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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Dear Editor&#58;</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">Renal transplant &#40;RT&#41; patients have a higher incidence of thrombotic events and an increased risk of recurrence after the withdrawal of anticoagulation&#46; Thrombosis of the allograft vein is a well-described complication of renal transplantation&#46; It can occur early after transplant&#44; related to surgical technical complications or many years post-transplant associated to multiple inciting factors&#46; The treatment includes surgery&#44; thrombolytics and anticoagulation&#46;</p><p class="elsevierStylePara">We present two cases of late allograft venous thrombosis with different treatments and outcome&#58; conventional hipocoagulation leaded to renal failure but surgical thrombectomy allowed&#160;patient improvement and renal function recovery&#46;&#160;Based on&#160;the cases&#44; a review of the literature about pathophysiology&#44; clinical presentation&#44; diagnosis and treatment options of late venous thrombosis of renal allograft was made&#46;</p><p class="elsevierStylePara">RT patients have a higher incidence &#40;ranging 0&#46;6-25&#37;&#41; of thrombotic events<span class="elsevierStyleSup">1&#44;2</span>&#46; Thrombosis of the allograft vein is a well-described early complication<span class="elsevierStyleSup">3</span>&#44; usually associated with acute rejection or surgical complications<span class="elsevierStyleSup">4</span>&#46; The typical presentation is that of a sudden painful and swollen allograft&#44; haematuria and oliguria with deterioration of graft function<span class="elsevierStyleSup">4&#44;5</span>&#46; Partial vein thrombosis presents as a late event&#44; with chronic oedema and progressive deterioration of renal function<span class="elsevierStyleSup">6</span>&#46;</p><p class="elsevierStylePara">Diagnosis can be made by Doppler ultrasound&#44; computed tomography &#40;CT&#41; or magnetic resonance venogram<span class="elsevierStyleSup">7</span> and the treatment includes surgery&#44; thrombolytics and anticoagulants<span class="elsevierStyleSup">7</span>&#46;&#160;</p><p class="elsevierStylePara">The authors present two cases of late allograft venous thrombosis with different treatments and outcome&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">CLINICAL CASES</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Case 1</span></p><p class="elsevierStylePara">A 63-year-old man&#44; with chronic renal failure &#40;CRF&#41; secondary to adult polycystic kidney disease &#40;APKD&#41;&#44; was submitted to RT in 1988 and treated with cyclosporine &#40;CsA&#41;&#44; azathioprine &#40;AZA&#41; and prednisolone &#40;P&#41;&#46; Nineteen years after RT&#44; serum creatinine &#40;Cr&#41; increased to 2&#46;5 mg&#47;dl and nephrotic proteinuria was documented&#46; In 2007&#44; chronic allograft nephropathy &#40;CAN&#41; was confirmed&#46; One year latter&#44; a rectal adenoma was diagnosed and after four months &#40;on March 2009&#41;&#44; he had acute diverticulitis complicated by peritonitis and needed surgery&#46;</p><p class="elsevierStylePara">On July 2009&#44; he was admitted with painful oedema of the right leg with one week of evolution&#46; Doppler&#160; revealed femoral vein thrombosis and partial thrombosis of allograft vein&#44; iliac and inferior vena cava &#40;IVC&#41;&#46; Renal function had declined &#40;Cr&#58; 5&#46;84 mg&#47;dl&#41; and serum albumin was reduced &#40;2&#46;68 g&#47;dL&#41;&#46; Pulmonary embolism was excluded and anticoagulation with low molecular weight heparin &#40;LMWH&#41; was started&#44; followed by accenocumarol&#46; Renal function deteriorated and one week latter he started haemodialysis&#46; The study for other neoplasms was negative&#46; Three months latter&#44; he is asymptomatic but remains on haemodialysis&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Case 2</span></p><p class="elsevierStylePara">A 58-year-old man&#44; with CRF secondary to APKD&#44; was submitted to RT in 1993&#46; He was treated with CsA&#44; AZA and P and renal function stabilized on Cr&#58; 1&#46;8 mg&#47;dl&#44; without proteinuria&#46; Posttransplant erytrocytosis was documented in 1996 and treated with phlebotomies&#46;</p><p class="elsevierStylePara">On May 2009&#44; he was admitted with thrombosis of right popliteal vein&#46; He had erytrocytosis &#40;Hb&#58; 18&#46;3g&#47;dL&#41; and deterioration of renal function &#40;Cr&#58; 2&#46;2 mg&#47;dl&#41;&#46; Anticoagulant treatment was maintained for 6 weeks&#44; with improvement&#46;</p><p class="elsevierStylePara">Three months latter&#44; he was readmitted with oedema of right leg with two days of evolution&#46; He maintained erytrocytosis &#40;Hb&#58; 16&#46;9 g&#47;dL&#41; and allograft dysfunction &#40;Cr&#58; 2&#46;02 mg&#47;dl&#41;&#46; Imagiological studies revealed thrombosis of femoral vein with extension to allograft and iliac veins&#44; without involvement of IVC &#40;figure 1&#41;&#46; No neoplasic disease was found&#46;</p><p class="elsevierStylePara">He was treated with heparin without improvement&#44; and started haemodialysis on the 3<span class="elsevierStyleSup">rd</span> day&#46; Surgical thrombectomy was preformed and&#44; one week latter&#44; renal function recovered &#40;to Cr&#58; 1&#46;8 mg&#47;dl&#41;&#46; He was discharged under oral anticoagulation and two months latter&#44; he is asymptomatic with stable renal function &#40;Cr&#58; 1&#46;79 mg&#47;dl&#41;&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">DISCUSSION </span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">Early allograft venous thrombosis accounts for one third of all graft losses within the first three postttransplant months<span class="elsevierStyleSup">5</span>&#46; Thrombosis occuring several months after RT is rare<span class="elsevierStyleSup">8</span> and is associated to inciting factors<span class="elsevierStyleSup">5&#44;7</span>&#46; RT patients have persistent hypercoagulable state that may play a role in latter thrombotic events &#40;TE&#41;<span class="elsevierStyleSup">2</span>&#46; Clotting activation is&#160;multifactorial&#44; with classic risk factors associated to specific ones related to RT<span class="elsevierStyleSup">1-4</span>&#46;</p><p class="elsevierStylePara">Allograft vein thrombosis is more frequent with some therapies&#44; particularly with OKT3 and high doses of steroids<span class="elsevierStyleSup">4&#44;9</span>&#46; CsA role remains controversial<span class="elsevierStyleSup">5&#44;9</span>&#46; Our patients were treated with low doses of immunosuppression and is unlikely that therapy alone caused thrombosis&#46;</p><p class="elsevierStylePara">Recurrent or <span class="elsevierStyleItalic">de novo</span> glomerulonephritis with proteinuria superior to 2 g&#47;day<span class="elsevierStyleSup">10</span> &#40;even without nephrotic syndrome&#41; generates hypercoagulable states<span class="elsevierStyleSup">1&#44;4&#44;7</span> and neoplasms increase the risk of thromboembolism by nearly five times in RT patients<span class="elsevierStyleSup">7</span>&#46;</p><p class="elsevierStylePara">Late renal vein thrombosis &#40;RVT&#41; was described following surgery&#44; related to immobilization or hypovolemia&#44; and&#160; associated with compression of the allograft vein<span class="elsevierStyleSup">4&#44;8</span>&#46; The first patient had nephrotic proteinuria&#44; a neoplasic lesion and was recovering from surgery with prolonged immobilization&#46; Either polycystic kidneys or adhesions could compress allograft vein and act as predisposing factors&#46;</p><p class="elsevierStylePara">Posttransplant erythrocytosis affects 10-15&#37; of RT recipients<span class="elsevierStyleSup">11</span> and was pointed as the inciting factor&#160;for thrombosis<span class="elsevierStyleSup">2&#44;5</span> in the second patient&#46;</p><p class="elsevierStylePara">Few weeks after the first episode&#44; we confirmed recurrence of venous thrombosis with extension to allograft vein&#46; After anticoagulants withdrawal&#44; the risk of TE recurrence is near 48&#37; in RT recipients<span class="elsevierStyleSup">3</span>&#44; which is 10 times higher than in normal population<span class="elsevierStyleSup">2&#44;3</span>&#46;</p><p class="elsevierStylePara">The treatment of RVT includes anticoagulants&#44; thrombolytics and thrombectomy&#46; Most cases of early post-surgical RVT are treated with thrombectomy&#44; but in the late posttransplant it has low success rate<span class="elsevierStyleSup">12</span>&#46; Some authors advice surgical thrombectomy only when a surgical cause is identified and there aren&#8217;t adhesions that make surgery unsafe<span class="elsevierStyleSup">7</span>&#46; The first 10-14 posttransplant days are considered the timing for an open approach&#46; Beyond that time&#44; a percutaneous approach is recommended<span class="elsevierStyleSup">7</span>&#46;</p><p class="elsevierStylePara">Mechanical thrombectomy can lead to pulmonary embolism &#40;PE&#41;<span class="elsevierStyleSup">13</span>&#44; specially if the thrombus has extension to the IVC&#44; as in our case 1&#46;</p><p class="elsevierStylePara">Alternative treatments for late RVT include anticoagulation with heparin&#47;LMWH or drug-induced thrombolysis<span class="elsevierStyleSup">7</span>&#46; Thrombolytic agents have proved better results&#44; with complete lysis in 40-60&#37; of patients&#44; compared to 10&#37; of those treated with heparin<span class="elsevierStyleSup">14</span>&#46;</p><p class="elsevierStylePara">Thrombolytics are more efficient when thrombi are less than 5 days-old<span class="elsevierStyleSup">15</span>&#44; but the most effective agent and the optimal duration of treatment remain uncertain<span class="elsevierStyleSup">7</span>&#46;</p><p class="elsevierStylePara">A combined approach of percutaneous mechanical and chemical thrombectomy has been used<span class="elsevierStyleSup">7&#44;13</span>&#46; It is advocated in RVT beyond the second week posttransplantation or when prolonged thrombolysis is contraindicated<span class="elsevierStyleSup">7&#44;13</span>&#46;</p><p class="elsevierStylePara">In our first case&#44; post-peritonitis adhesions made surgical approach difficult&#44; the organized thrombus reduced thrombolysis efficacy and the high probability of irreversible damage &#40;in a graft with CAN&#41; contributed to the decision for a conservative treatment&#46; In our second patient&#44; thrombectomy was really efficient&#44; allowing&#160;allograft recovery&#46;</p><p class="elsevierStylePara">In conclusion&#44; renal vein thrombosis in late pos-transplant period is not an indication to graftectomy neither a definitive evidence of graft failure&#46; Therapies such as thrombolysis or thrombectomy must be considered&#44; as they may allow better outcomes&#46;</p><p class="elsevierStylePara"><a href="grande&#47;10641&#95;108&#95;8966&#95;en&#95;10641&#95;f1&#46;jpg" class="elsevierStyleCrossRefs"><img src="10641_108_8966_en_10641_f1.jpg" alt="Thrombosis of renal graft vein&#46;"></img></a></p><p class="elsevierStylePara">Figure 1&#46; Thrombosis of renal graft vein&#46;</p>"
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