Korean J Transplant.  2023 Nov;37(Suppl 1):S96. 10.4285/ATW2023.F-6798.

The diagnosis of acute antibody-mediated rejection was delayed due to the initial suspicion of graft dysfunction caused by renal artery stenosis

• Cho HJ
• Moon J
• Kim M
• Ban TH
• Choi BS
• Jeon C
• Shin J
• Kim J
• Hwang JK

• KMID: 2551683
• DOI: http://doi.org/10.4285/ATW2023.F-6798

Abstract

Mechanical kinking leading to transplant renal artery stenosis is an uncommon yet noteworthy complication observed in kidney transplantation. This condition can result in graft dysfunction due to inadequate blood flow, potentially causing slow graft function or even complete kidney infarction. This case involves a 52-year-old male patient who received a kidney transplant. The patients panel reactive antibody was 75% for class I and 0% for class II. The number of human leukocyte antigens mismatches was four, and in class I donor-specific antibodies, there was a weak positive reaction to Cw9. Before the surgery, rituximab was administered, and basiliximab was used for induction. As the donors left renal function was better than the right kidney, they planned to receive the right. Afterward, anastomosis was performed, and due to the discrepancy in arterial and venous lengths, the graft kidney was positioned horizontally. An ultrasound was performed on the 4th postoperative day, revealing an elevated resistive index (RI) value (0.8) and an increased peak systolic velocity (PSV; 211 cm/sec) in the renal ar-tery. As a result, magnetic resonance angiography was conducted on the 6th postoperative day. The finding of focal tortuosity of the transplanted renal artery proximal portion causing minimal luminal narrowing was noted. However, on the 7th day after the surgery, a repeat ultrasound showed a decrease in the renal arteries PSV (130 cm/sec) and an RI value (1.0). Subsequently, a biopsy was performed and evidence of antibody-mediated rejection was confirmed. Following three rounds of therapeutic plasma exchange and intravenous immunoglobulin treatment, along with rituximab administration, the patient’s creatine level, which had been above two, decreased to 1.5. In conclusion, although there was sufficient suspicion for renal artery stenosis as the cause of slowly graft function, it is essential to explore various angles to identify the underlying factors.