Peripheral vascular disease and renal transplant artery stenosis: a reappraisal of transplant renovascular disease

Background: Renal transplant artery stenosis (RTAS) continues to be a probl ematic, but potentially correctable, cause of posttransplant hypertension a nd graft dysfunction. Older transplant recipients, prone to peripheral vasc ular disease (PVD), may have pseudoRTAS with PVD involving their iliac syst em. Methods: We retrospectively analyzed 819 patients who underwent kidney tran splantation between 1993 and 1997 to determine the contribution of pseudoRT AS to renal transplant renovascular disease. Univariate analyses were perfo rmed for donor and recipient variables, including age, weight, gender, race , renal disease, cholesterol and creatinine values, human leukocyte antigen (HLA) matching, cytomegalovirus (CMV) infection, and immunosuppressive med ications. Significant variables were then analyzed by a Cox proportional ha zards model. Results: Ninety-two patients (11.2%) underwent renal transplant arteriogram (Agram) or magnetic resonance angiography (MRA) for suspected RTAS. RTAS o r pseudoRTAS, defined as one or more hemodynamically significant lesions in the transplant artery or iliac system, was evident in 44 patients (5.4%). Variables significantly associated with RTAS by univariate analysis were we ight at the time of transplant (p = 0.0258), male gender (p = 0.034), disch arge serum creatinine > 2 mg/dL (p = 0.0041), and donor age (p = 0.0062). V ariables significantly associated with pseudoRTAS by univariate analysis we re weight at the time of transplant (p = 0.0285), recipient age (p = 0.0049 ), insulin-dependent diabetes mellitus (IDDM; p = 0.0042), panel reactive a ntibody (PRA) at transplant (p = 0.018), and body mass index (p = 0.04). We ight at transplant and donor age remained significantly associated with an increased risk for RTAS in a multivariate stepwise Cox proportional hazards model. IDDM, transplant PRA, weight at transplant, and donor age were sign ificantly associated with an increased risk for pseudoRTAS in a multivariat e stepwise Cox proportional hazards model. Importantly, both RTAS and pseud oRTAS were associated with poorer graft survival (p < 0.007 for each). Conclusions: Renal transplant renovascular disease encompasses pre-existing PVD acting as pseudoRTAS, as well as classical RTAS. Efforts to identify a nd correct renal transplant renovascular disease of either nature are impor tant, given its negative impact on graft survival.