Fibromuscular dysplasia in living renal donors: Still a challenge to computed tomographic angiography

https://doi.org/10.1016/j.ejrad.2009.03.014Get rights and content

Abstract

Background

Computed tomographic angiography has become the standard evaluating method of potential living renal donors in most centers. Although incidence of fibromuscular dysplasia is low (3.5–6%), this pathology may be relevant for success of renal transplantation. The incidence of FMD in our population of LRD and reliability of CTA for detecting vascular pathology were the aims of this study.

Materials and methods

101 living renal donors, examined between 7/2004 and 9/2008 by CTA, were included in a retrospective evaluation. The examinations were carried out using a 64 Multi-detector CT (Siemens Medical Solutions, Erlangen). The presence or absence of the characteristic signs of fibromuscular dysplasia, as “string-of-beads” appearance, focal stenosis or aneurysms, were assessed and graded from mild (=1) to severe (=3). Furthermore, vascular anatomy and arterial stenosis were investigated in this study. Retrospective analysis of CTA and ultrasound were compared with operative and histological reports.

Results

Four cases of fibromuscular dysplasia (incidence 3.9%) in 101 renal donors were diagnosed by transplanting surgeons and histopathology, respectively. Three cases could be detected by CTA. In one donor even retrospective analysis of CTA was negative. Ten accessory arteries, 14 venous anomalies and 12 renal arteries stenosis due to atherosclerosis were diagnosed by CTA and could be confirmed by the operative report.

Conclusion

CTA is sufficient for detection of hemodynamic relevant stenosis and vascular anatomy. Only one patient with a mild form of FMD was under estimated. Therefore, if the CTA shows slightest irregularities which are not typical for atherosclerotic lesions, further diagnostic work up by DSA might still be necessary.

Introduction

The increasing use of living renal donors has stimulated interest in making the donor evaluation process easier and less invasive. Therefore, in most centers standard donor vascular examination using digital subtraction angiography (DSA) was replaced by computed tomographic angiography (CTA) or magnetic resonance angiography (MRA), respectively.

The results of current studies with Multi-detector-CT indicate the possibility to precisely delineate vascular and ureteric anatomy using a “one-stop-shopping” concept [1], [2], [3]. Due to a higher spatial resolution, CTA reached better sensitivity than MRA (97–100% versus 90–97%) in several studies [2], [4], [5], [6]. The focus of most studies has been on the accuracy of defining small accessory arteries or anatomic variations of renal veins. One-third of potential living renal donors (LRD) are supposed to demonstrate clinically important variations in their vascular anatomy [1], [2], [3], [4], [5], [6], [7], [8], [9].

Concerning donor safety, subtle renovascular diseases like fibromuscular dysplasia (FMD) have to be diagnosed with high accuracy as well. If one renal artery is affected only, a living renal transplantation may still be possible [10], [11].

FMD is an arterial developmental disease of unknown etiology, most often affecting the medium and large arteries and is known to be the second major cause of renovascular hypertension. Renal FMD represents a group of disorders characterized by fibrous or muscular hyperplasia in one or more layers of the renal arterial wall [12]. It may occur in 0.5–3.0% of the general population. Angiographic studies disclosed an incidence of FMD from 3.5 to 6% in LRD [13], [14], [15], [16].

The majority of lesions documented in hypertensive FMD patients are mid or distal main renal artery lesions. FMD is frequently found in young or middle-aged women. In two-third of symptomatic patients FMD is bilateral [17].

In cases of more severe renal artery dysplasia, i.e. proximal stenosis, aneurysmatic changes, or classic string-of-beads appearance, CTA and MRA may reveal the diagnosis [18], [19].

The incidence of FMD in our population of LRD was one aim of the following retrospective analysis. The presence or absence of the characteristic signs of FMD, as string-of-beads appearance, focal stenosis or aneurysms, were noted. To the best of our knowledge, the diagnostic performance of 64-Detector-Row-CT concerning this entity in LRD has not been investigated as yet. Because most centers replaced DSA by CTA, the reliability of CTA was the second aim of this study.

Section snippets

Materials and methods

Institutional review board approval was obtained, with waiver of informed consent. Between 07/2004 and 09/2008 we evaluated 134 LRD using a 64-Detector-Row-CT (Somatom Sensation Cardiac, Siemens Medical Solutions, Germany). Living kidney transplantation has been performed in 101 LRD, sixty female and 41 male LRD (56.3 ± 10.9 mean age) were included in our retrospective evaluation. In this 101 LRD, 67 left and 34 right kidneys have been explanted for living kidney transplantation.

All CT

Results

CTA disclosed three cases of FMD (sensitivity 75%, Fig. 1), two in the right and one in the left renal artery of the donors. In two cases characteristic signs of FMD with “string-of-beads” appearance and focal stenosis were noted in the middle segment of the renal arteries in both cases and additionally in the intrarenal segment in one case. The dysplastic artery wall changes were graded as severe (=3) for the middle part and mild (=1) for the intrarenal part in one of the cases. The findings

Discussion

In the literature discussion about kidney transplantation of LRD presenting with FMD is controversal. Little is known about the long-term follow-up of normal LRD discovered to have mild FMD at the time of donor evaluation. Cragg et al. [20] reported, that 8 of 30 patients (26.6%) who did not undergo nephrectomy, developed hypertension during 7.5 years of follow-up. 5 of 19 patients (26.3%) who did undergo donor nephrectomy displayed hypertension during 4.4 years. Andreoni et al. confirmed this

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