Kidney Week

Abstract: SA-PO1206

Occult Aortoiliac Occlusion Masquerading as Resistant Post-Transplant Hypertension

Session Information

• Transplantation: Clinical - Complications, Pediatrics, and Multi-Organ Considerations
  October 24, 2026 | Location: Exhibit Hall A, Convention Center
  Abstract Time: 10:00 AM - 12:00 PM

Category: Transplantation

• 2002 Transplantation: Clinical

Authors

• Hubbi, Hassan, University of Central Florida, Orlando, Florida, United States

Hassan Hubbi, MD

• Chaccour, Maha, University of Central Florida, Orlando, Florida, United States

Maha Chaccour, MD

• Cail, Garrett Matthew, University of Central Florida, Orlando, Florida, United States

Garrett Matthew Cail, DO

• Asmar, Abdo, University of Central Florida, Orlando, Florida, United States

Abdo Asmar, MD, FASN

• Sanchez Russo, Luis F., Advent Health Transplant Institute, Orlando, Florida, United States

Luis F. Sanchez Russo, MD, MS

Introduction

Renal Artery stenosis (RAS) in kidney transplant recipients is most commonly sought at the transplant anastomosis. However, proximal vascular disease, including aortoiliac occlusion, can produce a similar hemodynamic profile and may be overlooked when conventional duplex ultrasound (DU) of the transplant vasculature demonstrates patency. We present a case of aortoiliac occlusion in a kidney transplant recipient manifesting as resistant hypertension (HTN) with a normal DU, unmasked when initiation of RAAS blockade precipitated hemodynamic collapse with severe anuric acute kidney injury.

Case Description

A 71-year-old woman with a history of kidney transplantation (2014) and diabetes millitus type 2 presented with hypertensive urgency despite being on multiple blood pressure (BP) medications. Secondary HTN workup revealed Renin 24.6 ng/mL/hr, aldosterone 51.9 ng/Dl, consistent with a high-renin state. Transplant renal artery DU demonstrated patent vasculature with normal resistive indices, and no anastomotic stenosis was identified. Her BP remained uncontrolled despite escalation to a six-drug antihypertensive regimen. Following up titration of Olmesartan, the patient developed acute anuria lasting 48 hours. Creatinine rose from 1.7 to 4.02 mg/dL. Repeat transplant DU remained unremarkable. Kidney biopsy demonstrated acute tubular necrosis. Dialysis was initiated. Clinical suspicion for renovascular disease remained a concern prompting magnetic resonance angiography of abdomen and pelvis, which revealed complete occlusion of the distal aorta and proximal iliac arteries. Following revascularization surgery, urine output recovered promptly, dialysis was discontinued, and creatinine improved to 0.9 mg/dL at six months. Anti hypertensive therapy was de-escalated to two agents.

Discussion

This case highlights a critical diagnostic blind spot: transplant renal artery DU does not interrogate the proximal inflow vasculature. Aortoiliac occlusion reduces perfusion pressure to both the transplant and native kidneys, generating a high-renin state that mimics transplant RAS. Persistently elevated plasma renin activity should be recognized as a biomarker of inflow-dependent perfusion in this setting. When clinical suspicion for proximal disease exists, cross-sectional imaging is essential as standard transplant surveillance does not assess the iliac or aortic vasculature.