To the Renal Transplant/Nephrological Specialists on RG
Our renal transplant programme here is Sydney Australia is faced with an unusual problem which we have not encountered before.
We have a female recipient aged 54 years of a blood group incompatible live donor renal allograft (transplanted in April 2014), who required a prolonged course of blood filtering via columns post transplantation due to persistingly high Ab levlels to the donor blood group. This was associated with two confimred epsisodes of Ab mediated rejection. Ultimately a splenectomy was performed mid June of this year in order to help alleviate the situation.
Now she has represented with what appeared to be a long segment stenosis of the mid aspect of the transplant ureter this last week. A ureteric stent was inserted via cystoscopy and the renal allograft function has stabilised. What is now apparent on CT scan imaging is that there is marked dystrophic calcification of the renal pelvis as well as the transplant ureter (such that the ureter has the appearances of a calcified blood vessel).
Any suggestions on how best to manage this patient now?
Well, nephrectomy is one solution, but I'm not sure it has come to that yet. We have had two approaches to refractory strictures that are not, perhaps, among the mainstream. We had a series of subcutaneous nephrocystic bypass grafts using a device called Detour from Coloplast, Inc. Denmark. We reported our series with some patients deriving many years of complication free function following this relatively easy procedure (attached). Unfortunately, I do not know if the Detour is still on the market. We have recently started using a covered metal stent which is akin to the one used for biliary strictures. Our radiologists place these and they are very resilient, well tolerated, and, most importantly, removable should the need arise.
There is mural calcification but is there an actual ureteric stricture as demonstrated by either contrast studies or functional radionuclide studies?
If so, I would attempt a stricture dilatation with a period of stenting in the first instance. If, however, re-stricturing or encrustations were to be bothersome, I would consider using a metallic ureteric stent such as the Memokath.
Thanks Deepak, the postscript for this case is that ultimately the patient lost their graft from ongoing Ab mediated rejection and the graft was removed surgically.
- Pity that the graft is lost. I hope she is on the pathway for a fresh transplant.
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