Renal artery rupture secondary to pretransplantation Candida contamination of the graft in two different recipients

Infected graft transplantation is an unwelcome complication that may lead to serious consequences in the immunosuppressed host. It can be caused by infection of the donor or by contamination of the organ during harvest, preservation and handling, or at transplantation. With current donor evaluation protocols, the risk of transmitting infections by exogenous contaminated grafts seems to be more frequent than true donor-transmitted infections. Nevertheless, although rare and usually free of clinically significant sequelae, if contamination is by some virulent organisms such as Staphylococcus aureus, gram-negative bacilli, or fungi, severe complications may occur. We report the clinical outcome of liver, heart, and kidney recipients from a single donor. Both renal allografts had to be removed because of renal artery rupture secondary to Candida albicans infection. Careful donor evaluation before transplantation, unusually early presentation of mycosis leading to anastomotic renal artery disruption, the histopathologic findings of the grafts, and the absence of Candida infection in the liver and heart recipients make us believe that exogenous contamination of the grafts occurred during donor procedure, kidney processing, or at transplantation. In summary, because infected grafts can lead to serious complications, besides careful donor screening, it is important to achieve early recognition of contaminated organs by culturing the perfusate to start specific antiobiotic or antifungal therapy after transplantation if necessary and avoid the rare but, in this case, fatal consequences of these infections.     

Renal artery aneurysm in a cadaveric donor kidney

Sir, Aneurysms of the renal artery are rare and have an estimatedincidence of 0.09% in the general population [1]. Although rare,they are more commonly found in the fourth to sixth decadesof life. With increasingly more donor kidneys being retrievedfrom an older population, it is     

Renal artery aneurysm in a cadaveric kidney transplantation.

A 44-year-old haemodialysis patient was admitted for a cadavericrenal transplant. The donor renal artery (from a     

Renal artery aneurysm with peripheral embolization of kidney

This case demonstrates that a renal artery aneurysm may give rise to microemboli which pass peripherally to occlude branches of the renal arterial tree. These microemboli will result in segmental infarction of the renal parenchyma.     

Revascularization of kidney allograft after renal artery occlusion secondary to angioplasty

Arterial thrombosis causing complete occlusion is a rare event in the natural history of a transplanted allograft; an incidence of 1.4% has been reported. This condition usually results from technical problems, hyperacute rejection, severe atherosclerosis, or injury to donor or recipient arteries. The treatment of choice is transplant nephrectomy. We report a case of renal artery occlusion after a therapeutic radiological procedure and subsequent salvaging of the graft. The case report shows that an aggressive surgical approach toward restoring circulation is worth the effort.     

Pneumonia in kidney allograft recipients

Infectious complications, including pneumonia, remain one of the leading causes of morbidity and mortality in kidney allograft recipients. The aim of the study was to evaluate the relationship between pneumonia occurrence and treatment duration and recipient age, cause of native kidney insufficiency, dialysis duration, time between transplantation and onset, HLA matching, PRA immunosuppressive protocol, acute rejection incidence and treatment, kidney function at the pneumonia onset, as well as presence of comorbid conditions. One hundred and twenty pneumonia cases occurred in kidney allograft recipients transplanted between 1991 and 2000 with 12 to 120 months follow-up. Twenty five percentage of pneumonia episodes were diagnosed during the first posttransplant month, 25% between 2 and 6 months, and 25% at 0.5 to 3 years. Treatment duration measured from pneumonia onset to the study endpoint of recovery, which was defined as antibiotic withdrawal, show 50% of patient we cured after 15 days and 75% after 24 days of treatment. The risk of prolonged pneumonia treatment was associated with: second versus first kidney transplantation with RR = 2.3 (P <.02) and medians of treated time 28 versus 15 days; as well as serum creatinine level above 2 mg/dL (RR = 1.4; P <.098). Exposure to enhanced-potency immunosuppressive protocols including induction therapy with mono- or polyclonal antibodies increased the RR = 1.65 (P <.02), and lengthened the time to 18 versus 14 days. Maintenance immunosuppression with agents other than cyclosporine also enhanced the risk. (RR = 2.18; P <.068).     

Renal artery aneurysm at the anastomosis after kidney transplantation

Vascular complications represent serious problems after kidney transplantation. An aneurysm of the transplanted renal artery is an extremely rare but potentially devastating complication that which occurs in fewer than 1% of recipients. It can cause hypertension, functional impairment, and even graft loss. A 49-year-old man was admitted 6 months after his second renal transplantation. Duplex ultrasonography demonstrated an aneurysm at the anastomosis of the transplanted renal artery. The patient has not had any complaints. The function of the graft was stable. A computed tomography scan confirmed the diagnosis. Because of the high risk of rupture we decided upon surgical repair. During the operation, blood flow to the kidney was occluded; the graft was cooled with Euro-Collin’s solution and ice-cold saline. After the resection there was enough usable arterial wall to construct a new anastomosis. The patient had an uneventful postoperative period, the serum creatinine decreased to the preoperative level, and the function of the graft was stable. Renal artery aneurysms represent high-risk complications. We decided on surgical repair, which was performed with simultaneous perfusion and cooling of the graft. There are only a few similar cases in the literature; it was the first operation using this method in our practice. Surgical reconstruction of a renal artery aneurysm, if feasible, is a safe procedure that prevents aneurysm rupture and saves the graft.     

Renal infarction secondary to fibrous dysplasia and aneurysm formation of renal artery

We report a case of a previously healthy forty-year-old man with bilateral renal artery stenosis secondary to bilateral medial fibrous dysplasia. He was additionally found to have a dissecting aneurysm of the left upper renal artery branch with resultant infarction of the upper and middle pole renal segments. We believe renal infarction secondary to medial fibrous dysplasia with occlusion of the renal artery associated with a dissecting aneurysm has not been reported, and we report the first such case. A multimodality treatment approach was utilized.     

Emphysematous prostatitis and cystitis secondary to Candida albicans

Emphysematous cystitis is characterized by gas collection within the bladder wall and lumen. Often it is the result of aerobic urinary tract infections but it may be caused by gastrointestinal fistulas or iatrogenic surgical and diagnostic instrumentation. We report a case of emphysematous cystitis owing to Candida albicans with the incidental finding of emphysematous changes within the prostate gland.     

Renal artery aneurysm.

More and more renal artery aneurysms are being diagnosed, especially after the introduction of selective arteriography for the evaluation of renovascular hypertension. However, renal artery aneurysm still remains a rare entity. The pathogenesis of renal artery aneurysm is identical to the pathogenesis of arterial aneurysm in other arteries. Symptoms of aneurysm of the renal artery are dependent on a variety of factors, the most important of which are the size of the aneurysm, its location, and whether or not rupture has occurred. The indication for operation on renal artery aneurysm is rupture or threat of rupture. Herein we present a review of the literature and a report of 2 cases which exemplify the capabilities of the surgeon in dealing with such cases.     

Renal allograft artery stenosis.

Thirteen renal artery stenoses occurred in 127 renal allograft transplantations performed at the University of Cincinnati Medical Center over a four year period. The most common symptoms were hypertension and decreasing renal function occurring from three days to three years post transplantation. Eight lesions occurred in patients with a single artery and five when double arteries had been joined together prior to anastomosis rather than implanted separately. The most common causes of renal artery stenosis was intimal hyperplasia of the donor vessel distal to the anastomosis (8 patients), atheromatous plaques (2), technical failure (2), and external compression (1). Surgical correction was facilitated by a midline incision. Resection of the stenotic segment and reanastomosis was the preferred procedure. Surgical failure and recurrence of hypertension were associated with involvement of small arteries or distal arteriolar level. When kidneys with multiple arteries are available, Carrel patches should be used when possible; if not, they should be implanted separately rather than joined together prior to anastomosis, thus decreasing the possibility of creating turbulent blood flow.     

Aortoiliac aneurysm repair in kidney transplant recipients

A potential problem during endovascular aortic aneurysm repair (EVAR) or open repair in renal allograft patients is ischemia of the transplanted kidney. In this study, kidney transplant patients who underwent aortic aneurysm repair in our institution were added to similar cases extracted from the literature to represent the basis of this work. Comparisons between patients treated with open surgery versus EVAR were performed in terms of renal function. In the EVAR group, most aneurysms were infrarenal, and 84% were treated with modular bifurcated devices. Protective kidney allograft perfusion measures were not used. The pre- and postoperative Cr was 1.69 and 1.73 mg/dL, respectively (P = .412). All EVAR patients had good outcomes. Complications included 8 endoleaks and 1 limb ischemia case. Three patients died from aortic repair-unrelated reasons. In the open group, the pre-and postoperative Cr was 1.45 and 1.37 mg/dL, respectively (P = .055). Most cases were infrarenal and mostly treated by aortobiiliac bypasses. In 16%, no adjuvant allograft perfusion was provided. In the rest, temporary axillofemoral bypasses were used most often. Most outcomes were favorable (57%). Reported procedural-related complications included arterial embolism, wound infection, and pneumonia. Deaths were reported in 5 occasions (none allograft failure dependent). No differences in Cr between EVAR and open techniques (P = .13) were seen. Aneurysm repair in kidney transplant recipients is associated with excellent renal preservation. Adverse outcomes were all allograft failure independent in both groups. EVAR without special allograft protection measures seems to be equally effective as open surgery with or without adjuvant kidney transplant perfusion.