Recurrent vascular thrombosis in an adolescent transplant recipient

Vascular thrombosis is one of the more difficult problems of pediatric renal transplantation; its etiology is multifactorial and, in most cases, it is irreversible. Vascular thrombosis accounts for 12.9% of graft failures in primary transplants in children and for 20% of graft failures in repeat transplants. Although it is seen most often in very young recipients and in recipients of kidneys from young donors, it can manifest in older children and adolescents as well. The peak incidence is seen in the first 48 h after transplantation; however, the event may be delayed until after the first week. When thrombosis occurs in an adolescent patient late in the course of transplantation, the pathogenesis is undetermined and immunosuppressive therapy is frequently implicated. This article describes a 19-yr-old patient with a three-antigen-matched cadaveric kidney who received cyclosporine and anti-thymocyte globulin for induction. Vascular thrombosis occurred after 7 d of initial good function. Eventually the graft was removed after attempts to re-establish vascularization failed. The patient received a second graft and despite an optimal six-antigen match and different immunosuppression with tacrolimus, thrombosis recurred by the fifth postoperative day. The discussion that follows reviews the incidence and the factors implicated in the pathogenesis of this entity.