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Abstract: TH-PO869

Case of Kidney Allograft Failure: A Pandora Box

Session Information

Category: Transplantation

  • 2102 Transplantation: Clinical


  • Sankar, Lakshna, Geisinger Health, Danville, Pennsylvania, United States
  • Sanghi, Pooja, Geisinger Health, Danville, Pennsylvania, United States

Post kidney transplant acute kidney injury could be due to drug toxicity, recurrence of primary disease, transplant rejection and vascular complications.

Case Description

43 year old male with end stage kidney disease secondary to IgA nephropathy status post living related kidney transplant from an outside hospital in 2011, presented with shortness of breath of 1 week duration. He was on mycophenolate mofetil 500 twice daily and tacrolimus 3 mg twice daily. On clinical examination, he appeared hypervolemic. Review of labs showed elevated creatinine of 21.4 mg/dl (baseline 1.8 mg/dl) and was started on hemodialysis. Serology, infectious work up and echocardiogram were unremarkable. Tacrolimus level was supratherapeutic at 11 ng/ml. A doppler ultrasound showed large parenchymal arteriovenous fistula (AVF) in the midpole (Figure 1A). He underwent transplant arteriogram and was successfully embolized (Figure 1B). Subsequently, allograft biopsy showed recurrence of Ig A nephropathy, acute T-cell mediated rejection Banff criteria grade 1A, interstitial fibrosis and tubular atrophy of 70%, features suggestive of chronic thrombotic microangiopathy and glomerular sclerosis favoring chronic calcineurin inhibitor toxicity (Figure 2 A-C). Given the severity of scarring in the kidney, we did not treat him for rejection, as the adverse effects outweighed the benefits.


Incidence of AVF in kidney allograft ranges from 0.5-16.9%; they can be traumatic (after biopsy), congenital or from the donor kidney. Our patient never had a biopsy since his transplant. Thus it is possible that this was donor derived. He was asymptomatic all these years till the AVF was diagnosed in his allograft and endovascularly ligated. Kidney biopsy revealed a myriad of other etiologies that ultimately lead to his graft failure. This case brings on a better insight to causes of allograft failure highlighting the gargantuan effort in evaluation and management of complications in a transplanted kidney.