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OBJECTIVES: It was reported that steal syndrome caused by transplanted kidney may result in limb threatening ischemia in pediatric patients. However, the steal phenomenon and its clinical significance have not been well defined in adults. It has been a concern that “blood steal” from iliac artery by transplanted kidney may deteriorate ischemia in the ipsilateral lower extremity with underline peripheral arterial disease (PAD). This study was designed to investigate the progression of lower extremity ischemia following kidney transplantation to iliac artery.
METHODS: A retrospective chart review of all renal transplants completed at a university teaching medical center from January 2005 to December of 2010 was performed. Patients were excluded if renal artery was anastomosed to the aorta. A total of 219 patients underwent successful kidney transplantation to the common, external, or internal iliac artery. Data including pre- and post-transplantation limb ischemic changes, conventional angiography, CT angiography (CTA), and MR angiography (MRA) of the ipsilateral lower extremity were collected and analyzed.
RESULTS: Of the 219 patients with successful renal transplantation to the common, external or internal iliac arteries, 143 were male and 76 were female. The median age was 52 years, ranging from 28 to 77 years. Sixty-nine patients underwent preoperative conventional angiogram, CTA, or MRA to rule out PAD. Thirty-eight were diagnosed to have ipsilateral lower extremity arterial disease, including 30 mild, 4 moderate and 4 severe arterial stenosis/occlusion. No arterial revascularization was performed. Seven patients were symptomatic preoperatively and 8 became symptomatic after kidney transplantation. In the 7 with preoperative lower extremity ischemia, symptoms/signs remained same in 6 and improved in 1. Of the 8 patients who developed ischemic symptoms after transplantation, 4 had claudication and 4 sustained chronic foot ulcers or toe gangrene 12 months later. The ulcers were healed in 2 patients with wound care, and toe amputation was performed in the rest 2. No major amputation above the level of mid-foot was required during the follow-up between 6 to 48 months.
CONCLUSIONS: “Blood steal” from iliac artery by transplanted kidney does not significantly deteriorate ischemia in adults with lower extremity PAD. Late developed ischemic complications maybe due to the progression of underline arterial disease. Further study comparing limb ischemia in renal failure patients with and without kidney transplantation will be performed.