Unusual causes of increased vascular impedance in renal transplants: duplex Doppler evaluation

Duplex Doppler ultrasound (US) examination of the renal vasculature has proved valuable in assessing the kidney transplant. The normal renal allograft exhibits low-impedance arterial inflow similar to that seen in the normotopic kidney. The authors and others previously reported that a high vascular impedance, defined as either a pulsatility index (PI) greater than 1.8 or a resistive index greater than 0.9, indicates acute vascular rejection (AVR). Although AVR remains the most common cause of increased PI, the authors noted ten episodes among 180 serially followed-up transplants in which abnormal waveforms were clearly not due to rejection. Four other causes of increased vascular impedance are reported, including renal vein obstruction, severe acute tubular necrosis, pyelonephritis, and extrarenal compression of the graft. These new causes only slightly decrease the specificity of high vascular impedance for rejection. Furthermore, the cause can usually be recognized from the clinical history or other US findings.