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PURPOSE: To describe a single-center experience with robotic-assisted endovascular treatment for transplant renal artery stenosis. MATERIALS AND METHODS: This is a single-center, retrospective, feasibility study of 4 consecutive cases of robotic-assisted endovascular surgery for transplant renal artery stenosis from October 2021 to August 2022. RESULTS: All lesions were identified, and stenting was performed with no complications. Conversion to manual control was not necessary. The mean fluoroscopy time was 25.25 min (range 12-60.9). A control Doppler ultrasound was routinely performed, demonstrating no residual lesions in all cases. There was no reintervention during the follow-up period. The operator learning curve was felt to be acceptable. CONCLUSION: Robotic-assisted endovascular treatment is a feasible technique for transplant renal artery stenosis.

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BACKGROUND: This study evaluated the long-term effects of percutaneous intervention in children and adolescents with transplant renal artery stenosis (TRAS). METHODS: Twenty patients had significant stenosis (>50%) and underwent percutaneous transluminal angioplasty (PTA/stenting) (TRAS group-intervention); 14 TNS (non-significant group -control) patients did not have significant stenosis (≤50%) and were treated clinically. The combined primary endpoints were death from all causes and late graft failure. The secondary endpoints were serum creatinine (SCr), systolic blood pressure (SBP), and diastolic blood pressure (DBP). RESULTS: No statistically significant difference was found between TRAS-Intervention(N = 20) and TNS groups-Control (N = 14) for these clinical parameters: deaths, 1 (5.0%) vs. 0 (0.0%) (p = 1.000) and graft loss, 4 (20.0%) vs. 2 (14.3%) (p = 1.000). For the secondary endpoints, after 1 month and 1 year the values of SCr, SBP, and DBP were similar between the two groups but not statistically significant. DISCUSSION: In the TRAS group (intervention), the stent implantation was beneficial for treating refractory hypertension and reducing blood pressure (BP) in children and adolescents. Despite the outcomes being similar in the two groups, it can be inferred that the patients in the TRAS group (intervention) would have had a worse outcome without the percutaneous intervention. CONCLUSION: TRAS treatment with stenting can be considered for children and adolescents. Because the sample in the present study comprised of only a specific population, further studies are needed for generalization. TRIAL REGISTRATION: The trial was registered at clinictrials.gov with trial registration number NCT04225338.

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An 18-year-old man with past medical history of secondary arterial hypertension diagnosed at age 15 presented with an abdominal magnetic resonance imaging (MRI) that exhibited left renal artery stenosis.

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BACKGROUND: Transplant Renal Artery Stenosis (TRAS) is a recognized vascular complication after kidney transplantation. The overall risk predictors of TRAS are poorly understood. METHODS: Retrospective analysis of patients with suspected TRAS (Doppler ultrasound PSV > 200 cm/s) who underwent angiographic study in a single center between 2007 and 2014. All patients with stenosis > 50% were considered with TRAS. Stenosis restricted in the body of the artery was also analyzed in a subgroup. RESULTS: 274 patients were submitted to a renal angiography and 166 confirmed TRAS. TRAS group featured an older population (46.3 ± 11.0 vs. 40.9 ±14.2 years; p = 0.001), more frequent hypertensive nephropathy (30.1% vs. 15.7%; p = 0.01), higher incidence of Delayed Graft Function (DGF) (52.0% vs. 25.6%; p < 0.001) and longer Cold Ischemia Time (CIT) (21.5 ± 10.6 vs. 15.7 ± 12.9h; p < 0.001). In multivariable analyses, DGF (OR = 3.31; 95% CI 1.78‒6.30; p < 0.0001) was independent risk factors for TRAS. DM and CIT showed a tendency towards TRAS. The compound discriminatory capacity of the multivariable model (AUC = 0.775; 95% CI 0.718‒0.831) is significantly higher than systolic blood pressure and creatinine alone (AUC = 0.62; 95% CI 0.558-0.661). In body artery stenosis subgroup, DGF (OR = 1.86; 95% CI 1.04‒3.36; p = 0.03) and Diabetes Mellitus (DM) (OR = 2.44; 95% CI 1.31‒4.60; p = 0.005) were independent risk factors for TRAS. CONCLUSION: In our transplant population, DGF increased more than 3-fold the risk of TRAS. In the subgroup analysis, both DGF and DM increases the risk of body artery stenosis. The addition of other factors to hypertension and renal dysfunction may increase diagnostic accuracy. TRAS TRIAL REGISTRED: clinicaltrials.gov (n° NCT04225338).

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Spontaneous renal artery dissection is an unusual and idiopathic condition in most cases. In young, mildly symptomatic patients, diagnosis may be difficult, frequently culminating in delay in treatment. This report presents the case of a 40-year-old male patient, with severe hypertension of sudden onset, and difficult management of oral medication. In etiological investigation, Echo-Doppler of renal arteries showed signs of hemodynamically relevant right renal artery stenosis. Arteriography showed presence of double-lumen and thrombus in the vessel lumen, indicating dissection. The proposed treatment was endovascular approach after failure of isolated medical treatment, option which included the aspiration of the thrombus by Penumbra System® device and balloon angioplasty, followed by right renal artery stenting. Improvement of immediate sonographic control of peak systolic velocity and renal-aortic ratio was shown, with a consequent reduction of systemic arterial blood pressure and stabilization of renal function. Within the following year, the patient presented in-stent stenosis and was successfully treated with balloon angioplasty.

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BACKGROUND: Calorie restriction (CR) is a type of dietary intervention that is essential in weight loss through modulation of critical metabolic control pathways, is well established and understood in cases of systemic arterial hypertension, however, its role in renovascular hypertension is still unclear. METHODS: Rats were divided into three groups: SHAM, and two groups that underwent surgery to clip the left renal artery and induce renovascular hypertension (OH and OHR). The SHAM diet was as follows: 14 weeks normolipidic diet; OH: 2 weeks normolipidic diet + 12 weeks hyperlipidic diet, both ad libitum; OHR, 2 weeks normolipidic diet + 8 weeks ad libitum high-fat diet + 4 weeks 40% calorie-restricted high-fat diet. RESULTS: Rats in the OHR group had decreased blood pressure, body weight, and glucose levels. Reductions in insulinemia and in lipid and islet fibrotic areas in the OHR group were observed, along with increased insulin sensitivity and normalization of insulin-degrading enzyme levels. The expression of nicotinamide phosphoribosyltransferase (NAMPT), insulin receptor (IR), sirtuin 1 (SIRT1), and complex II proteins were increased in the liver tissue of the OHR group. Strong correlations, whether positive or negative, were evaluated via Spearman's model between SIRT1, AMPK, NAMPT, PGC-1α, and NNMT expressions with the restoration of normal blood pressure, weight loss, glycemic and lipid panel, and mitochondrial adaptation. CONCLUSION: CR provided short-term beneficial effects to recover the physiological parameters induced by a high-fat diet and renal artery stenosis in obese and hypertensive animals. These benefits, even in the short term, can provide physiological benefits in the long term.

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BACKGROUND: Transplant renal artery stenosis (TRAS) is the main vascular complication of kidney transplantation. For research and treatment purposes, several authors consider critical renal artery stenosis to be greater than 50%, and percutaneous intervention is indicated in this scenario. However, there are no reports in the current literature on the evolution of patients with less than 50% stenosis. METHOD: This retrospective study included data from all patients who underwent kidney transplantation and were suspected of having TRAS after transplantation with stenosis under 50% independent of age and were referred for angiography at a single centre between January 2007 and December 2014. RESULTS: During this period, 6,829 kidney transplants were performed at Hospital do Rim, 313 of whom had a clinical suspicion of TRAS, and 54 of whom presented no significant stenosis. The average age was 35.93 years old, the predominant sex was male, and most individuals (94.4%) underwent dialysis before transplantation. In most cases in this group, transplants occurred from a deceased donor (66.7%). The time between transplantation and angiography was less than one year in 79.6% of patients, and all presented nonsignificant TRAS. Creatinine levels, systolic blood pressure, diastolic blood pressure and glomerular filtration rate improved over the long term. The outcomes found were death and allograft loss. CONCLUSION: Age, sex and ethnic group of patients were factors that did not interfere with the frequency of renal artery stenosis. The outcomes showed that in the long term, most patients evolve well and have improved quality of life and kidney function, although there are cases of death and kidney loss.

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OBJECTIVE: Endovascular treatment through either percutaneous transluminal angioplasty (PTA) alone or stenting has been previously used as a treatment for transplant renal artery stenosis (TRAS). This review aimed to investigate the results of endovascular treatment for renal artery stenosis in transplanted kidneys as compared with the outcomes of interventions, medical management, and graft survival in non-TRAS patients. METHODS: A systematic review of PubMed, Google Scholar, Cochrane, and Scopus was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines in which studies that reported outcomes of the treatment of TRAS via the endoluminal approach were identified, and their results were meta-analyzed. RESULTS: Fifty-four studies with a total of 1522 patients were included. A significant reduction of serum creatinine level was found, favoring the stenting group, with a mean difference of 0.68 mg/dL (95% confidence interval (CI), 0.17-1.19; Z=2.60, p=0.0009). Comparison of pre- and post-intervention values of any intervention revealed a significant decrease in overall serum creatinine level (0.65 mg/dL; 95% CI, 0.40-0.90; Z=5.09, p=0.00001), overall blood pressure, with a mean difference of 11.12 mmHg (95% CI, 7.29-14.95; Z=5.59, p=0.00001), mean difference in the use of medications (0.77; 95% CI, 0.29-1.24; p=0.002), and peak systolic velocity (190.05; 95% CI, 128.41-251.69; p<0.00001). The comparison of serum creatinine level between endovascular interventions and best medical therapy favored endovascular intervention, with a mean difference of 0.23 mg/dL (95% CI, 0.14-0.32; Z=5.07, p<0.00001). Graft survival was similar between the treated patients and those without TRAS (hazard ratio, 0.98; 95% CI, 0.75-1.28; p=0.091). The overall pooled success rate was 89%, and the overall complication rate was 10.4%, with the most prevalent complication being arterial dissection. CONCLUSION: The endovascular treatment of TRAS improves graft preservation and renal function and hemodynamic parameters. PTA + stenting appears to be a more effective option to PTA alone in the stabilization of renal function, with additional benefits from decreased restenosis rates. Further high-quality studies could expand on these findings.

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Renovascular hypertension (RVH) is defined as an elevated blood pressure caused by kidney hypoperfusion, generally as a result of anatomic stenosis of the renal artery with consequent activation of the Renin Angiotensin-Aldosterone System. The main causes include genetic and inflammatory disorders, extrinsic compression, and idiopathic alterations. RVH is often asymptomatic and should be suspected in any child with refractory hypertension, especially if other suggestive findings are present, including those with severe hypertension, abdominal bruit, and abrupt fall of glomerular filtration rate after administration of angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers. There is a consensus that digital subtraction angiography is the gold standard method for the diagnosis of RVH. Nevertheless, the role of non-invasive imaging studies such as Doppler ultrasound, magnetic resonance angiography, or computed tomographic angiography remains controversial, especially due to limited pediatric evidence. The therapeutic approach should be individualized, and management options include non-surgical pharmacological therapy and revascularization with percutaneous transluminal renal angioplasty (PTRA) or surgery. The prognosis is related to the procedure performed, and PTRA has a higher restenosis rate compared to surgery, although a decreased risk of complications. This review summarizes the causes, physiopathology, diagnosis, treatment, and prognosis of RVH in pediatric patients. Further studies are required to define the best approach for RVH in children.

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Abstract Renal transplant remains the preferred therapy for end-stage renal disease (ESRD). Given the shortage of suitable donor kidneys, use of an expanded criteria donor (ECD) allows marginal kidneys to be transplanted; albeit at risk of increased graft failure due to lower nephron mass. To reduce the risk of graft failure, double kidney transplant (DKT) is advocated, with favorable outcomes. Transplant renal artery stenosis (TRAS) is one of the most common vascular complications following renal transplant. Unlike single kidney transplants, where TRAS usually presents with fluid overload, uncontrolled hypertension, and worsening kidney functions; it may be clinically silent in DKT patients since they have two functional transplanted kidneys. We hereby report a case of TRAS in a DKT patient who had 2 years of favorable clinical outcomes following successful endovascular stenting. He however recently died of COVID-19 associated pneumonitis.

Resumo O transplante renal continua sendo a terapia preferida para doenças renais em fase terminal. Dada a escassez de rins de doadores adequados, o doador com critérios expandidos permite que rins marginais sejam transplantados, embora haja um maior risco de falha do enxerto devido à diminuição da massa nefrótica. Para diminuir o risco de falha do enxerto, recomenda-se o transplante renal duplo (TRD), com resultados favoráveis. A estenose de artéria renal transplantada (EART) é uma das complicações vasculares mais comuns após o transplante renal. Ao contrário dos transplantes de rim simples, nos quais a EART geralmente se manifesta como sobrecarga de fluido, hipertensão descontrolada e piora das funções renais, ela pode ser clinicamente silenciosa em pacientes com TRD, pois eles têm dois rins funcionais transplantados. Relatamos aqui um caso de EART em um paciente com TRD que teve resultados clínicos favoráveis por dois anos após o sucesso do implante de stent endovascular. No entanto, ele morreu recentemente de pneumonite associada à covid-19.

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