Iliac vein stenosis as a reversible cause of renal transplant dysfunction

A 47-year-old female received a well-matched cadaveric renal transplant for treatment of end-stage renal failure secondary to type 1 diabetes. The kidney had three arteries on a patch with a single vein and was anastamosed end to side onto the corresponding right external iliac vessels. The iliac vessels were normal at the time of surgery. The post-operative period was complicated by bleeding around the transplant and formation of a peri-transplant collection which required repeated surgical drainage. During the first 4 weeks, she had delayed graft function and was dialysed via an internal jugular line. She did not have any femoral venous access inserted. A transplant biopsy on day 23 showed acute tubular necrosis and mild tubulitis, suggestive of rejection, and she was treated with methylprednisolone. By day 36 post-transplant, she was noted to have a swollen right leg. A leg venogam excluded thrombosis but revealed a tight right iliac vein stenosis (Figure 1a) for which she underwent a successful venoplasty with good radiological resolution (Figure 1b). Her urine output started to improve, and by day 41 she was dialysis independent with a falling creatinine. Her creatinine stabilized at 140–150 mmol/l but 72 days posttransplant, her creatinine started to rise in association with swelling of her leg. On day 81 post-transplant (creatinine 194 mmol/l), she underwent a further successful venoplasty. One year post-transplant, the patient remains well with a creatinine of 128 mmol/l and no swelling of her leg. Discussion