Abstract: PO2168
Pickering Syndrome in a Kidney Transplant Recipient
Session Information
- Transplantation: Clinical - Underrecognized Risk Factors, Traditional Considerations, and Outcomes
November 04, 2021 | Location: On-Demand, Virtual Only
Abstract Time: 10:00 AM - 12:00 PM
Category: Transplantation
- 1902 Transplantation: Clinical
Authors
- Tabbara, Jad, Cleveland Clinic, Cleveland, Ohio, United States
- Hassanein, Mohamed, Cleveland Clinic, Cleveland, Ohio, United States
- Aleter, Omar A., Cleveland Clinic, Cleveland, Ohio, United States
- Augustine, Joshua J., Cleveland Clinic, Cleveland, Ohio, United States
Introduction
Pickering syndrome (PS) refers to hypertensive urgency with recurrent flash pulmonary edema (FPE) due to bilateral renal artery stenosis (RAS) or unilateral RAS in patients with a solitary kidney or kidney allograft. We report a case of PS in a kidney transplant recipient.
Case Description
A 68-year-old gentleman with a history of end-stage kidney disease secondary to diabetic nephropathy treated with deceased donor kidney transplantation (on Belatacept, Mycophenolate Mofetil, and Prednisone) and a history of recurrent admissions for FPE presented 3-months post kidney transplantation with hypertensive urgency, acute kidney injury (AKI) and FPE. Blood pressure was 170/85 mmHg and serum creatinine was 2.5 mg/dL (baseline 1.8 mg/dL). Echocardiogram showed preserved left ventricular function. Kidney transplant ultrasonography (US) showed patent vasculature with no hydronephrosis. Kidney biopsy showed no evidence of acute rejection. Duplex ultrasound showed a high proximal peak systolic velocity (PSV) 622 cm/sec and a low renal arterial resistive index (RI = 0.55) with severe (60-99%) transplant RAS. An intravascular-ultrasound (IVUS) guided stent placement facilitated safe renal artery revascularization using only 2 mL of contrast agent subsequently leading to a complete resolution of AKI and no further episodes of FPE.
Discussion
Transplant RAS causes 1-5% of post-transplant hypertension, and usually occurs within the first 6 months post-transplantation. Activation of the renin-angiotensin-aldosterone system leads to worsening hypertension, allograft dysfunction and fluid retention with FPE. Although duplex US is used for screening, angiography with simultaneous percutaneous angioplasty is often needed for definitive diagnosis and treatment. IVUS guided stenting is beneficial in patients with AKI to minimize contrast exposure and further worsening of graft function. Early diagnosis and prompt treatment of PS are the key to minimize morbidity and mortality in these patients.