Fibromuscular Dysplasia in a Deceased Donor Renal Allograft: Staged Hybrid Endovascular Management and Review of the Literature

• Fibromuscular dysplasia (FMD) in renal allografts is rare and lacks consensus on optimal management. • Intraoperative duplex ultrasonography can detect renal artery FMD despite normal macroscopic appearance. • Early graft dysfunction despite urine output should prompt consideration of vascular causes. • Percutaneous balloon angioplasty successfully restored renal function in the acute post-transplant period. • Endovascular management of renal allograft FMD is safe and effective in experienced centers. Fibromuscular dysplasia (FMD) in deceased donor renal allografts is rarely reported in the transplant literature, and there is currently no consensus regarding graft utilization when identified prior to retrieval or optimal operative management following implantation. We report a case of deceased donor renal transplantation in which a focal mid–renal artery FMD lesion causing significant stenosis was identified intraoperatively using routine duplex ultrasonography, despite a normal macroscopic appearance of the renal artery on the back table. As the donor had demonstrated normal renal function, a decision was made not to intervene on the lesion at the time of implantation. Post-operatively, the renal allograft produced urine; however, serum creatinine failed to improve. On post-operative day 3, percutaneous balloon angioplasty of the transplant renal artery stenosis was performed successfully. Renal function normalized promptly following the intervention and remained stable at 12 months of follow-up. This case highlights several important considerations. A deceased donor kidney with normal donor renal function may still fail to provide adequate recipient function due to previously unsuspected FMD, potentially accounting for unexplained early graft dysfunction in some cases. Routine intraoperative duplex ultrasonography facilitated early detection of the lesion, allowing timely elective intervention. Endovascular repair represents an effective and safe management strategy for FMD in renal allografts when performed in appropriately experienced centers.