RENAL TRANSPLANT RELATED ANAESTHESIA EXPERIENCE, CONSIDERATIONS AND PRACTICE OVERVIEW OF AFIU, RAWALPINDI

Objective: To describe our experience of renal transplant operations in our institute. Study Design: Prospective observational study. Place and Duration of Study: Department of Anaesthesiology, Armed Forces Institute of Urology, Rawalpindi, from Sep 2016 to Sep 2019. Methodology: A total of 170 living related renal transplants were included in this study. Soda bicarbonate was given intra operatively to recipients according to arterial blood gas results. Blood transfusion was done where indicated. Results: Out of 340 (100 %) patients, 170 (50%) were living related donors and 170 (50%) were transplant recipients General anesthesia was the technique of choice. Three (1.76%) recipients out of 170 were awaked from anesthesia and postponed. Five (2.94%) patients were reopened on the same evening and 2 (1.17%) patients had transplant nephrectomy over a period 1 month. Soda bicarbonate was given to 143 (84.1%) and blood transfusion in 4 (2.35%) transplant recipients where as one patient had anaphylaxis intra-operatively. Conclusion: Living related kidney transplant is the standard transplant procedure in our institute because of non-availability of cadaveric donor. It’s now time that deceased donor program be started in Pakistan due to increased cases of renal failure and decreased living donors.

Endovascular treatment of the pseudoaneurysm using stent-graft after transplant nephrectomy

Introduction. Vascular complications after transplant nephrectomy are rather rare. The aim of this article is to analyze the effectiveness of the stent-graft implantation in the treatment of pseudoaneurysm after transplant nephrectomy. Clinical case. In the previous 23 years, a 50-year-old patient underwent 3 kidney transplantations from a cadaveric donor and 2 transplant nephrectomies. At 12 years after the left transplant nephrectomy he complained of abdominal pain and was admitted for a pulsating mass in his left pelvic region. Computed tomography angiography, ultrasonography, and arteriography were performed and showed a large pseudoaneurysm arising from the left external iliac artery. The stentgraft implantation solved the problem providing successful clinical and radiological results. Conclusion. Treatment options in this case were open or endovascular techniques. Surgical revision associated with high risk of complications. Endovascular treatment had the benefits of a minimally invasive approach with low blood loss.

A Case of Transplant Nephrectomy due to Chronic Graft Intolerance Syndrome

We report a case of graft intolerance syndrome in which transplant nephrectomy was performed 11 years after kidney transplantation. A 46-year-old man was admitted to our hospital in February 2018 with a mild fever, left lower abdominal pain, and gross hematuria with enlargement of the transplanted kidney. Urinary tract infection was ruled out. Because the symptoms developed after the immunosuppressants had been stopped after kidney graft loss, graft intolerance syndrome was suspected. He had lost his graft in 2016 and had stopped all immunosuppressants since January of 2017. Immunosuppressive therapy was intensified, and steroid half-pulse therapy was added for 3 days. After the steroid pulse therapy, the C-reactive protein (CRP) decreased from 6.47 mg/dL to 0.76 mg/dL, but there was little improvement in the symptoms, and the CRP then increased to 4.44 mg/dL. Transplant nephrectomy was performed in March 2018. Postoperatively, the symptoms disappeared without the administration of immunosuppressants, and the CRP decreased. Pathologically, the resected kidney graft showed persistent active allograft rejection with severe endarteritis, transplant glomerulopathy, and diffuse interstitial fibrosis. Massive thrombi occluded the large arteries, and there was extensive hemorrhagic cortical necrosis. Transplant nephrectomy is uncommon in patients >6 months after transplantation. However, even if more time has passed since transplantation, as in this case, transplant nephrectomy may be a valid option in some cases of severe graft intolerance syndrome.

Life-Threatening Hematuria as Initial Presentation of a Complicated Transplant Renal Artery Pseudoaneurysm

In this case report, we describe the clinical course of a complicated transplant renal artery (TRA) pseudoaneurysm, clinically featured by gross and massive hematuria one month after a kidney transplant was performed on a 50 year-old male patient. TRA pseudoaneurysm is a rare but potentially life-threatening complication that may result in bleeding, infection, graft dysfunction/loss, lower limb ischemia/loss, hemorrhagic shock, and death. TRA pseudoaneurysm treatment remains challenging as it needs to be tailored to the patient characteristics including hemodynamic stability, graft function, anatomy, presentation, and pseudoaneurysm features. This publication discusses the clinical scenario of massive gross hematuria that derived from a retroperitoneal hematoma which originated from an actively bleeding TRA pseudoaneurysm. This case highlights the combined approach of endovascular stent placement and subsequent transplant nephrectomy as a last resort in the management of intractable bleeding from a complicated TRA pseudoaneurysm. To the best of our knowledge, this is the first published case report of an actively bleeding TRA anastomotic pseudoaneurysm that caused a massive retroperitoneal bleed that in turn evacuated via the bladder after disrupting the ureter-to-bladder anastomosis. A temporizing hemostatic arterial stent placed percutaneously allowed for a safer and controlled emergency transplant nephrectomy.

Pembrolizumab-induced severe rejection and graft intolerance syndrome resulting in renal allograft nephrectomy

Introduction Pembrolizumab is a selective anti-programmed cell death protein-1 (PD-1) humanized monoclonal antibody that inhibits PD-1 activity by binding to the PD-1 receptor that is found on activated T-cells. The goal of the treatment is to allow the immune system to target and destroy cancer cells by preventing cancer cells from binding to PD-1 receptors, leading to decreased tumor growth. The activation of T-cells by pembrolizumab not only leads to the destruction of malignant cells but also attacks the donor alloantigens that are present in a renal transplant, resulting in graft rejection. Case report We present a case of a 46-year-old African American female with history of renal transplant who was treated with pembrolizumab for stage IV B endometrial adenocarcinoma and experienced renal transplant rejection and severe graft intolerance syndrome. Management and outcome: Due to ongoing graft intolerance, a transplant nephrectomy was performed. Allograft pathology was consistent with non-viable kidney with tubulitis, interstitial fibrosis and necrosis consistent with transplant rejection without any evidence of malignancy. Discussion As emphasized in our case, there is a very high risk of graft rejection in patients who need to be placed on immunomodulators such as pembrolizumab, so the risk versus benefit needs to be assessed and discussed. Our case is unique because pembrolizumab not only caused graft rejection but also severe graft intolerance syndrome which led to transplant nephrectomy. Further guidelines are needed in renal transplant patients requiring PD-1 inhibitors to establish the ideal treatment plan of immunosuppression management and anti-cancer treatments.

BK polyomavirus—pathogen, paradigm and puzzle

BK virus is a polyomavirus with seroprevalence rates of 80% in adults. Infection is usually acquired during childhood, and the virus is benign or pathologic depending on immune status. The virus reactivates in immunodeficiency states, mostly among transplant (either kidney or bone marrow) recipients. There are approximately 15 000 renal transplants every year in the USA, of which 5–10% develop BK polyomavirus nephropathy; 50–80% of patients who develop nephropathy go on to develop graft failure. BK virus is associated with BK polyomavirus nephropathy, ureteral stenosis, late-onset hemorrhagic cystitis, bladder cancer and other nonlytic large T-expressing carcinomas. The renal spectrum begins with viruria and can end with graft failure. The clinical spectrum and outcomes vary among transplant patients. New noninvasive diagnostic methods, such as urinary polyomavirus Haufen detected by electron microscopy, are currently under study. Treatment is primarily directed at decreasing immunosuppression but may be associated with graft rejection. Repeat transplantation is encouraged as long as viral clearance in plasma prior to transplant is accomplished. There remain no definitive data regarding the utility of transplant nephrectomy.

Painful angiomyxoid tumor in a failed renal allograft presenting as post-transplant lymphoproliferative disorder

Introduction: There exist few reports of de novo tumors involving an allograft kidney, and to the best of our knowledge there are only two previous reports of angiomyxoma Case Presentation: A 53-year-old Caucasian male with end-stage renal disease (ESRD) on hemodialysis (HD) secondary to malakoplakia with three failed prior renal transplants presented for repeat transplant evaluation. Imaging demonstrated a mass of the transplanted kidney suggestive of posttransplant lymphoproliferative disease (PTLPD). A biopsy was obtained revealing a predominance of myxoid material. The patient became increasingly symptomatic from the mass and underwent a palliative right transplant nephrectomy. Final pathology revealed angiomyxoid tumor. Conclusions: Angiomyxomas are asymptomatic, appear as PTLD on imaging and should be considered in the differential diagnosis of masses occurring in renal transplant allografts.