Available online 22 October 2023, 100925

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Renal transplantation is the most commonly performed solid-organ allograft surgery; in 2021, 25487 kidneys were transplanted in the United States, and nearly 42,000 adult patients were listed for transplant. As the treatment of choice for patients with end-stage renal disease, transplantation is performed at more than 250 centers. Despite a high rate of success, renal transplantation is not without complication, and the interventional radiologist plays a crucial role in the management of the post-operative patient. Knowledge of post-surgical anatomy, imaging findings, and technical challenges unique to these patients is important for the safe and effective treatment of transplant-related conditions. We offer a guide to the most common interventions in the renal transplant population, including biopsy, vascular interventions, and the management of urinary obstruction.

Section snippetsTransplant Biopsy

Percutaneous biopsy is the most commonly performed procedure in the renal transplant population. Nearly all transplant patients will undergo graft biopsy at some point in time, as tissue sampling guides treatment decisions. The safe performance of successful percutaneous biopsy is a crucial skill for the interventional radiologist.

Many patients who present for biopsy – whether of the native kidney or the transplant graft – do so with hypertension, and careful attention to blood pressure

Vascular Interventions

Maintaining adequate blood flow to the renal transplant is essential for preserving graft function. Vascular complications involving the renal graft include renal artery stenosis (RAS), arterial pseudoaneurysm, and renal vein thrombosis. At the time of consultation, the transplant team is typically aware of the diagnosis and further workup is usually unnecessary. Familiarity with typical clinical scenarios, however, will aid in proper management.

Renal Artery Stenosis (RAS)

The incidence of RAS in the transplant kidney ranges from 4-8% in larger studies7,8. RAS can present months to years after transplantation9 and is associated with decreased graft and patient survival9,10. Clinical findings associated with RAS are nonspecific, but the patient may be asymptomatic or present with poorly controlled hypertension and/or graft dysfunction. Color Doppler imaging can demonstrate elevated velocities, usually at the level of anastomosis, but these studies can be

Pseudoaneurysm

Renal transplant artery pseudoaneurysm is a rare postoperative complication that typically occurs due to a defect at the anastomosis between the transplant renal artery and the recipient's external iliac artery. Pseudoaneurysms affecting renal transplants can be associated with adjacent infection and can result in hemorrhage, graft dysfunction, and even graft loss. While surgeons may opt to repair the vascular defect operatively, endovascular stent graft may be the only viable option in certain

Transplant Ureteral Interventions

Stricture is the most common ureteral complication after renal transplantation, with a reported incidence of 2-10%13. These occur most commonly in the distal transplant ureter14 and usually result from a combination of ischemia, inflammation, and infection. Surgical trauma to the distal ureteral blood supply during organ harvest, prolonged cold ischemia time (>435 min), the presence of multiple small allograft arteries, complex arterial reconstructions, and advanced donor age can increase the

Summary

Interventional radiology plays a pivotal role in the care of post-renal transplant patients, offering a wide range of diagnostic and therapeutic procedures to manage graft-related complications and ensure optimal outcomes. By utilizing minimally invasive techniques and advanced imaging guidance, interventional radiologists provide essential services in the areas of vascular interventions, urinary tract interventions, and diagnostic evaluations.

The future of interventional radiology holds great

References (22)FP Hurst et al.Incidence, predictors and outcomes of transplant renal artery stenosis after kidney transplantation: analysis of USRDS

Am J Nephrol

(2009)

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