Normothermic and hypothermic oxygenated perfusion for donation after circulatory death in kidney transplantation: do we pay higher risk of severe infection after transplantation?: a case report.

BACKGROUND: Normothermic and hypothermic oxygenated perfusion for donation after circulatory death in kidney transplantation are becoming popular in Italy, with the purpose of reducing the risk of primary non function and delayed graft function due to the prolonged warm ischemia time. Potential complications related to these procedures are currently under investigation and are continuously emerging with the increasing experience. Post-operative infections - in particular graft arteritis - are a rare complication but determine high risk of mortality and of graft loss. The acute onset of the arterial complications makes it very difficult to find an effective treatment, and early diagnosis is crucial for saving both patient and graft. Prevention of such infections in this particular setting are advisable. CASE PRESENTATION: We present a patient with an acute arterial rupture after transplantation of a DCD graft treated in-vivo hypothermic oxygenated perfusion. The cause was a severe arteritis of the renal artery caused by Candida krusei and Pseudomonas aeruginosa. We discussed our treatment and we compared it to the other reported series. CONCLUSION: Fungal infections in DCD transplant may be treacherous and strategies to prevent them should be advocated.

Single Donor-Derived Pseudomonas aeruginosa Pseudoaneurysms in Two Kidney Transplant Recipients: A Case Report of Dichotomous Allograft Outcomes.

Infectious pseudoaneurysm (IPA) is a rare but devastating complication following renal transplantation that typically leads to graft loss and occasionally patient death. IPAs following kidney transplantation are most often mycotic in etiology, but have been sporadically reported to result from Pseudomonas aeruginosa infection. These IPAs occur at various anatomic sites, most commonly at the vascular anastomosis or iliac artery, and very rarely in the transplanted renal artery or hilum. Here we report the occurrence of single donor-derived P aeruginosa IPAs in two kidney transplant recipients with divergent allograft outcomes. Both recipients manifested Pseudomonas infections and early, hemodynamically relevant postoperative hemorrhage as a result of pseudoaneurysm rupture. One recipient required allograft nephrectomy during emergent operative exploration due to rupture of a pseudoaneurysm at the vascular anastomosis. Conversely, the other recipient's allograft was salvaged by endovascular stenting of a pseudoaneurysm unusually located in the main donor renal artery. To the best of our knowledge, this is the first case of a ruptured IPA occurring in the transplanted renal artery with successful allograft salvage via endovascular technique. In this report, we discuss details of the two cases, relevant literature, and possible clinical implications.

Fifty-one cases of fungal arteritis after kidney transplantation: A case report and review of the literature.

Fungal arteritis affecting graft arteries is a rare but life-threatening complication in kidney transplantation (KT). Here, we report the case of a patient with Aspergillus arteritis who experienced renal artery rupture 8 days after KT. We also reviewed 50 other reported cases of fungal arteritis after KT. We found that fungal contamination can occur during kidney graft harvest, preservation, and/or transplantation. Typically, early diagnosis, timely antifungal treatment, and emergency surgery seem crucial for avoiding life-threatening vascular complications.

Mycotic Pseudoaneurysm After Kidney Transplantation: Two Case Reports.

BACKGROUND: Vascular complications after kidney transplantation may cause allograft loss. Here, we describe 2 patients with extrarenal mycotic pseudoaneurysm after kidney transplantation. PATIENTS: Patient 1 was a 54-year-old man who developed pseudoaneurysm 60 days after transplantation, and patient 2 was a 48-year-old woman who was diagnosed with a pseudoaneurysm 5 months after transplantation. RESULTS: Patient 1 had a deceased-donor kidney transplant with end-to-side external iliac arterial anastomosis that was reconstructed 8 days after transplantation owing to rupture and major bleeding. At 60 days after transplantation, he had high serum creatinine level and Doppler ultrasonography showed a pseudoaneurysm of the arterial graft anastomosis and postanastomotic renal artery stenosis. Treatment included surgical excision of the pseudoaneurysm, vascular reconstruction, and fluconazole, with mycologic culture of the resected pseudoaneurysm showing Candida albicans. Patient 2 developed nondisabling intermittent claudication at 5 months after kidney transplantation, with a pseudoaneurysm subsequently observed on Doppler ultrasonography and computerized tomographic angiography. Treatment included renal artery thrombectomy and common iliac bypass to the hilar donor renal artery with inverted ipsilateral long saphenous vein. Operative samples showed C albicans, and she was treated with fluconazole. Both patients had satisfactory outcomes, and both kidney allografts were preserved. CONCLUSIONS: Extrarenal mycotic pseudoaneurysms after kidney transplantation require a high index of suspicion for early diagnosis, and preservation of the kidney graft may be achieved with the use of surgical treatment and antifungal therapy.

Contained rupture of a mycotic infrarenal aortic aneurysm infected with Campylobacter fetus.

Mycotic abdominal aortic aneurysms (MAAAs) are rare entities accounting for 0.65-2% of aortic aneurysms. Campylobacter fetus has a tropism for vascular tissue and is a rare cause of mycotic aneurysm. We present a 73-year-old male patient with contained rupture of a MAAA caused by C. fetus, successfully treated with endovascular aortic repair (EVAR) and antibiotics, which is not previously described for this aetiology. Although open surgery is the gold standard, EVAR is nowadays feasible and potentially represents a durable option, especially in frail patients.

Candida arteritis in kidney transplant recipients: case report and review of the literature.

Multi-organ procurement is a risk factor for contamination of preservation fluid with intestinal flora including fungi (e.g., Candida). Transmission of fungal species to the graft vessel can cause mycotic arteritis. This is a very rare but life-threatening complication of renal transplantation. We present 2 cases of renal transplant recipients from the same multi-organ donor. Both recipients suffered from severe hemorrhages from renal graft anastomosis and renal artery pseudoaneurysm due to Candida albicans arteritis (CAA). The culture of the preservation fluid revealed growth of Escherichia coli, but neither preservation fluid nor multiple routine blood cultures performed before hemorrhagic complications revealed fungal growth (media non-selective for fungal growth were applied). The first recipient suffered from sudden severe hemorrhage in the area of graft anastomosis on day 10 post surgery (without any preceding clinical or radiological symptoms). This led to urgent surgery and graftectomy, which was complicated by cardio-respiratory arrest with resuscitation in the operating room; despite resuscitation, irreversible brain damage, and subsequent death occurred in the intensive care unit (ICU) 2 weeks later (on day 24 after transplantation). The second patient underwent urgent vascular surgery on day 22 (after transplantation), because of hemorrhage from a pseudoaneurysm of the graft artery. She required repeated vascular operations, extended antimicrobial and antifungal therapy, and ICU monitoring and, despite these interventions, she died on day 80 after transplantation as a result of Pseudomonas aeruginosa sepsis. Arteritis of the renal artery in both patients was caused by C. albicans. This was confirmed by histopathology: infiltration of renal artery with budding yeast forming pseudohyphae (Case 1), and the presence of C. albicans in the culture of the renal artery and surrounding tissue (Case 2). We conclude that organ preservation solution should be cultured with use of media selective for fungal growth. As soon as the positive culture is detected, appropriate measures protecting patients against CAA should be undertaken.

Use of autogenous internal iliac artery for bridging the external iliac artery after excision of Aspergillus mycotic aneurysm in renal transplant recipients.

Repair of vascular defects in the presence of infection remains a challenging task in immunocompromised patients. We report two patients with postrenal transplant Aspergillus mycotic aneurysms of the allograft renal artery involving the external iliac artery which were excised along with the allograft. The defect in the external iliac artery was repaired successfully with interposition of autogenous internal iliac artery graft. Use of an internal iliac artery graft in such settings has been rarely reported in English literature. Autogenous internal iliac artery grafts provide a useful method to bridge the vascular defects created by radical debridement in the presence of fungal infections.

Anastomotic pseudoaneurysm complicating renal transplantation: treatment options.

INTRODUCTION: Anastomotic pseudoaneurysm following renal transplantation is uncommon. Indications for repair, treatment options and outcomes remain controversial. REPORT: We present 6 renal transplant recipients with large anastomotic pseudoaneurysms. Five of the patients underwent open repair while one had a stent-grafting and delayed transplant nephrectomy for a ruptured pseudoaneurysm. A transplant nephrectomy was needed in all cases but one. Arterial reconstruction enabled limb salvage in all cases. One patient died of sepsis postoperatively. No patient presented late infection, failure of vascular reconstruction, nor pseudoaneurysm recurrence. CONCLUSIONS: Surgical excision of anastomotic pseudoaneurysms results in high rates of allograft loss. Less invasive techniques have a place in selected cases.

Renal artery stent infection and pseudoaneurysm management.

BACKGROUND: Infection of a renal artery stent and pseudoaneurysm is extremely uncommon, with four reports in the literature. We present a fifth case and the complex management resulting in kidney salvage. METHODS AND RESULTS: A 56-year-old female underwent right renal artery stenting for hypertension. Postoperatively, she developed methicillin-resistant Staphylococcus infection, treated with antibiotics. Eight-month follow-up duplex ultrasound revealed a right renal artery pseudoaneurysm just distal to the stent. Computed tomography angiography (CTA) showed 2.8 cm proximal and 4.2 cm distal mycotic aneurysms. Antibiotics and planning angiogram were prescribed. A Chevron incision and duodenal kocherization were employed. The aorta below the superior mesenteric artery and below the renal vein was mobilized, as were the right renal artery and vein, hepatic artery, and saphenous vein. Following heparinization, the aorta was cross-clamped, as was the right renal artery at the hilum. The kidney was infused with cold saline. The renal artery stent was explanted, and aneurysmectomy was performed. The renal artery ostium was oversewn. A renal artery to hepatic artery saphenous vein bypass was fashioned, and patency was confirmed with intraoperative duplex ultrasound. Postoperatively, creatinine was normal, renal scan showed the right kidney to be functional, and duplex ultrasound showed a patent bypass graft. The patient was discharged on postoperative day 11 on long-term antibiotics. Eight-month follow-up duplex and CTA showed a patent bypass and durable repair. CONCLUSION: Renal artery stent infection with pseudoaneurysm is rare and can be diagnosed with duplex ultrasound. Renal salvage can be obtained but requires stent removal and autologous bypass grafting.

Tuberculosis of the renal artery: a rare cause of renovascular arterial hypertension.

Tuberculosis is an endemic disease in Morocco. Main blood vessels are rarely affected; the few mentioned cases are aneurysmal. We report a 17-year-old patient presenting with renovascular arterial hypertension, revealed thanks to the discovery of an occlusion of the right renal artery in Duplex scan. During the intervention, the observation of pararenal and mesenteric tuberculous polyadenopathy let us suggest the same kind of lesion at the level of the occluded renal artery. Once antituberculosis treatment had been carried out, the right renal artery was revascularized with a right iliorenal bypass using reversed internal saphenous vein. The postoperative course was uneventful, with an 18-month follow-up. Arterial pressure was normal without antihypertensive treatment, and the bypass was patent. As far as we know, this is the first case of renovascular arterial hypertension resulting from tuberculosis treated with an iliorenal bypass.

Aspergillus infection limited to the anastomosed artery following renal transplantation: a report of 4 cases.

We present 4 cases of Aspergillus fumigatus infection limited to the anastomosed artery following renal transplantation. All grafts were nephrectomized. Two patients received 2 weeks of itraconazole therapy; both showing recurrence of pseudoaneurysms following discontinuation of therapy. Another 2 patients received 3 months of itraconazole therapy without recurrence of pseudoaneurysms. Surgical interventions were life saving. Resection of infected tissues and 3 months of antifungal therapy seemed to give better results than shorter antifungal strategies.

Hepatic and renal artery rupture due to Aspergillus and Mucor mixed infection after combined liver and kidney transplantation: a case report.

Fungal infection is a major cause of death in patients who undergo organ transplantation. The incidence of Aspergillus or Mucor infection is low compared with Candida species. We report a case in which Aspergillus and Mucor infected both the hepatic and renal arteries, leading the 2 arteries to rupture at the same time. The patient died 4 days after the second operation. We review the recent literature about this topic and explore the possible route of transmission in our patient. We also discuss the prophylactic methods for Aspergillus and Mucor infections.

Rupture of renal artery aneurysm due to Salmonella infection in a patient with systemic lupus erythematosus.

Patients with systemic lupus erythematosus (SLE) are prone to infection. Immunomodulation treatment increases the susceptibility. Salmonella infections in SLE patients may present with various clinical pictures, like pneumonia, septic arthritis, osteomyelitis, peritonitis, abscess and so on. The vascular complications commonly seen in the general population with salmonella infection are rarely encountered in SLE patients. Here we report an SLE patient who presented with spontaneous rupture of salmonella mycotic aneurysm involving the left renal artery. The 54 year-old woman had a stable premorbid condition and had 30 mg prednisolone per day. Acute abdomen and hypotensive shock developed suddenly without warning signs in advance. Image and tissue culture confirmed the diagnosis. The patient had an uneventful recovery. The rare clinical scenario is reported.

[Native valve Aspergillus fumigatus endocarditis with blood culture positive and negative for galactomannan antigen. Case report and literature review]. / Endocarditis por Aspergillus fumigatus en válvula nativa con hemocultivo positivo y galactomanano negativo. Descripción de un caso y revisión de la literatura.

Native valve endocarditis caused by Aspergillus spp. is an uncommon disease with a high mortality rate. Generally, Aspergillus is isolated from affected valve in post-mortem or biopsy specimens. However, its isolation from blood cultures is exceedingly rare. We report a case of fungal endocarditis in a native mitral valve with the isolation of Aspergillus fumigatus both in valve vegetation and in blood culture bottles. The patient underwent valve replacement and antifungal treatment with voriconazole and caspofungin, but he died on post-operative day 45 with disseminated aspergillosis confirmed by necropsy. Paradoxically, galactomannan antigen detection in serum was negative. This is the third case of Aspergillus endocarditis with positive blood culture reported in the literature.

Candida albicans arteritis transmitted by conservative liquid after renal transplantation: a report of four cases and review of the literature.

BACKGROUND: Mycotic arteritis and/or aneurysms are infrequent complications of renal transplantation. They are mostly secondary to bacterial infection and rarely to Candida albicans. We report four cases of mycotic arteritis due to C. albicans after renal transplantation but which have been inoculated during organ harvesting or conservation. METHODS: In all the four cases corresponding to two independent donors, C. albicans was isolated few days later in the systematic culture of the conservative liquid. We also review the clinical features and outcomes of 13 cases previously reported in the literature. RESULTS: In two cases, the diagnosis of fungal arteritis was confirmed only during autopsy after the patient's death due to massive bleeding. In the other two cases, the diagnosis was made on the arterial section of the anastomotic wall after detransplantation for massive bleeding for arterial leakage although an immediate antifungal treatment with fluconazole and caspofungin was given and was found to be inefficient. CONCLUSION: This is a serious complication of renal transplantation because it leads to graft loss in the majority of the cases and even to death in a few cases despite an efficient and rapid treatment. Routine fungal cultures of preservation media are important for early diagnosis and timely surgical interventions are life-saving.

Mycotic aneurysm of the renal transplant artery.

A case of mycotic aneurysm secondary to septicemia is reported. A 59-year-old man with end-stage renal failure underwent renal transplantation from a living donor. On the fifteenth postoperative day, he was febrile and his arm around an entry wound of the drip infusion had infectious signs. Cultures of the blood and pus discharge grew Methicillin-resistant Staphylococcus aureus. Vancomycin was administered intravenously for 30 days. Then the existence of a mycotic aneurysm on the transplant artery was not suspected by computed tomography. After his infectious signs disappeared, examinations revealed a pseudoaneurysm measuring 4 cm in diameter at the site of anastomosis between the renal transplant and external iliac arteries by computed tomography. He has been carefully followed up with a conservative management. This is the first case of a mycotic aneurysm treated conservatively and displaying an uneventful course without rupture.

Infected aortic aneurysms: imaging findings.

PURPOSE: To determine the imaging characteristics of infected aortic aneurysms. MATERIALS AND METHODS: Review of records of patients with surgical and/or microbiologic proof of infected aortic aneurysm obtained over a 25-year period revealed 31 aneurysms in 29 patients. This study included 21 men and eight women (mean age, 70 years). One radiologist reviewed 28 computed tomographic (CT) studies (22 patients underwent CT once and three patients underwent CT twice), 12 arteriograms (12 patients underwent arteriography once), eight nuclear medicine studies (six patients underwent nuclear medicine imaging once and one patient underwent nuclear medicine imaging twice), and three magnetic resonance (MR) studies (three patients underwent MR imaging once). Features evaluated included aneurysm size, shape, and location; branch involvement; aortic wall calcification; gas; radiotracer uptake on nuclear medicine studies; and periaortic and associated findings. The location of infected aortic aneurysms was compared with that of arteriosclerotic aneurysms. RESULTS: Aneurysms were located in the ascending aorta (n = 2, 6%), descending thoracic aorta (n = 7, 23%), thoracoabdominal aorta (n = 6, 19%), paravisceral aorta (n = 2, 6%), juxtarenal aorta (n = 3, 10%), infrarenal aorta (n = 10, 32%), and renal artery (n = 1, 3%). Two patients had two infected aortic aneurysms. CT revealed 25 saccular (93%) and two fusiform (7%) aneurysms with a mean diameter at initial discovery of 5.4 cm (range, 1-11 cm). Paraaortic soft-tissue mass, stranding, and/or fluid was present in 13 (48%) of 27 aneurysms, and early periaortic edema with rapid aneurysm progression and development was present in three (100%) patients with sequential studies. Other findings included adjacent vertebral body destruction with psoas muscle abscess (n = 1, 4%), kidney infarct (n = 1, 4%), absence of calcification in the aortic wall (n = 2, 7%), and periaortic gas (n = 2, 7%). Angiography showed 13 saccular aneurysms with lobulated contour in 10 (77%). Nuclear medicine imaging showed increased activity consistent with infection in six (86%) of seven aneurysms. MR imaging showed three saccular aneurysms. Adjacent abnormal vertebral body marrow signal intensity was seen in one (33%) of three patients. CONCLUSION: Saccular aneurysms (especially those with lobulated contour) with rapid expansion or development and adjacent mass, stranding, and/or fluid in an unusual location are highly suspicious for an infected aneurysm.