Voiculescu Adina, Hollenbeck Markus, Plum Jörg, Hetzel Gerd Rüdiger, Mödder Ulrich, Pfeiffer Tomas, Sandmann Wilhelm, Grabensee Bernd
Department of Nephrology and Rheumatology, Heinrich-Heine-University, Düsseldorf, Germany.
Transplantation. 2003 Jul 27;76(2):332-9. doi: 10.1097/01.TP.0000072805.40996.B1.
Stenosis of the iliac segment proximal to the transplant renal artery (Prox-TRAS) is an uncommon cause of graft dysfunction and hypertension. We assessed the role of duplex sonography (DS) in regard to clinical and angiographic findings and followed the patients after percutaneous transluminal angioplasty (PTA), PTA stenting (PTAS), or surgery.
From January 1988 to August 2001, 97 of 1,064 kidney recipients underwent angiography for clinical or Doppler-sonographic suspicion of vascular problems. Kidney function, blood pressure, medication, and DS findings after renal transplantation (RTx) at the time of diagnosis of Prox-TRAS and after treatment were evaluated.
Prox-TRAS was diagnosed in 16 patients (1.5%) (49.6+/-6.9 years). Four patients demonstrated early presentation of Prox-TRAS 1 to 7 days after RTx (group A), leading to acute renal failure but without hypertension. In all patients, DS revealed pulsus parvus et tardus, low pulsatility index (PI) (<1.0), and a pathologic flow profile in the iliac artery proximal and distal to the graft. After treatment (surgery in two patients, PTA in one patient, PTAS in one patient), all patients developed good renal function (creatinine 1.7+/-0.9 mg/dL). PI increased from 0.9+/-0.1 to 1.2+/-0.1 (P=0.04), and flow profile within the iliac artery distal to the graft normalized. Late presentation (3-209 months after RTx) of Prox-TRAS was observed in 12 patients (group B), causing an increase of creatinine in 11 patients (two patients receiving dialysis treatments), impairment of blood pressure (141+/-15 and 80.7+/-7 to 160+/-18 and 85+/-7 mm Hg, P=0.009), and an increase in antihypertensive drugs (2.1+/-1.1 and 4.3+/-1, P=0.003) in all patients. The PI was decreased when compared with values early after RTx (1.6+/-0.4 to 1.2+/-0.3, P=0.007), and flow profile in the iliac artery was pathologic. All patients except one were managed by surgery (n=6), PTA (n=1), or PTAS (n=4). Creatinine (2.7+/-1.4 to 1.8+/-0.4 mg/dL, P=0.02) and blood pressure (160+/-18/85+/-7 mm Hg to 138+/-7/82+/-9, P=0.018) improved. Antihypertensive drugs were reduced to 2.8+/-0.8 (P=0.01). PI increased from 1.2+/-0.3 to 1.9+/-0.5 (P=0.01). Flow profile within the iliac artery distal to the graft anastomosis normalized. Kidney function, blood pressure, and PI remained unchanged during follow-up (82+/-69.9 months) in both groups.
Prox-TRAS is rare. Because clinical symptoms are similar to those of transplant renal artery stenosis, DS is a valuable tool for diagnosis and follow-up for this type of vascular lesion. Selective treatment with PTA, PTAS, or surgery improves kidney function and hypertension.
移植肾动脉近端（Prox - TRAS）的髂段狭窄是移植肾功能障碍和高血压的罕见原因。我们评估了双功超声（DS）在临床和血管造影结果方面的作用，并在经皮腔内血管成形术（PTA）、PTA支架置入术（PTAS）或手术后对患者进行了随访。
1988年1月至2001年8月，1064例肾移植受者中有97例因临床或多普勒超声怀疑血管问题而接受血管造影。评估了诊断Prox - TRAS时及治疗后肾移植（RTx）后的肾功能、血压、用药情况及DS检查结果。
16例患者（1.5%）（49.6±6.9岁）被诊断为Prox - TRAS。4例患者在RTx后1至7天出现Prox - TRAS早期表现（A组），导致急性肾衰竭但无高血压。所有患者DS均显示小慢脉、低搏动指数（PI）（<1.0）以及移植肾近端和远端髂动脉的病理性血流频谱。治疗后（2例手术，1例PTA，1例PTAS），所有患者肾功能良好（肌酐1.7±0.9mg/dL）。PI从0.9±0.1升至1.2±0.1（P = 0.04），移植肾远端髂动脉内的血流频谱恢复正常。12例患者（B组）出现Prox - TRAS晚期表现（RTx后3 - 209个月），11例患者肌酐升高（2例接受透析治疗），血压受损（141±15和80.7±7至160±18和85±7mmHg，P = 0.009），所有患者抗高血压药物增加（2.1±1.1和4.3±1，P = 0.003）。与RTx早期相比，PI降低（1.6±0.4至1.2±0.3，P = 0.007），髂动脉血流频谱呈病理性。除1例患者外，所有患者均接受手术（n = 6）、PTA（n = 1）或PTAS（n = 4）治疗。肌酐（2.7±1.4至1.8±0.4mg/dL，P = 0.02）和血压（160±18/85±7mmHg至138±7/82±9，P = 0.018）改善。抗高血压药物减至2.8±0.8（P = 0.01）。PI从1.2±0.3升至1.9±0.5（P = 0.01）。移植肾吻合口远端髂动脉内的血流频谱恢复正常。两组随访期间（82±69.9个月）肾功能、血压和PI均无变化。
Prox - TRAS罕见。由于临床症状与移植肾动脉狭窄相似，DS是诊断和随访此类血管病变的重要工具。PTA、PTAS或手术的选择性治疗可改善肾功能和高血压。
