A 51-year-old woman with hypothyroidism.
In 2000, the patient presented with renal failure and was admitted to chronic hemodialysis.
During the following 5 years, she had multiple occlusions of her vascular accesses, performing bilateral radiocephalic arteriovenous fistulas, axillary and tuclavian prostheses and bilateral submandibular PTugal catheters.
In 2003, prothrombin time, TTPK, lupus anticoagulant, VDRL, antithrombin III and anticardiolipin IgG and IgM antibodies were determined, which were normal or negative.
Diabetes mellitus was diagnosed in 2004 2.
In March 2005 he received a kidney from a cadaver donor, which shared two DR antigens and contained in the two antigens A and B. His historical and pre-transplant reactivity to panel lymphocytes was 0%.
There was abundant intraoperative bleeding and clopidogrel was used to prevent catheter occlusion.
She received red blood cells, platelets, fresh frozen plasma and immunosuppression with cyclosporine (CsA), mycophenolate (MMF) and steroids.
The patient developed acute tubular necrosis and was treated six times during the first 14 days.
He received insulin, and for not having anti-CMV IgG antibodies, he used ganvir intravenously and then valganvir orally (VGC).
Complications included urinary tract infection and urinoma, which required surgical drainage.
He was discharged at 34 days with a creatinine level of 1.6 mg/dl. One week later, he noticed edema of the right upper limb, cough and exertional dyspnea.
Doppler ultrasonography revealed thrombosis of the right axillary vein and a pulmonary scintigraphy showed an image compatible with pulmonary embolism.
He started therapy with low molecular weight heparin and then acenocoumarol.
She was discharged 2 weeks later with a creatinine level of 1.6 mg/dl and creatinine clearance of 35 ml/min.
At four months of renal transplant (TxR) and days after lowering the MMF dose from 1,500 to 500 mg/ day for leucopenia, prednisone cleared 10 mg and CsA 80 mg (obtaining a blood concentration of
Acute rejection was diagnosed.
A renal biopsy was not performed because he was under anticoagulant therapy.
She was treated with methylprednisolone for 3 days, lowering creatinine to 1.7 mg/dl and proteinuria to 780 mg/day, increasing creatinine clearance to 40 ml/min.
She was discharged with the same scheme.
11 weeks later, receiving MMF 1000 mg, CsA 70 mg (obtaining a level of 457 ng/ml antigen in the second hour of ingestion) and prednisone 10 mg, a new pulse of tacrolimus was induced to
Seven months after the KTx and six months after starting anticoagulant therapy, anticoagulant therapy was suspended, as scheduled at the beginning.
He was discharged with a creatinine level of 1.6 mg/dl. Two days later, 12 days after anticoagulant discontinuation, he suddenly fell into anuria.
Doppler ultrasonography showed no arterial flow and a scintigraphy showed no renal perfusion.
Renal artery thrombosis was suspected.
New tunneled catheters were installed through the right femoral approach and hemodialysis was initiated.
Three days later a renal biopsy showed a renal infarction and a nephrectomy was performed.
Renal artery thrombosis was confirmed with infarction of the entire graft, and an interstitial infiltrate consistent with mild rejection was observed.
Given the suspicion of thrombophilia as a cause of arterial thrombosis, samples were taken to confirm this hypothesis.
Levels of antithrombin III, resistance to activated protein C, factor V Leiden, mutation of the G20210A gene of prothrombin, protein S, lupus anticoagulant, IgG anticardiolipin antibodies were normal.
The activity of PrC was only 39.1% (VN: 72-106%) and total homocysteine levels were slightly elevated 16.6 umol/L (VN: 4.5-11).
Days later she developed a thrombosis of the right common and deep femoral vein.
He was treated with low molecular weight heparin and then permanent acenocoumarol therapy was started.
