Technical Feasibility of Renal Artery Embolization on a Transplanted Kidney Due to Intractable Unilateral Hydronephrosis After En Bloc Kidney Transplantation: Case Report

Patient History

The recipient was an 18-year-old female with congenital mitochondrial encephalomyopathy with lactic acidosis and stroke-like episodes (MELAS) syndrome who was on dialysis for end-stage renal disease (ESRD), secondary to focal segmental glomerulosclerosis. The donor was a 10-month-old male, who became brain dead after drowning in a bathtub. Both kidneys were retrieved from the donor en bloc with the aorta and inferior vena cava (IVC). However, injury to the left ureter of allograft occurred during the retrieval procedure, which was repaired during the bench procedure before transplanting it into the recipient. The suprarenal aorta and IVC were closed with 6–0 polypropylene running sutures. The caudal ends of the aorta and IVC were anastomosed with recipient’s right common iliac artery (CIA) and right external iliac vein (EIV), respectively. The ureters were anastomosed to the recipient bladder by an ureteroneocystostomy procedure, and ureteral double-J (DJ) catheters were inserted intraoperatively (Figure 1A). Postoperative recovery was uneventful. Immunosuppression induction was achieved using basiliximab and maintenance immunosuppression was done by means of a triple drug regimen consisting of tacrolimus, mycophenolate, and prednisolone. The serum creatinine level was 0.94 mg/dL on the fifth postoperative day and was since steadily maintained in the normal range. There were no specific findings regarding renal perfusion or complications evaluated by color Doppler ultrasound on the seventh postoperative day. The patient was discharged without complications after 2 weeks postoperatively.

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Figure 1.

En bloc kidney transplantation (EBKT), preoperative computed tomography (CT), and antegrade pyelography (AGP) findings. (A) EBKT was performed using both kidneys of a single donor. (B) Noncontrast CT shows hydronephrosis of the left transplanted kidney, (C) Follow-up CT performed after double-J (DJ) catheter removal showed mild aggravation of hydronephrosis. (D) Ureter outflow obstruction (arrow) as seen on AGP.

Eight weeks after EBKT, the patient presented to the emergency room with a fever of 38.3°C. Laboratory findings showed mild leukocytosis and elevated C-reactive protein (CRP), and bacteriuria was confirmed on urinalysis. We found severe hydronephrosis of the transplanted left kidney on noncontrast computed tomography (CT) (Figure 1B). Therefore, antibiotic therapy and DJ catheter removal were performed under the diagnosis of urinary tract infection (UTI) due to DJ catheter dysfunction. However, the fever did not subside despite continued therapy. Differential tests for the infection of BK virus and cytomegalovirus (CMV), and for acute rejection were performed, all of which came out negative. Follow-up contrast-enhanced CT was performed, which showed a slightly aggravated left hydronephrosis (Figure 1C). Ureter outflow obstruction was confirmed on antegrade pyelography (AGP), and a percutaneous nephrostomy (PCN) tube was inserted for the treatment of hydronephrosis (Figure 1D). To resolve the ureter outflow obstruction, balloon dilatation and DJ catheter reinsertion were performed. After 10 days of hospitalization, the patient recovered and was discharged with the DJ catheter in situ and the PCN removed. However, 5 weeks later, the patient returned to the hospital with the same symptoms and received the same treatment as the first hospitalization. The patient was hospitalized and discharged 5 times during a period of 10 months after EBKT, and obstructive uropathy did not resolve despite continuous antibiotic treatment and repeated radiologic interventions (PCN insertion, DJ catheterization and ureteral balloon dilatation). Eventually we decided to sacrifice the culprit transplanted left kidney by endovascular embolization.

Embolization Procedure

After 42 weeks of EBKT, embolization of the transplanted left kidney was performed through a left common femoral artery access with 5 Fr sheath. An arteriogram of the right common iliac artery showed the allograft aorta and both transplanted renal arteries on the right side of the patient (Figure 2A). The transplanted kidneys had normal renal artery anatomy and a left hydronephrosis was also visualized. Selective catheterization of the transplanted left renal artery was achieved using a 5 Fr Davis catheter (A&A M.D, SeongNam, Korea) and 1.7 to 2.8 Fr tapered Progreat Lambda 17 microcatheter (Terumo, Somerset, New Jersey, USA) (Figure 2B). Selective embolization for the renal artery of the transplanted left kidney was performed with gelatin (Nexsphere 100-300 um, Next Biomedical, Incheon, Korea), polyvinyl alcohol particles (PVA, COOK MEDICAL, Bloomington, Indiana, USA), and detachable coils (Concerto Coils, Medtronic, Minneapolis, MN, USA) (Figure 2C). The embolization procedure was considered to be completed successfully. Also, 100 cc/day of urine was continuously excreted through the PCN of transplanted left kidney after the procedure. One month after embolization, we decided to perform an additional embolization procedure since the culprit transplanted left kidney was still functional. Diagnostic arteriography was performed in the same way as the first embolization. Digital subtraction angiography (DSA) showed a small branch of transplanted left renal artery and an accessory left renal artery arising from the allograft aorta, which was not detected during the first embolization (Figure 2D). We tried to select this artery by exchanging various catheters with different shapes (Cobra, Davis, Simmons catheter) and wires. However, due to the multiple angulations and complicated anatomy to reach the desired branches, selection was unsuccessful. In addition, as the procedure time prolonged, the patient became irritable and did not cooperate, so the procedure was terminated. We tried a third embolization 2 weeks later, and this time the right common femoral artery was accessed. Conventional angiography with digital subtraction failed to demonstrate the target arteries, but we then performed a 3-dimensional rotational angiography (3D-RA) with low-contrast imaging (LCI) to visualize and reconstruct the anatomical configuration of the target arteries (Figure 3). Based on the exact information from the 3D reconstructed images, we selected the small branch arising from the transplanted left renal artery with a pre-shaped 90° bent 1.7 Fr microcatheter (Excelsior SL-10, Stryker Neurovascular, Freemont, California, USA) and wire (Synchro-14, Stryker Neurovascular, Freemont, California, USA). Selective embolization was then performed using detachable coils (Concerto coils, Medtronic, Minneapolis, MN, USA) (Figure 4A and B). For selection of the accessory left renal artery arising from the allograft aorta, we changed access to the left common femoral artery, and selective catheterization of the allograft aorta was performed using a 5 Fr Simmons catheter (A&A M.D, Seong Nam, Korea). A 1.7 to 2.8 Fr tapered Progreat Lambda 7 (Terumo, Somerset, New Jersey, USA) was successfully advanced into the accessory renal artery (Figure 4C), and embolization was performed using a mixture of histoacryl-lipiodol. A completion angiography showed total occlusion of the transplanted left renal arteries with no visible allograft parenchyme (Figure 4D). After embolization, urine was no longer excreted through the PCN, and a mild fever (up to 38°C) persisted for 2 days, but recovered with supportive care. Serum creatinine level was 0.83 mg/dL, similar to pre-embolization values. After 5 days of completion embolization, urine was no longer excreted through the inserted PCN, so it was removed. The patient was discharged on the seventh day after procedure and is currently under follow-up on an outpatient basis for 11 months.

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Figure 2.

The procedure of first and second embolization. (A) The digital subtraction angiography (DSA) through the right common iliac artery shows that transplanted kidneys have normal anatomy of the renal artery arising from the allograft aorta. (B) Selective catheterization of left transplanted kidney for embolization. (C) Final angiography shows successful embolization of the left transplanted kidney. (D) Angiography through allograft aorta demonstrated a small branch of the left transplanted renal artery and accessory renal artery (arrow) that was not detected at the time of the first embolization.

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Figure 3.

Low contrast imaging (LCI) and 3-dimensional rotational angiography (3D-RA) imaging. (A and B) Multi-angle imaging with 3D-RA can be used to structure the anatomical location of the renal artery of the transplanted kidney. (C) The LCI image shows the exact location of the origin of the accessory renal artery of the left transplanted kidney.

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Figure 4.

The procedure of third embolization. (A) Selective catheterization on the small branch of left transplanted renal artery using microcatheter and wire. (B) Successful coil embolization of small branch of the left transplanted kidney. (C) Selection and embolization of the accessory renal artery using histoacryl-lipiodol. (D) Final angiography show complete blockage of blood flow to the left transplanted kidney.