Kobayashi K et al: Interventional radiologic management of renal transplant dysfunction: indications, limitations, and technical considerations. Radiographics. 27(4):1109-30, 2007
                                                                      15. Beecroft JR et al: Transplant renal artery stenosis: outcome after percutaneous intervention. J Vasc Interv Radiol. 15(12):1407-13, 2004
                                                                      16. Surlan M et al: The role of interventional radiology in management of patients with end-stage renal disease. Eur J Radiol. 46(2):96-114, 2003
                                                                      17. Patel NH et al: Renal arterial stenosis in renal allografts: retrospective study of predisposing factors and outcome after percutaneous transluminal angioplasty. Radiology. 219(3):663-7, 2001
                                                                      18. Perini S et al: Transcatheter embolization of biopsy-related vascular injury in the transplant kidney: immediate and long-term outcome. J Vasc Interv Radiol. 9(6):1011-9, 1998
                                                                      19. Kuzuhara K et al: Ethanol ablation of lymphocele after renal transplantation: a minimally invasive approach. Transplant Proc. 29(1-2):147-50, 1997
                                                                      20. Lorenzo V et al: Ablation of irreversibly rejected renal allograft by embolization with absolute ethanol: a new clinical application. Am J Kidney Dis. 22(4):592-5, 1993