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Dtsch Med Wochenschr 2004; 129(19): 1075-1081
DOI: 10.1055/s-2004-824850
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Nephrologie/Transplantationsmedizin
© Georg Thieme Verlag Stuttgart · New York

Vaskuläre Stenosen nach Nierentransplantation mit Einfluss auf Blutdruck und Nierenfunktion

Vascular stenosis after kidney transplantation with influence on blood pressure and renal functionA. Voiculescu1 , M. Schmitz1 , W. Sandmann2 , U. Mödder3 , B. Grabensee1
  • 1Klinik für Nephrologie und Rheumatologie
  • 2Klinik für Gefäßchirurgie und Nierentransplantation
  • 3Institut für diagnostische Radiologie
  • 4Heinrich Heine Universität, Düsseldorf
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Publication History

eingereicht: 4.9.2003

akzeptiert: 15.1.2004

Publication Date:
22 July 2004 (online)

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Zusammenfassung:

Meist heilbare Ursachen der arteriellen Hypertonie nach Nierentransplantation (NTX) und Einschränkung der Nierenfunktion bis hin zur Dialysepflichtigkeit sind Stenosen der Arterien mit einer Diameterreduktion von > 70 %, die die Transplantatperfusion beinträchtigen. Atherosklerotische Verschlusserkrankungen des Spenders oder des Empfängers sind in erster Linie für die Stenosen verantwortlich, gefolgt von Gefäßläsionen, die während der Entnahme oder der NTX entstehen. Insofern unterscheidet man Stenosen der Transplantatarterie selbst (TRAS) und Stenosen der aorto-iliacalen Strombahn proximal der Transplantatarterie (Prox-TRAS). Die Inzidenz von TRAS liegt bei 1,5 - 12 %, die von Prox-TRAS bei 1,5 - 2,4 %. Leitsymptome für beide Lokalisationen sind eine meist schwer einstellbare Hypertonie und/oder eine Nierenfunktionsverschlechterung bis hin zur Dialysepflichtigkeit, insbesondere unter ACE-Hemmer bzw. AT-1-Blockern. Bei Prox-TRAS werden vom Patienten nur in ca. 50 % der Fälle Symptome der peripheren arteriellen Verschlusserkrankung angegeben.

Als Screening-Untersuchung und zur Verlaufskontrolle hat sich die farbkodierte Duplex-Sonographie bewährt. Die MR-Angiographie (MRA) weist verfahrens-assoziierte Ungenauigkeiten auf. Der diagnostische Goldstandard ist weiterhin die intraarterielle digitale Subtraktionsangiographie (ia DSA) auch unter Berücksichtigung der kontrastmittel induzierten Nephrotoxizität.

Bei progredienter Stenose drohen unkontrollierbare Hypertonie und Transplantatverlust. Somit stellt die Beseitigung der Stenose die kausale Therapie dar, wobei das therapeutische Spektrum von interventionellen Methoden mittels perkutaner Angioplastie ohne (PTA) und mit Stent (PTAS) bis zu verschiedenen operativen Verfahren reicht. Die Auswahl der Therapieform hängt von der Art, Lokalisation und Morphologie der Stenose und von der Verfügbarkeit der Methoden ab.

Die Ergebnisse der operativen Behandlung sind gegenüber der PTA in bisherigen klinischen Beobachtungen günstiger. Über Verläufe nach PTAS sind bisher nur wenige Berichte mit kleinen Patientenzahlen vorhanden. Eine gelungene Intervention/Operation führt fast immer zu einer Besserung der Hypertonie und Verbesserung/Stabilisierung der Nierenfunktion.

Summary

Vascular stenoses > 70 % with influence on the kidney transplant perfusion are potentially curable causes for posttransplant hypertension and deterioration of kidney function including requirement of dialysis. Two locations of stenosis can be differentiated: stenosis of the transplant renal artery (TRAS) and stenosis proximal to the kidney graft (Prox-TRAS). Causes of TRAS and Prox-TRAS are mainly due to atherosclerosis of the donor or recipient, trauma to donor or recipient vessels during organ harvesting and transplantation. The incidence of TRAS varies from 1,5 - 12 %, and from 1,5 - 2,4 % for Prox-TRAS. The most frequent clinical presentation is severe hypertension with or without graft dysfunction, which is even more pronounced under treatment with ACE-inhibitors/AT-1-blockers. Patients with Prox-TRAS complain in only 50 % about symptoms of peripheral arterial occlusive disease.

According to our experience, colour coded Doppler sonography (CDS) is a very sensitive and useful tool for detection and follow-up of TRAS and Prox-TRAS. MR-angiography is also sensitive but exaggerates the degree of obstruction. Although selective angiography remains gold standard, the injection of contrast material may further deteriorate kidney function.

Progressive stenosis bears the risk of uncontrollable hypertension and loss of graft function, therefore invasive treatment for removal of stenosis is indicated. Percutaneous transluminal balloon angioplasty without (PTA) and with sent (PTAS) deployment as well as surgical techniques are treatment options and are applied depending on the type, morphology and localisation of the stenosis. Results after surgery are better as compared to PTA. Comparison to PTAS is not yet possible, due to very few data obtained until today. Technically successful management of the stenosis results nearly always in improvement of hypertension and of renal function.

Literatur

  • 1 Bachy C, Alexandre G P, van Ypersele de Strihou C. Hypertension after renal transplantation.  Br Med J. 1976;  2 1287-1289
    Search in Google Scholar
  • 2 Baxter G M, Ireland H, Moss J G. et al . Colour Doppler ultrasound in renal transplant artery stenosis: which Doppler index?.  Clin Radiol. 1995;  50 618-622
    Search in Google Scholar
  • 3 Becker B N, Odorico J S, Becker Y T. et al . Peripheral vascular disease and renal transplant artery stenosis: a reappraisal of transplant renovascular disease.  Clin Transplant. 1999;  13 349-355
    Search in Google Scholar
  • 4 Benoit G, Moukarzel M, Hiesse C, Verdelli G, Charpentier B, Fries D. Transplant renal artery stenosis: experience and comparative results between surgery and angioplasty.  Transpl Int. 1990;  3 137-140
    Search in Google Scholar
  • 5 Bohm M, Fries R, Hennen B. et al . Indications for renal angiography and for percutaneous transluminal renal artery dilatation: interdisciplinary consensus statement regarding renal artery stenosis.  Dtsch Med Wochenschr. 2003;  128 150-156
    Search in Google Scholar
  • 6 Brekke I B, Lien B, Sodal G. et al . Aortoiliac reconstruction in preparation for renal transplantation.  Transpl Int. 1993;  6 161-163
    Search in Google Scholar
  • 7 Curtis J J. Hypertension and kidney transplantation.  Am J Kidney Dis. 1986;  7 181-196
    Search in Google Scholar
  • 8 de Smet A A, Ermers E J, Kitslaar P J. Duplex velocity characteristics of aortoiliac stenoses.  J Vasc Surg. 1996;  23 628-636
    Search in Google Scholar
  • 9 Deane C, Cairns T, Walters H. et al . Diagnosis of renal transplant artery stenosis by color Doppler ultrasonography.  Transplant Proc. 1990;  22 1395
    Search in Google Scholar
  • 10 Eiberg J P, Jensen F, Gronvall Rasmussen J B, Schroeder T V. Screening for aortoiliac lesions by visual interpretation of the common femoral Doppler waveform.  Eur J Vasc Endovasc Surg. 2001;  22 331-336
    Search in Google Scholar
  • 11 Erley C M, Duda S H, Wakat J P. et al . Noninvasive procedures for diagnosis of renovascular hypertension in renal transplant recipients - a prospective analysis.  Transplantation. 1992;  54 863-867
    Search in Google Scholar
  • 12 Farmer C K, Cook G J, Blake G M, Reidy J, Scoble J E. Individual kidney function in atherosclerotic nephropathy is not related to the presence of renal artery stenosis.  Nephrol Dial Transplant. 1999;  14 2880-2884
    Search in Google Scholar
  • 13 Ferreiros J, Mendez R, Jorquera M. et al . Using gadolinium-enhanced three-dimensional MR angiography to assess arterial inflow stenosis after kidney transplantation.  AJR Am J Roentgenol. 1999;  172 751-757
    Search in Google Scholar
  • 14 Fervenza F C, Lafayette R A, Alfrey E J, Petersen J. Renal artery stenosis in kidney transplants.  Am J Kidney Dis. 1998;  31 142-148
    Search in Google Scholar
  • 15 Gavras H, Brunner H B, Vaughan E D, Laragh J H. Angiotensin-sodium interaction in blood pressure maintenance of renal hypertensive and normotensive rats.  Science. 1973;  180 1369-1371
    Search in Google Scholar
  • 16 Goldblatt H. Studies on experimental hypertension I. The production of persistent elevation of systolic blood pressure by means of renal ischemia.  J Exp Med. 1934;  59 347
    Search in Google Scholar
  • 17 Gray D WR. Graft renal artery stenosis in the transplanted kidney.  Transpl Rev. 1994;  8 15-21
    Search in Google Scholar
  • 18 Grenier N, Douws C, Morel D. et al . Detection of vascular complications in renal allografts with color Doppler flow imaging.  Radiology. 1991;  178 217-223
    Search in Google Scholar
  • 19 Halimi J M, Al-Najjar A, Buchler M. et al . Transplant renal artery stenosis: potential role of ischemia/reperfusion injury and long-term outcome following angioplasty.  J Urol. 1999;  161 28-32
    Search in Google Scholar
  • 20 Hofmann L V, Smith P A, Kuszyk B S, Kraus E, Fishman E K. Three-dimensional helical CT angiography in renal transplant recipients: a new problem-solving tool.  AJR Am J Roentgenol. 1999;  173 1085-1089
    Search in Google Scholar
  • 21 Hohnke C, Abendroth D, Schleibner S, Land W. Vascular complications in 1,200 kidney transplantations.  Transplant Proc. 1987;  19 3691-3692
    Search in Google Scholar
  • 22 Hollenbeck M, Kutkuhn B, Grabensee B. Colour Doppler ultrasound in the diagnosis of transplant renal artery stenosis.  Bildgebung. 1994;  61 248-254
    Search in Google Scholar
  • 23 Huber A, Heuck A, Scheidler J. et al . Contrast-enhanced MR angiography in patients after kidney transplantation.  Eur Radiol. 2001;  11 2488-2495
    Search in Google Scholar
  • 24 Imanishi M, Akabane S, Takamiya M. et al . Critical degree of renal arterial stenosis that causes hypertension in dogs.  Angiology. 1992;  43 833-842
    Search in Google Scholar
  • 25 Johnson D B, Lerner C A, Prince M R. et al . Gadolinium-enhanced magnetic resonance angiography of renal transplants.  Magn Reson Imaging. 1997;  15 13-20
    Search in Google Scholar
  • 26 Kotval P S. Doppler waveform parvus and tardus. A sign of proximal flow obstruction.  J Ultrasound Med. 1989;  8 435-440
    Search in Google Scholar
  • 27 Krumme B, Mann J F. Atherosclerotic renal artery stenosis in 2001 - are we less confused than before?.  Nephrol Dial Transplant. 2001;  16 2124-2127
    Search in Google Scholar
  • 28 Lacombe M. Arterial stenosis complicating renal allotransplantation in man: a study of 38 cases.  Ann Surg. 1975;  181 283-288
    Search in Google Scholar
  • 29 Laragh J H. The renin system in essential, renovascular and adrenocortical hypertension: an overview.  Adv Nephrol Necker Hosp. 1977;  7 157-189
    Search in Google Scholar
  • 30 Leung D A, Hagspiel K D, Angle J F, Spinosa D J, Matsumoto A H, Butty S. MR angiography of the renal arteries.  Radiol Clin North Am. 2002;  40 847-865
    Search in Google Scholar
  • 31 Loubeyre P, Cahen R, Grozel F. et al . Transplant renal artery stenosis. Evaluation of diagnosis with magnetic resonance angiography compared with color duplex sonography and arteriography.  Transplantation. 1996;  62 446-450
    Search in Google Scholar
  • 32 Loubeyre P, Revel D, Garcia P. et al . Screening patients for renal artery stenosis: value of three- dimensional time-of-flight MR angiography.  AJR Am J Roentgenol. 1994;  162 847-852
    Search in Google Scholar
  • 33 Merkus J W, Huysmans F T, Hoitsma A J, Buskens F G, Skotnicki S H, Koene R A. Renal allograft artery stenosis: results of medical treatment and intervention. A retrospective analysis.  Transpl Int. 1993;  6 111-115
    Search in Google Scholar
  • 34 Merkus J W, van Asten W N, Hoitsma A J, Buskens F G, Koene R A, Skotnicki S H. Iliac artery stenosis after kidney transplantation.  Acta Chir Belg. 1993;  93 242-248
    Search in Google Scholar
  • 35 Morris P J, Yadav R V, Kincaid-Smith P. et al . Renal artey stenosis in renal transplantation.  Med J Aust. 1971;  1 1255-1257
    Search in Google Scholar
  • 36 Newman-Sanders A P, Gedroyc W G, al-Kutoubi M A, Koo C, Taube D. The use of expandable metal stents in transplant renal artery stenosis.  Clin Radiol. 1995;  50 245-250
    Search in Google Scholar
  • 37 Nicita G, Villari D, Marzocco M, Li Marzi V, Trippitelli A, Santoro G. Endoluminal stent placement after percutaneous transluminal angioplasty in the treatment of post-transplant renal artery stenosis.  J Urol. 1998;  159 34-37
    Search in Google Scholar
  • 38 Opelz G. Influence of original disease on long-term outcome of cadaver kidney transplant. Collaborative Transplant Study.  Transplant Proc. 1996;  28 1148-1149
    Search in Google Scholar
  • 39 Patel N H, Jindal R M, Wilkin T. et al . Renal arterial stenosis in renal allografts: retrospective study of predisposing factors and outcome after percutaneous transluminal angioplasty.  Radiology. 2001;  219 663-667
    Search in Google Scholar
  • 40 Patel U, Khaw K K, Hughes N C. Doppler ultrasound for detection of renal transplant artery stenosis-threshold peak systolic velocity needs to be higher in a low-risk or surveillance population.  Clin Radiol. 2003;  58 772-777
    Search in Google Scholar
  • 41 Pfeiffer T, Bohner H, Luther B, Voiculescu A, Grabensee B, Sandmann W. Aortoiliac reconstruction after kidney transplantation. Strategies to avoid ischemic damage of the transplant.  Chirurg. 2002;  73 57-64
    Search in Google Scholar
  • 42 Pouria S, State O I, Wong W, Hendry B M. CMV infection is associated with transplant renal artery stenosis.  QJM. 1998;  91 185-189
    Search in Google Scholar
  • 43 Rengel M, Gomes-Da-Silva G, Inchaustegui L. et al . Renal artery stenosis after kidney transplantation: diagnostic and therapeutic approach.  Kidney Int Suppl. 1998;  68 S99-106
    Search in Google Scholar
  • 44 Roberts J P, Ascher N L, Fryd D S. et al . Transplant renal artery stenosis.  Transplantation. 1989;  48 580-583
    Search in Google Scholar
  • 45 Ruggenenti P, Mosconi L, Bruno S. et al . Post-transplant renal artery stenosis: the hemodynamic response to revascularization.  Kidney Int. 2001;  60 309-318
    Search in Google Scholar
  • 46 Safian R D, Textor S C. Renal-artery stenosis.  N Engl J Med. 2001;  344 431-442
    Search in Google Scholar
  • 47 Sagalowsky A I, Peters P C. Renovascular hypertension following renal transplantation.  Urol Clin North Am. 1984;  11 491-502
    Search in Google Scholar
  • 48 Sankari B R, Geisinger M, Zelch M, Brouhard B, Cunningham R, Novick A C. Post-transplant renal artery stenosis: impact of therapy on long-term kidney function and blood pressure control.  J Urol. 1996;  155 1860-1864
    Search in Google Scholar
  • 49 Sawaya B, Provenzano R, Kupin W L, Venkat K K. Cyclosporine-induced renal macroangiopathy.  Am J Kidney Dis. 1988;  12 534-537
    Search in Google Scholar
  • 50 Scoble J E, Mikhail A, Reidy J, Cook G J. Individual kidney function in atherosclerotic renal-artery disease.  Nephrol Dial Transplant. 1998;  13 1048-1049
    Search in Google Scholar
  • 51 Seymour H R, Matson M B, Belli A M, Morgan R, Kyriou J, Patel U. Rotational digital subtraction angiography of the renal arteries: technique and evaluation in the study of native and transplant renal arteries.  Br J Radiol. 2001;  74 134-141
    Search in Google Scholar
  • 52 Sharafuddin M J, Stolpen A H, Dixon B S, Andresen K J, Sun S, Lawton W J. Value of MR angiography before percutaneous transluminal renal artery angioplasty and stent placement.  J Vasc Interv Radiol. 2002;  13 901-908
    Search in Google Scholar
  • 53 Sierre S D, Raynaud A C, Carreres T, Sapoval M R, Beyssen B M, Gaux J C. Treatment of recurrent transplant renal artery stenosis with metallic stents.  J Vasc Interv Radiol. 1998;  9 639-644
    Search in Google Scholar
  • 54 Sutherland R S, Spees E K, Jones J W, Fink D W. Renal artery stenosis after renal transplantation: the impact of the hypogastric artery anastomosis.  J Urol. 1993;  149 980-985
    Search in Google Scholar
  • 55 Tejani A. Post-transplant hypertension and hypertensive encephalopathy in renal allograft recipients.  Nephron. 1983;  34 73-78
    Search in Google Scholar
  • 56 van Jaarsveld B C, Krijnen P, Pieterman H. et al . The effect of balloon angioplasty on hypertension in atherosclerotic renal-artery stenosis. Dutch Renal Artery Stenosis Intervention Cooperative Study Group.  N Engl J Med. 2000;  342 1007-1014
    Search in Google Scholar
  • 57 Voiculescu A. Renovaskuläre Hypertonie nach Nierentransplantation. Aachen: Shaker Verlag In Sandmann W, Pfeiffer T, Grabensee B, Mödder U (Eds.). Renovaskuläre Erkrankungen, Vaskuläre Synoptische Konferenz 2003: 82-102
    Search in Google Scholar
  • 58 Voiculescu A, Hollenbeck M, Plum J. et al . Iliac artery stenosis proximal to a kidney transplant: clinical findings, duplex-sonographic criteria, treatment, and outcome.  Transplantation. 2003;  76 332-339
    Search in Google Scholar
  • 59 Washer G F, Schroter G P, Starzl T E, Weil R. Causes of death after kidney transplantation.  Jama. 1983;  250 49-54
    Search in Google Scholar
  • 60 Wong W, Fynn S P, Higgins R M. et al . Transplant renal artery stenosis in 77 patients - does it have an immunological cause?.  Transplantation. 1996;  61 215-219
    Search in Google Scholar

Dr. Adina Voiculescu

Klinik für Nephrologie und Rheumatologie, Heinrich-Heine-Universität

Moorenstraße 5

40225 Düsseldorf

Phone: 0211/8117726

Fax: 0211/8117722

Email: voicules@uni-duesseldorf.de