Renal artery aneurysm is a rare vascular condition that could remain silent or could lead to potential life -threatening consequences, especially when there are multiple lesions. Endovascular treatment and open in situ surgical reconstruction are often considered first -line options, although not always feasible or durable. We report the case of a successful kidney autotransplant in a 56 -year -old female patient who had bilateral multiple renal artery aneurysms with calcified walls and parietal thrombotic apposition. Given the history of hypertension and the risks related to aneurysm rupture, the patient underwent laparoscopic nephrectomy followed by ex situ repair and heterotopic graft reimplant. We also compared our approach with the literature to report on the current evidence and the recommended management for renal artery aneurysms.

Situs inversus totalis is a rare congenital anomaly in which the thoracic and abdominal viscera are arranged in mirror image. The use of liver grafts from deceased donors with situs inversus totalis is a challenge because of the profound anatomical and technical variations that complicate implantation. Approximately 11 such transplants have been reported worldwide. Here, we present a case of orthotopic liver transplant in a 66 -year -old man with hepatitis C -related cirrhosis and hepatocellular carcinoma in which the graft was from a 17 -year -old deceased donor with situs inversus totalis. The graft, which displayed mirror -image hilar anatomy, was implanted with a modified piggyback technique, orienting the donor right lobe anteriorly; direct duct -to -duct biliary reconstruction was performed. Graft function was preserved through most of the first postoperative year, after which the patient developed progressive cholestasis and diffuse biliary strictures. Allograft biopsies demonstrated ischemic changes of the bile ducts and parenchyma consistent with ischemic cholangiopathy in the absence of hepatic arterial thrombosis, without evidence of acute rejection but potential features of subtle chronic rejection. The patient was not a candidate for retransplant and died 14 months after transplant. This case illustrates a technically successful situs inversus totalis donor graft that was complicated by late, diffuse, and irreversible biliary obstruction.

Distinguishing BK virus nephropathy from T -cell -mediated rejection remains a clinicopathological challenge in kidney transplants, because the 2 entities may share overlapping histological features while requiring opposite therapeutic approaches. We report a kidney transplant recipient with biopsy -proven BK virus nephropathy who later underwent repeat biopsy showing low -level BK virus nephropathy with borderline T -cell -mediated rejection. Despite histological concern for rejection, the broader clinical picture did not support clinically significant T -cell -mediated rejection; specifically, serum creatinine remained stable, BK viral load showed marked improvement, donor -specific antibodies were negative, and there were no vascular or microvascular features of active rejection. A peripheral blood next-generation RNA sequencing gene expression profile yielded a low -risk acute rejection score of 6. Antirejection therapy was deferred, immunosuppression was not escalated, and the patient remained clinically stable. This case highlights the potential adjunctive role of peripheral blood RNA profiling for resolution of histologically ambiguous cases of BK virus nephropathy and borderline T -cell-mediated rejection.