Letters to the Editor – Brief Case Reports
Iliac artery obliteration as a cause of renovascular hypertension in kidney graft recipients: A difficult and uncommon diagnosis
Obliteración de la arteria ilíaca como causa de hipertensión renovascular en el paciente trasplantado renal, un diagnóstico difícil y poco frecuente
Ana Patricia González-Cáceres, Ioana Bancu
, Francisco Javier Juega-Mariño, Laura Cañas-Solé, Josep Bonet, Ricardo Lauzurica
Corresponding author
Servicio de Nefrología, Hospital Universitario Germans Trias i Pujol, Universidad Autónoma de Barcelona, Badalona, Barcelona, Spain
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class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 2 => array:2 [ "nombre" => "Francisco Javier" "apellidos" => "Juega-Mariño" ] 3 => array:2 [ "nombre" => "Laura" "apellidos" => "Cañas-Solé" ] 4 => array:2 [ "nombre" => "Josep" "apellidos" => "Bonet" ] 5 => array:2 [ "nombre" => "Ricardo" "apellidos" => "Lauzurica" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Nefrología, Hospital Universitario Germans Trias i Pujol, Universidad Autónoma de Barcelona, Badalona, Barcelona, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Obliteración de la arteria ilíaca como causa de hipertensión renovascular en el paciente trasplantado renal, un diagnóstico difícil y poco frecuente" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1360 "Ancho" => 1626 "Tamanyo" => 182300 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Obliteration of the distal portion of the left common iliac artery.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Our patient is a 70-year-old woman with chronic kidney disease secondary to polycystic kidney disease. She began haemodialysis in 1995 and received the first deceased-donor kidney transplant (DDKT) in 1997; the graft was lost 15 days later due to acute rejection, followed by removal of the graft. In 2004, a second DDKT was performed, and a kidney graft was implanted in the left iliac fossa with end-to-side anastomosis of the external iliac artery with the renal artery; as induction immunosuppressive therapy, she received sequential quadruple therapy with basiliximab, prednisone, mycophenolate mofetil and tacrolimus. The patient became stabilised with creatinine levels of 2<span class="elsevierStyleHsp" style=""></span>mg/dL. Her medical history also included type 2 diabetes mellitus, moderate-severe mitral insufficiency and severe peripheral arterial disease with bilateral femoropopliteal obliteration diagnosed in 2007.</p><p id="par0010" class="elsevierStylePara elsevierViewall">After kidney transplantation, blood pressure was controlled with an α-blocker until 5 months prior to the current episode, when she presented at office visits with poor blood pressure (BP) control of 190/90<span class="elsevierStyleHsp" style=""></span>mmHg, Ambulatory blood pressure monitoring (ABPM) showed a mean 24<span class="elsevierStyleHsp" style=""></span>h BP of 166/89<span class="elsevierStyleHsp" style=""></span>mmHg and a riser pattern despite treatment with 3 drugs (α-blocker, ß-blocker and diuretic). Treatment with angiotensin-converting enzyme (ACE) inhibitors was initiated, and 2 weeks later renal function decreased with creatinine levels of 3.2<span class="elsevierStyleHsp" style=""></span>mg/dl; this drug was withdrawn and renal function improved.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The patient reported symptoms that had been progressing over a week period, including progressive dyspnoea, oedema and a weight gain of 5<span class="elsevierStyleHsp" style=""></span>kg. Upon hospitalisation, she presented a BP of 180/90<span class="elsevierStyleHsp" style=""></span>mmHg. Physical examination detected bibasilar crackles, systolic murmur in the mitral area, absence of bilateral dorsalis pedis pulses, pitting oedema and murmur in the right groin. The workup upon admittance showed serum creatinine 3.1<span class="elsevierStyleHsp" style=""></span>mg/dL; chest X ray presented signs of heart failure.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The oriented diagnosis was biventricular heart failure in the context of a hypertensive crisis, and treatment was initiated with nitro-glycerine and endovenous furosemide, which resulted in improvement of both BP and heart failure. Afterwards, oral antihypertensive treatment was renewed and ACE inhibitors were initiated. 24<span class="elsevierStyleHsp" style=""></span>h after having begun treatment with ACE inhibitors, the patient presented oliguria and a serum creatinine of 3.9<span class="elsevierStyleHsp" style=""></span>mg/dL. Once again, the signs of heart failure worsened, which required the initiation of ultrafiltration. Doppler ultrasound of the kidney graft demonstrated that size and corticomedullary differentiation were preserved; the intra-arterial flow had flat waves and a resistance index (RI) of more than 0.54, while main renal artery velocities were within normal ranges.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Despite the fact that Doppler ultrasound, repeated on 2 occasions, did not suggest stenosis of the renal artery, we decided to perform an angiography. The study detected obliteration of the distal portion of the left common iliac artery (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), with permeability of the rest of the iliac axis and of the artery of the renal graft. After pre-dilatation, a stent was inserted in the area of the obliteration, with almost complete recovery of the vascular calibre (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Immediately after, the patient presented polyuria of 6<span class="elsevierStyleHsp" style=""></span>L in 24<span class="elsevierStyleHsp" style=""></span>h and excellent BP control. Moreover, 24<span class="elsevierStyleHsp" style=""></span>h later, renal function had improved (creatinine 2.5<span class="elsevierStyleHsp" style=""></span>mg/dL), so no further ultrafiltration sessions were necessary. At the follow-up visit one-month later, the patient was normotensive with 3 drugs (α-blocker, ß-blocker and diuretic) and renal function had improved, with serum creatinine levels of 1.85<span class="elsevierStyleHsp" style=""></span>mg/dL.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Discussion: As the age and survival of kidney transplant recipients increase, atherosclerotic disease, which is the Achilles heel of renal disease, is more prevalent and severer among our patients.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Renovascular hypertension especially affects patients with previous vascular disease. Clinical manifestations usually include difficult-to-treat hypertension and deterioration of renal function due to the hypoperfusion and activation of the renin–angiotensin system. Secondarily, patients may present water retention, oliguria and episodes of heart failure.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">In the literature, there are numerous cases of renal artery stenosis described in transplanted patients, but there have been only scarce reports of iliac artery stenosis<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1–4</span></a> as a cause of renovascular hypertension.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Both renal artery stenosis of transplanted kidneys as well as the stenosis of the iliac arteries are potentially reversible entities and have good therapeutic results with percutaneous angioplasty.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">5,6</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">With the case that we have presented, our intention is to call the attention of the need to assess the permeability of the pre-transplantation aorto-iliac axis. Furthermore, although stenosis of the iliac artery is an uncommon cause that is undetectable with Doppler ultrasound, when there is high clinical suspicion it should be ruled out as it is a reversible cause of hypertension and kidney function decline in transplanted patients.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: González-Cáceres AP, Bancu I, Juega-Mariño JF, Cañas-Solé L, Bonet J, Lauzurica R. Obliteración de la arteria ilíaca como causa de hipertensión renovascular en el paciente trasplantado renal, un diagnóstico difícil y poco frecuente. Nefrologia. 2015;35:413–414.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1360 "Ancho" => 1626 "Tamanyo" => 182300 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Obliteration of the distal portion of the left common iliac artery.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1366 "Ancho" => 1626 "Tamanyo" => 170046 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Recuperation of the vascular calibre after stent placement.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0035" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Renal artery stenosis due to fibromuscular dysplasia in a transplanted kidney from a deceased donor: a difficult diagnosis at color Doppler ultrasonography" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 6 | 9 | 15 |
| 2024 October | 60 | 42 | 102 |
| 2024 September | 65 | 26 | 91 |
| 2024 August | 80 | 66 | 146 |
| 2024 July | 48 | 44 | 92 |
| 2024 June | 74 | 49 | 123 |
| 2024 May | 103 | 32 | 135 |
| 2024 April | 75 | 33 | 108 |
| 2024 March | 51 | 24 | 75 |
| 2024 February | 46 | 34 | 80 |
| 2024 January | 36 | 33 | 69 |
| 2023 December | 37 | 20 | 57 |
| 2023 November | 101 | 28 | 129 |
| 2023 October | 60 | 41 | 101 |
| 2023 September | 46 | 26 | 72 |
| 2023 August | 47 | 25 | 72 |
| 2023 July | 61 | 22 | 83 |
| 2023 June | 70 | 18 | 88 |
| 2023 May | 78 | 35 | 113 |
| 2023 April | 53 | 14 | 67 |
| 2023 March | 44 | 22 | 66 |
| 2023 February | 44 | 23 | 67 |
| 2023 January | 49 | 16 | 65 |
| 2022 December | 65 | 26 | 91 |
| 2022 November | 53 | 30 | 83 |
| 2022 October | 65 | 40 | 105 |
| 2022 September | 40 | 31 | 71 |
| 2022 August | 58 | 42 | 100 |
| 2022 July | 51 | 49 | 100 |
| 2022 June | 52 | 22 | 74 |
| 2022 May | 54 | 27 | 81 |
| 2022 April | 68 | 47 | 115 |
| 2022 March | 50 | 42 | 92 |
| 2022 February | 48 | 35 | 83 |
| 2022 January | 64 | 30 | 94 |
| 2021 December | 76 | 33 | 109 |
| 2021 November | 69 | 35 | 104 |
| 2021 October | 59 | 49 | 108 |
| 2021 September | 31 | 32 | 63 |
| 2021 August | 36 | 41 | 77 |
| 2021 July | 91 | 36 | 127 |
| 2021 June | 37 | 24 | 61 |
| 2021 May | 48 | 31 | 79 |
| 2021 April | 109 | 44 | 153 |
| 2021 March | 61 | 33 | 94 |
| 2021 February | 42 | 24 | 66 |
| 2021 January | 60 | 12 | 72 |
| 2020 December | 32 | 15 | 47 |
| 2020 November | 37 | 19 | 56 |
| 2020 October | 31 | 18 | 49 |
| 2020 September | 31 | 13 | 44 |
| 2020 August | 47 | 10 | 57 |
| 2020 July | 51 | 12 | 63 |
| 2020 June | 42 | 13 | 55 |
| 2020 May | 49 | 8 | 57 |
| 2020 April | 36 | 17 | 53 |
| 2020 March | 36 | 12 | 48 |
| 2020 February | 41 | 33 | 74 |
| 2020 January | 49 | 22 | 71 |
| 2019 December | 71 | 29 | 100 |
| 2019 November | 45 | 24 | 69 |
| 2019 October | 46 | 13 | 59 |
| 2019 September | 30 | 21 | 51 |
| 2019 August | 28 | 16 | 44 |
| 2019 July | 22 | 28 | 50 |
| 2019 June | 33 | 18 | 51 |
| 2019 May | 34 | 22 | 56 |
| 2019 April | 61 | 50 | 111 |
| 2019 March | 31 | 17 | 48 |
| 2019 February | 24 | 16 | 40 |
| 2019 January | 33 | 12 | 45 |
| 2018 December | 114 | 40 | 154 |
| 2018 November | 151 | 25 | 176 |
| 2018 October | 144 | 19 | 163 |
| 2018 September | 102 | 12 | 114 |
| 2018 August | 73 | 11 | 84 |
| 2018 July | 63 | 9 | 72 |
| 2018 June | 54 | 11 | 65 |
| 2018 May | 44 | 11 | 55 |
| 2018 April | 76 | 9 | 85 |
| 2018 March | 33 | 7 | 40 |
| 2018 February | 62 | 9 | 71 |
| 2018 January | 41 | 6 | 47 |
| 2017 December | 63 | 8 | 71 |
| 2017 November | 48 | 9 | 57 |
| 2017 October | 30 | 11 | 41 |
| 2017 September | 32 | 8 | 40 |
| 2017 August | 34 | 6 | 40 |
| 2017 July | 44 | 7 | 51 |
| 2017 June | 56 | 11 | 67 |
| 2017 May | 77 | 13 | 90 |
| 2017 April | 45 | 14 | 59 |
| 2017 March | 35 | 10 | 45 |
| 2017 February | 52 | 9 | 61 |
| 2017 January | 33 | 14 | 47 |
| 2016 December | 69 | 18 | 87 |
| 2016 November | 73 | 22 | 95 |
| 2016 October | 102 | 10 | 112 |
| 2016 September | 133 | 2 | 135 |
| 2016 August | 149 | 3 | 152 |
| 2016 July | 172 | 9 | 181 |
| 2016 June | 121 | 0 | 121 |
| 2016 May | 132 | 0 | 132 |
| 2016 April | 126 | 0 | 126 |
| 2016 March | 81 | 0 | 81 |
| 2016 February | 92 | 0 | 92 |
| 2016 January | 74 | 0 | 74 |
| 2015 December | 114 | 0 | 114 |
| 2015 November | 70 | 0 | 70 |
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