Case Report: A Kidney Transplant with Unique Challenges : Why So “Access”ious?

Abstract

This case report highlights the challenges encountered in a kidney transplant recipient with poor vascular access, ABO incompatibility, and a tendency for thrombosis. It outlines the implications for dialysis management, post-operative care, and the strategies used to address these complications.

Introduction

Kidney transplantation is a well-established treatment for end-stage renal disease, improving both survival and quality of life. However, vascular access poses a significant challenge, especially for patients who require haemodialysis before or after transplantation. This report discusses a patient who underwent a kidney transplant and experienced substantial vascular access issues.

 The Case:

# Clinical Presentation and Evaluation:

1. The patient had a long history of hypertension and renal stone disease, ultimately progressing to end-stage renal disease. He had been on haemodialysis for two years before the transplant. Additionally, he had an HCV infection, successfully treated with antiviral therapy. He opted for an ABO-incompatible renal transplant with his wife as the donor. His baseline Anti-B titre was 1:64 (Table 1).

2. Initial Vascular Access: 

The patient had an indwelling tunnelled cuffed catheter placed in the left femoral vein due to thrombosis of bilateral jugular, subclavian, right femoral, and iliac veins. The transplant anastomosis was planned with the left external iliac artery and vein, as the right iliac vessels were thrombosed. Since this was the planned site for the donor kidney, the left indwelling catheter had to be removed. Notably, the patient had previously undergone bilateral AV fistula surgeries, both of which were non-functioning.

3. Thrombotic Tendency: 

Genetic testing revealed a Factor V mutation and hyperhomo-cysteinemia, contributing to a heightened risk of thrombosis. Anticoagulation was initiated under the guidance of a haematologist.

4. ABO Incompatibility and Immunosuppression: 

The patient received Rituximab 500 mg 14 days before the transplant, followed by four cycles of plasma exchange to reduce ABO titres to acceptable levels (Table 1). Standard triple-drug immunosuppression began seven days before the surgery, with r-ATG used as an induction agent during the procedure.

Management of Poor Vascular Access

A multidisciplinary team managed the patient's vascular access challenges. A CT angiogram revealed thrombosed veins in both the neck, and the right external iliac, common iliac, and femoral veins. A vascular surgeon and interventional radiologist were consulted, and a temporary 24 cm triple-lumen dialysis catheter was inserted under real-time angio guidance from the right external iliac vein to the obturator vein and inferior vena cava. Dialysis was closely monitored, and the patient and family were informed about the risks of thrombosis in the newly placed vascular access or renal graft vessels. Lifelong oral anticoagulant therapy was recommended.

Post-Transplant Course

The transplant was performed in the left iliac fossa due to vascular complications. Anticoagulation was started post-operatively due to the patient's thrombotic risk. On Day 0, the patient developed hypotension and decreased urine output, requiring inotropic support. Continuous Renal Replacement Therapy (CRRT) was initiated due to acidosis and anuria. On Day 2, the patient developed a hematoma in the left iliac fossa, which was surgically drained on Day 4, necessitating the discontinuation of anticoagulation due to bleeding. By Day 8, the patient achieved hemodynamic stability, and inotropic support was discontinued. The patient underwent three sessions of haemodialysis due to delayed graft function. Urine output began to improve on Day 10 and continued to recover.

Outcome

The patient was successfully discharged on Day 18 with all catheters removed and a serum creatinine level of 2.67. At follow-up, the graft function continued to improve, with a serum creatinine level of 1.05, and the patient remained in stable condition.

Discussion

This case underscores the complexities of managing vascular access in kidney transplant recipients, particularly in patients with a propensity for thrombosis. It highlights the importance of early intervention and collaboration between nephrologists, surgeons, and dialysis teams to secure vascular access and ensure a positive transplant outcome.

Conclusion

Vascular access difficulties can significantly complicate post-operative care in kidney transplant recipients. Prompt evaluation, patient education, and a collaborative approach are crucial to optimising patient outcomes and ensuring the longevity of the transplanted kidney.