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Diagnosis: Vascular rejection in the ureter (chronic and acute)

Urological complications are the most common surgical problems after renal transplantation. In large series, the complication rates vary from 5.3 to 19% (Dreikorn K. Problems with the distal ureter. Urol Int. 1992;49(2):76-89 [PubMed link]). The most frequent urological complications include ureteral stenosis, urinary fistula, renal artery stenosis and lymphocele formation. Most often these complications occur in the first months after transplantation. Ureteral stenosis affects 3.1–10.2% of patients after transplantation (Dreikorn K. Problems with the distal ureter. Urol Int. 1992;49(2):76-89.[PubMed link]; Rigg KM, et al. Urological complications following renal transplantation. Transplant Int Transpl Int. 1994;7(2):120-6. [PubMed link]). Usual causes of ureteral stenosis are post-operative edema, ureteral torsion or compression (from haematoma or lymphocele) and non-optimal length of the ureter. Ureteral ischaemia may also be present, and the distal ureter is particularly vulnerable. The proximal half of the ureter receives arterial blood from renal, aortic and gonadal vessels while the distal half is supplied by branches from common iliac, vesical, obturator and deferential (in male) or uterine (in female) vessels. Following harvesting of the kidney, the ureter receives its entire blood supply from the ureteral branch of the renal artery. Any damage by traction, stripping or diathermy is liable to render the ureter, in particular its distal portion, ischaemic. Acute rejection involves the kidney and the ureter equally, and the resultant edema with possible ischaemia may also lead to ureteral obstruction (Doehn C, et al. Nephrol Dial Transplant. 1999;14(10):2492-4 [PubMed link][Free full text]).

It is usual for nephrologists and pathologist to think that BK virus infection is the "main cause" of ureteral stenosis, however we do not think so. Although has been informed that BK virus frequently cause ureteric obstruction, there are only some reports of this association; these reports were published in the 70s and 80s. More recent literature arguing BK virus as cause of stenosis usually references these reports. Although was demonstrated that the virus infection may cause ureteric obstruction due to ulceration and stenosis at the ureteric anastomosis in immunosuppressed monkeys (Van Gorder MA, et al. Cynomolgus polyoma virus infection: a new member of the polyoma virus family causes interstitial nephritis, ureteritis, and enteritis in immunosuppressed cynomolgus monkeys. Am J Pathol 1999;154(4):1273-84 [PubMed link][Free full text]), this finding has been not demonstrated in humans. Then, our opinion opinion is that this association: ureteral stenosis and decoy cells in urine, is a casual (and not causal) association.

This case illustrates a common urological problem in renal transplantation and alert about the possibility of rejection (acute and chronic) in cases of ureteral stenosis.

In this patient allograft function was worse and two months after she started dialysis. Graft nephrectomy was carried out subsequently.

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Bibliography

• Lang EK, Colon I, Cheung WW, Thomas R. Cadaver transplant ureteroneocystostomy dehiscence after 5 years: a case of chronic rejection. J Urol. 2008;179(5):2008. [PubMed link]
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• Rigg KM, Proud G, Taylor RMR. Urological complications following renal transplantation. Transplant Int Transpl Int. 1994;7(2):120-6. [PubMed link]
• Dreikorn K. Problems with the distal ureter. Urol Int. 1992;49(2):76-89.[PubMed link]
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