Recovery of Prolonged Kidney Allograft Dysfunction Due to Transplant Renal Artery Restenosis Following Stenting: A Case Report

Introduction: Transplant renal artery stenosis (TRAS) is the commonest vascular cause of renal graft dysfunction. We present a case of prolonged graft dysfunction due to TRAS requiring multiple interventions. Case Description: A 63-year-old man's creatinine rose from a trough of 1.7 to 2.9 mg/dl within 5 months following a deceased transplant. He was on Tacrolimus, Belatacept and Prednisone. Donor specific antibodies, Cytomegalo and BK virus were negative. Renal ultrasound showed increased velocity and CO2 angiography showed severe stenosis at TRA anastomosis with the external iliac artery. There was a 60 mm Hg pressure gradient, which fell to 2 mm Hg following a 4 mm balloon angioplasty. Creatinine decreased to 1.9 mg/dl. Renal function started to deteriorate again after 2 months. Over a short period, he became anuric and was reinitiated of hemodialysis. There was 80% stenosis of TRA. Balloon angioplasty followed by a non-covered 6-mm stent within TRA resulted in immediate resolution of stenosis and pressure gradient and resumed brisk flow. Following anuria for 2 weeks and 6 hemodialysis sessions, he started to produce urine, and creatinine fell to 2.6 over the next 2 weeks. Discussion: TRAS ranges between 1-23%, mostly para-anastomotic and occurs within 3-6 months after transplant. Balloon angioplasty with or without stenting is the treatment of choice, resulting in both short- and long-term improvement in graft function. 1-year patency is 72-94%. Restenosis is more common in balloon angioplasty. Complication rates are up to 9%. Our patient was likely in dense ischemic ATN, which resolved following stenting. TRAS is a treatable cause of renal allograft dysfunction, which should always be in our list of differentials.Transplant renal artery stent