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Clinical Considerations1

  • Renal artery thrombosis, renal artery stenosis, and renal vein thrombosis are serious complications, requiring prompt diagnosis and management.

  • Uncommon but can lead to graft loss.

  • Vascular thrombosis presentation: Sudden anuria or oliguria, tenderness, swelling, ipsilateral extremity edema.

  • Ultrasound with Doppler is the initial study of choice.

  • Ultrasound findings: Edematous and enlarged kidney, decreased echogenicity, altered parenchymal architecture.

  • Doppler findings: Peaked systolic signals with retrograde signal on diastole and absent venous signal.

Major Clinical Thrombophilic Risk Factors

  • History of ≥2 arteriovenous access thromboses

  • Prior allograft thrombosis

  • Multiple miscarriages (in the setting of antiphospholipid syndrome and hereditary thrombophilia)

  • Prior deep vein thrombosis (DVT) or pulmonary embolism (PE)

  • Collagen vascular diseases

  • Diabetic nephropathy

  • Positive family history of thrombosis

Additional Clinical Risk Factors

  • Estrogen replacement

  • Malignancy

  • Age over 40 years

  • Obesity

  • Nephrotic syndrome

  • Chronic tobacco use

  • Hepatitis C virus

Mechanical Risk Factors2

  • Arterial diameter size (differs with body size)

  • Multiple renal arteries

  • Stenosis of the donor renal artery

  • Atherosclerosis in donor or recipient

  • Surgical trauma

  • Acute rejection

  • Prolonged cold ischemia time with reperfusion damage

Pharmacologic Risk Factors

  • Erythropoietin can increase thrombosis risk

  • Calcineurin inhibitors like cyclosporine A (CSA) and tacrolimus (FK-506) increase thrombophilia

  • CSA can increase factor VIII and tissue factor (TF), in addition to reducing protein C

  • Antithymocyte globulins (ATGs) can cause platelet activation, thrombosis, and thrombocytopenia

Types of Hereditary and Acquired Thrombophilia

  • Activated protein C (APC) resistance (factor V Leiden [FVL])

  • Prothrombin gene mutation

  • Decreased Proteins C and S and antithrombin III (ATIII) deficiency

  • Lipoprotein(a)

  • Antiphospholipid syndrome (APLS): Elevation of Beta 2 glycoprotein 1 (B2GP1), and/or anticardiolipin (ACL), and/or lupus anticoagulant positivity.

  • Heparin-induced thrombocytopenia (HIT)

Reported Effects of Hereditary and Acquired Thrombophilia

  • FVL:

    • 3 X increased risk of DVT

    • 3.3 X increased risk of graft loss when compared to those without FVL

  • Prothrombin gene mutation

    • 3.1× increased risk of DVT

    • 7.4× increased risk of graft loss

  • Protein S deficiency is associated with renal graft loss and arterial and venous thromboses.

  • Hyperhomocysteinemia increases the occurrence of coronary artery disease threefold if levels of homocysteine surpass 30 μmol/L. It may increase the occurrence of DVT, but increase in graft loss has not been reported.

  • APLS: Up to 19% serology positive prevalence in chronic renal failure (CRF).

  • APLS in combination with hepatitis C virus (HCV) infection with high titers exceeding 40 IgG phospholipid units (GPL) has been found to increase incidence of graft loss and DVT.

  • Risk is enhanced in patients with a prior history of thrombosis.

Incidence of Posttransplant Thrombosis3

  • Renal transplant is associated with an 8% risk of DVT/PE within the ...

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