RENAL TRANSPLANT FAILURE IN THE CONTEXT OF BK NEPHROPATHY AND HIGH-OUTPUT CARDIAC FAILURE

G MYLONAS 2,3, M TUNBRIDGE 1,3, M WOLLEY 2,3

1Royal Adelaide Hospital, Adelaide, Australia, 2Royal Brisbane and Women’s Hospital, Brisbane, Australia, 3University of Queensland, Brisbane, Australia

Background: Idiopathic pelvic arteriovenous malformations (AVMs) are a rare cause of cardiac failure, and this is the first case report in a kidney transplant recipient.

Case report: A 61-year-old female was transferred for management of a fungating squamous cell carcinoma (SCC), with end-stage kidney disease from reflux nephropathy and kidney transplantation in 2011.

On admission the patient was hypotensive at 85/50 mmHg  with atrial fibrillation (AF). She had a left brachiocephalic fistula, and bilateral masses in iliac fossae .

Serum creatinine increased from 74 – 98 µmol/L indicating transplant kidney injury. Management of AF was complicated by hypotension, despite rate control. She had hyperdynamic circulatory state with ejection fraction 79%. Kidney function worsened, with BK viremia  (105 copies/mL). Transplant kidney ultrasound was unremarkable, but doppler revealed a large AVM in the left iliac fossa.

Transplant biopsy suggested polyomavirus nephropathy with 2% SV40 tubular reactivity, mild focal tubulitis and cytoplasmic vacuolation, but minimal interstitial inflammation. She was treated with leflunomide while reducing mycophenolate and tacrolimus. Renal decline necessitated haemodialysis, complicated by intradialytic hypotension and difficult ultrafiltration.

Angiography showed a large, left pelvic sidewall AVM with numerous feeding arteries, and single outflow vein to a large varix feeding into the left internal iliac vein. The patient underwent embolization of the malformation with improvement in blood pressure, suggesting high-output cardiac failure in context of shunting from an upper limb arteriovenous fistula and visceral AVM.

Conclusions: The patient’s clinical status improved allowing surgical management of the SCC, while urine production improved enough to facilitate twice-weekly haemodialysis. Renal patients with arteriovenous fistulae are at high risk of cardiac failure from idiopathic AVMs, and endovascular intervention is a useful therapeutic approach.

 


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