in adult renal transplant recipient, the graft vein was anastomosed to the recipient external iliac vein. many factors contribute thrombosis: recombanc postoperative ? ABMR & VASCULITIS SURGICAL ANASTOMOSIS

1. 200707683
Case No. 1
A 34 year old male patient.
C.R.F. was maintained on C.H.D.
The donor was his brother , Same blood group.
HLA & DR mismatch
PRA : class I= 4% (DNS) class II= zero%
Renal transplant 19th Jan., 2008
50%

2. Operative details
Artery internal iliac artery
Vein external iliac vein
Ischemia time : 45 minutes
Immediate duiresis &

3. Smooth immediate postoperative course
Maintained on steroid , CSA, AZA
S.Cr. On discharge : 1.1mg/dl

4. One month Post transplantation
• oliguria
• ↑ S.cr.1.1 →3.2 mg/dl
Clinical picture:
Differential
diagnosis:
?rejection
?Obstruction
?Vascular occlusion

5. Graft Doppler & U.S.
Patchy perfusion Absent diastolic flow
Basal
On day of event

6. BiopsyBiopsy
Picture of Acute Humoral Rejection
Focal +ve C4d StainingATN like picture

7. Marked right Lower limb oedema.
Doppler US
Sluggish flow in the deep venous system
Next Day:

8. MRA
Thrombosed graft vein.
Thrombosed RT external iliac vein.
Patent IVC Patent graft artery
Thrombosed RT common femoral vein.

9. OPTIONS FOR TREATMENT:
Local injection of streptokinase
Exploration & thrombectomy
Graft nephrectomy
GRAFT VEIN THROMBOSIS
Systemic injection of streptokinase
Combined local & systemic injection of streptokinase

16. Follow up MRA

17. Angiography was done
Local injection of streptokinase 750 000 IU
Systemic injection of Streptokinase 100 000IU/hr
LMWH Plus oral anti-coagulant
LMWH stopped when target INR 2-3 achieved
GRAFT VEIN THROMBOSIS

18. CurrentlyCurrently
Recovered graft functionRecovered graft function::
S. cr = 0.8 mg/dlS. cr = 0.8 mg/dl
UU.O.P = 5 L/day.O.P = 5 L/day
Patient under treatment of CMV
disease

20. Graft vein thrombosis
RVT has incidence of 0.55:3.4%
One third of early allograft losses.
One case reported just compression
of the vein due to abnormal position of
the graft
(Nephron 1996;73:480-481)

21. diagnosis time management reference
Renal vein
compression
3rd
day Exploration&
nephropexy
Nephron
1996
Partial
thrombosis
of graft vein
11months Selective intra-
arterial
administration
of
streptokinase
Nephrol
Dial
Transplant
1998
Renal vein
thrombosis
8th
day Exploration&
thrombectomy
Nephrol
Dial
Transplant
2006

22. •Number of transplanted cases : 1969
•2003:
one case suffered from both graft artery &
vein thrombosis managed by nephrectomy
•2008
One case of graft vein thrombosis managed by
local & systemic injection of streptokinase

23. Conclusion:
Close follow up
Early detection & diagnosis
Perfect intervention & cooperation
Recent advances in treatment of
vascular rejection
=Good outcome