Living Donor Kidney Transplantation Using Laparoscopically Procured Multiple Renal Artery Kidneys and Right Kidneys

Right and left living donor nephrectomy and operative approach: A systematic review and meta-analysis of donor and recipient outcomes

INTRODUCTION

The left kidney is preferable in living donor nephrectomy (LDN). We aimed to investigate the safety and efficacy of right versus left LDN in both donor and recipients. A subgroup analysis of outcomes based on operative approach was also performed.

METHODS

A systematic review and meta-analysis was performed as per PRISMA guidelines. Outcomes of interest were extracted from included studies and analysed.

RESULTS

There were 31 studies included with 79,912 transplants. Left LDN was performed in 84.1 % of cases and right LDN in 15.9 %. Right LDN was associated with reduced EBL (P = 0.010), intra-operative complications (P = 0.030) and operative time (P = 0.006), but higher rates of conversion to open surgery (1.4 % vs 0.9 %). However, right living donor renal transplantation (LDRT) had higher rates of delayed graft function (5.4 % vs 4.2 %, P < 0.0001) and graft loss (2.6 % vs 1.1 %, P < 0.0001). Graft survival was reduced in right LDRT at 3 years (92.0 % vs 94.2 %, P = 0.001) but comparable to left LDRT at 1- and 5-years. Otherwise, donor and recipient peri-operative outcomes and serum creatinine levels were comparable in both groups. Hand-assisted LDN was associated with shorter warm ischaemia time (P < 0.0001) but longer length of stay (LOS) than laparoscopic LDN and robotic-assisted LDN (P < 0.0001). RA-LDN was associated with less EBL and shorter LOS (both P < 0.0001) while patients who underwent L-LDN had a lower mean serum creatinine (SCr) level on discharge (P < 0.0001).

CONCLUSION

Right LDRT has higher rates of delayed graft function and graft loss compared to left LDRT. Minimally-invasive surgical approaches potentially offer improved outcomes but further large-scale randomised controlled trials studies are required to confirm this finding.

Vascular reconstructions in living donor kidney transplantation: a single-center experience over the last 17 years

Introduction

In living donor kidney transplantation (LDKT), vascular anastomosis is more difficult due to missing arterial patches and shorter renal veins. The surgical challenge is even more demanding in kidneys with multiple arteries. Although renal transplantation is feasible in most cases of complex donor vascular anatomy and similar results compared with standard LDKT are reported, the discussion on potentially increased complication rates and graft function continues. This prompted us to review our results of LDKT with multiple renal artery (MRA) grafts with a special concentration on complications and long-term function.

Patients and methods

We reviewed the records of all LDKT in our center from the beginning of the program in 2005 until 2022 for arterial vascular reconstructions. The cohort was divided into two groups: transplantation with vascular reconstruction (VR) and standard transplantation. These groups were compared for operative parameters and short- and long-term results.

Results

From 2005 to 2022, 211 LDKT were completed in our unit. In 32 (15.2%), a VR was performed, including single ostium side-to-side anastomosis, end-to-side anastomosis, patch reconstruction, and vein interposition. There was no significant difference in operative time (169 min vs. 180 min; p = 0.118) and time for anastomosis (28 min vs. 26 min; p = 0.59) between both groups. Postoperative complications (5.7% vs. 7.4%; p = 0.72) were not significantly different. During the follow-up period (110 months, range 10-204), the risk of organ loss was comparable after VR (13.625% vs. 11.56% p = 0.69).

Conclusion

In LDKT, arterial vascular reconstructions for kidneys with MRA provide similar results compared to grafts with a single renal artery (SRA). Short- and long-term results are comparable with standard procedures.

European Association of Urology Guidelines on Renal Transplantation: Update 2024

BACKGROUND AND OBJECTIVE

The European Association of Urology (EAU) Panel on Renal Transplantation released an updated version of the renal transplantation (RT) guidelines. This report aims to present the 2024 EAU guidelines on RT.

METHODS

A broad and comprehensive scoping exercise covering all areas of RT guidelines published between May 31, 2020 and April 1, 2023 was performed. Databases covered by the search included Medline, Embase, and the Cochrane Libraries. Previous guidelines were updated, and levels of evidence and grades of recommendation were assigned.

KEY FINDINGS AND LIMITATIONS

It is strongly recommended to offer pure or hand-assisted laparoscopic/retroperitoneoscopic surgery for living donor nephrectomy. One should not base decisions regarding the acceptance of a donor organ on histological findings alone, since this might lead to an unnecessary high rate of discarded grafts. For the ureterovesical anastomosis, a Lich-Gregoir-like extravesical technique protected by a ureteral stent is the preferred technique. A list of RT patients with a history of appropriately treated low-stage/grade renal cell carcinoma or prostate cancer should be made without additional delay. In the potential donor kidney, the main surgical tumoral approach is ex vivo tumor excision and finally transplantation. It is also strongly recommended to perform initial rejection prophylaxis with a combination therapy of a calcineurin inhibitor (preferably tacrolimus), mycophenolate, steroids, and an induction agent (either basiliximab or antithymocyte globulin). The long version of the guidelines is available at the EAU website (www.uroweb.org/guidelines).

CONCLUSIONS AND CLINICAL IMPLICATIONS

These abridged EAU guidelines present updated information on the clinical and surgical management of RT for incorporation into clinical practice.

PATIENT SUMMARY

The European Association of Urology has released the renal transplantation guidelines. Implementation of minimally invasive surgery for organ retrieval and the latest evidence on transplant surgery as well as on immunosuppressive regimens are key to minimizing rejection and achieving long-term graft survival.

Surgical Strategies for Renal Transplantation: A Pictorial Essay

This pictorial essay aims to navigate through the complexities and challenges of renal transplantation (RT), by weaving together visual imagery with clinical insights within a comprehensive illustrative surgical guide. Herein, we provide a detailed visual exploration of the intricate anatomy and surgical processes necessary for both renal graft retrieval from the donor and also for an adequate implantation in the recipient. Regarding graft retrieval, after reviewing the relevant retroperitoneal surgical anatomy, and donor nephrectomy techniques, graft preservation and optimal backbench graft dissection principles were meticulously analyzed. Thereafter, the recipient surgical strategy for graft implantation was addressed, focusing on preoperative preparations, the site of implantation selection, exposure, operative bed dissection, graft revascularization, and urinary tract reconstruction. Careful donor and recipient selection, meticulous surgical execution, and rigorous postoperative management clearly hold a pivotal role in optimizing patient outcomes. Fostering a deeper understanding of the surgical nuances and clinical management practices that contribute to successful results post-RT, we hope to provide a useful practical tool for clinicians about to embark on the treacherous road of RT surgery. Innovative technologies and surgical practices that have already significantly improved the safety and effectiveness of RT stand testament to the importance of further scientific inquiry, conceptual developments, and clinical integration. Moving forward, it is essential that the medical community continues to refine these strategies and advocate for equitable access to transplantation, ensuring that advancements in the field translate into real-world benefits for all patients grappling with ESRD. The collaborative efforts of multidisciplinary teams are essential in addressing the complex clinical challenges associated with RT, with the ultimate goal of improving patient survival, enhancing graft longevity, and reducing healthcare disparities.

Single versus multiple renal arteries in living donor kidney transplantation: A systematic review and patient-level meta-analysis

INTRODUCTION

Grafts with multiple renal arteries (MRAs) were historically considered a relative contraindication to transplantation due to the higher risk of vascular and urologic complications. This study aimed to evaluate graft and patient survival between single renal artery (SRA) and MRA living-donor kidney transplants.

METHODS

An electronic literature search was conducted on PubMed, EMBASE, and Scopus for prospective or retrospective studies comparing SRA versus MRA in living donor renal transplantation, with the provision of Kaplan-Meier curves for recipient overall survival (OS) or graft survival (GS). A graphical reconstructive algorithm was used to obtain OS and GS of individual patients, which was then pooled under random-effects individual patient data (IPD) meta-analysis using Cox-models to determine hazard ratios (HRs) and 95% confidence intervals (CIs). Meta-regression of baseline covariates versus HRs of OS and GS was performed for variables reported in 10 or more studies.

RESULTS

Fourteen studies were retrieved, of which 13 (8400 patients) reported OS and 9 (6912 patients) reported GS. There were no significant differences in OS (shared-frailty HR = .94, 95%CI = .85-1.03, p = .172) or GS (shared-frailty HR = .95, 95%CI = .83-1.08, p = .419) between SRA and MRA. This comparison remained non-significant even when restricted to open- or laparoscopic-only studies. Meta-regression yielded no significant associations of GS with donor age, recipient age, and percentage of double renal arteries within the MRA arm.

CONCLUSIONS

The similar rates of GS and OS between MRA and SRA grafts suggest that there is no need for discrimination between the two when evaluating donors for nephrectomy.

"Triple V-Plasty": Creation of a Single Orifice for Three Renal Arteries in Live-Donor Transplantation

BACKGROUND

Donor renovascular anatomic variations can hinder renal transplantation (RT), especially from live donors. Back-table vascular reconstruction can be effective in the use of renal allografts with multiple renal arteries (RAs), helping to expand the pool of live donors.

SURGICAL TECHNIQUE

Sequential V-plasty of 3 donor RAs using fine, non-absorbable, monofilament (7-0 or 8-0 polypropylene) suture in an uninterrupted fashion successfully enabled the creation of a single, wide ostium for anastomosis with the target inflow recipient artery.

RESULTS

Creation of a single ostium for 3 RAs was successfully performed on a 31-year-old man during a live-donor left RT, resulting in good inflow and outflow with arterial and venous anastomoses, respectively, at graft implantation. Excellent postoperative allograft perfusion was achieved, and the patient continued to have normal allograft function at >1 year post-transplantation.

CONCLUSIONS

Novel ex vivo renovascular reconstruction potentiates expansion of live-donor RT successfully despite variant renovascular anatomy.

Risk aversion in the use of complex kidneys in paired exchange programs: Opportunities for even more transplants?

This retrospective review of the largest United States kidney exchange reports characteristics, utilization, and recipient outcomes of kidneys with simple compared to complex anatomy and extrapolates reluctance to accept these kidneys. Of 3105 transplants performed, only 12.8% were right kidneys and 23.1% had multiple renal arteries. 59.3% of centers used fewer right kidneys than expected and 12.1% transplanted zero right kidneys or kidneys with more than 1 artery. Five centers transplanted a third of these kidneys (35.8% of right kidneys and 36.7% of kidneys with multiple renal arteries). 22.5% and 25.5% of centers currently will not entertain a match offer for a left or right kidney with more than one artery, respectively. There were no significant differences in all-cause graft failure or death-censored graft loss for kidneys with multiple arteries, and a very small increased risk of graft failure for right kidneys versus left of limited clinical relevance for most recipients. Kidneys with complex anatomy can be used with excellent outcomes at many centers. Variation in use (lack of demand) for these kidneys reduces the number of transplants, so systems to facilitate use could increase demand. We cannot know how many donors are turned away because perceived demand is limited.

The effect of single or multiple arteries in the donor kidney on renal transplant surgical outcomes

BACKGROUND

As the number of end-stage renal disease (ESRD) patients is increasing, but there are not enough living donors, it is necessary to broaden the criteria for candidates who can undergo donor nephrectomy. Thanks to surgeons' increasing experience with laparoscopic donor nephrectomy (LND), multiple renal artery grafts, previously considered a relative contraindication to donor nephrectomy, have become candidates for LDN. We aimed to compare the outcomes of donors and recipients with single artery and with multiple arteries in LDN.

METHODS

A total of 214 patients were included in the study. Patients were divided into two groups according to the number of donor arteries: donors with one artery (group 1) and donors with multiple arteries (group 2). The number of donor arteries, operative time, warm ischemia time (WIT), cold ischemia time (CIT), arterial anastomosis time, venous anastomosis time, the extent of bleeding, and preoperative complications were recorded to evaluate the preoperative data.

RESULTS

The mean operation time in group 1 was 90.3 ± 11.8 min, while in group 2, it was 102.1 ± 5.5 min (p = 0.000). WIT group 1 was 90.9 ± 4.3 s and group 2 100.6 ± 2.1 s (p = 0.000). Arterial anastomosis time was 12.25 ± 3.8 in group 1 and 22.5 ± 4.5 in group 2 (p = 0.000). No statistically significant difference was found between the two groups in other parameters.

CONLUSION

Increasing the number of donor arteries in renal transplantation (RT) operations prolonged the operation time on both the donor and recipient sides. Still, it had no negative impact on complications or graft function in the postoperative period.

Creating a Single Inflow Orifice From Living Donor Kidney Allografts With Multiple Renal Arteries

Background: Multiple renal arteries (MRA) are often encountered during living-donor kidney transplantation (LDKT), requiring surgeons to pursue complex renovascular reconstructions prior to graft implantation. With improvements in reconstruction and anastomosis techniques, allografts with MRA can be successfully transplanted with similar outcomes to allografts with a single renal artery. Here, we describe in detail various surgical techniques for reconstruction of MRA grafts with the intent of creating a single arterial inflow.

Methods: We retrospectively reviewed the medical records of all LDKT recipients with laparoscopically procured MRA kidneys between March 2008 and July 2021. Recipient and donor characteristics, operative data, type of reconstruction, and recipient outcomes were analyzed. The primary outcomes were the incidence of developing delayed graft function (DGF) and/or a vascular or urological complication within 12 months post-transplant.

Results: Seventy-three LDKT recipients of MRA donor allografts were evaluated. Two renal arteries (RA) were encountered in 62 allografts (84.9%) and three RA in 11 allografts (15.1%). Renal artery reconstruction was performed in 95.8% (70/73) of patients. Eighteen different reconstruction techniques of MRA were utilized, the most common being side-to-side anastomosis in allografts with two RA (N = 44) and side-to-side-to-side anastomosis in allografts with three RA (N = 4). Interposition grafting was performed in seven cases (9.6%). A single ostium was created in 69 cases (94.5%), and the median warm ischemia time was 27 (range 20–42) minutes. None of the patients developed DGF or post-operative vascular or urological complications. Median creatinine at 3, 6, and 12 months post-transplant remained stable at 1.1 mg/dl. With a median follow-up of 30.4 months post-transplant, only one graft failure has been observed–death-censored graft survival was 98.6%.

Conclusion: Complex reconstruction techniques to create a single renal artery ostium for graft implantation anastomosis in allografts with MRA show acceptable warm ischemic times, with no increased risk of post-operative vascular or urological complications.

Number of Donor Renal Arteries and Early Outcomes after Deceased Donor Kidney Transplantation

Background

Anatomic abnormalities increase the risk of deceased donor kidney discard, but their effect on transplant outcomes is understudied. We sought to determine the effect of multiple donor renal arteries on early outcomes after deceased donor kidney transplantation.

Methods

For this retrospective cohort study, we identified 1443 kidneys from 832 deceased donors with ≥1 kidney transplanted at our center (2006-2016). We compared the odds of delayed graft function and 90-day graft failure using logistic regression. To reduce potential selection bias, we then repeated the analysis using a paired-kidney cohort, including kidney pairs from 162 donors with one single-artery kidney and one multiartery kidney.

Results

Of 1443 kidneys included, 319 (22%) had multiple arteries. Multiartery kidneys experienced longer cold ischemia time, but other characteristics were similar between groups. Delayed graft function (50% multiartery versus 45% one artery, P=0.07) and 90-day graft failure (3% versus 3%, P=0.83) were similar between groups before and after adjusting for donor and recipient characteristics. In the paired kidney analysis, cold ischemia time was significantly longer for multiartery kidneys compared with single-artery kidneys from the same donor (33.5 versus 26.1 hours, P<0.001), but delayed graft function and 90-day graft failure were again similar between groups.

Conclusions

Compared with single-artery deceased donor kidneys, those with multiple renal arteries are harder to place, but experience similar delayed graft function and early graft failure.

Comparing outcomes in right versus left kidney transplantation: A systematic review and meta-analysis

INTRODUCTION

Transplantation of right kidneys can pose technical challenges due to the short right renal vein. Whether this results in inferior outcomes remains controversial.

METHOD

Healthcare Database Advanced Search (HDAS) was used to identify relevant studies. Two authors independently reviewed each study. Statistical analyses were performed using random effects models and results expressed as HR or relative risk (RR) with 95% confidence intervals. Subgroup analyses were performed in kidneys from deceased donors (DD) and living donors (LD).

RESULTS

A total of 35 studies (257,429 participants) were identified. Both deceased and living donor right kidneys were at increased risk of delayed graft function (DGF; RR = 1.12[1.06-1.18] and RR = 1.33[1.21-1.46] respectively; both p < .0001). In absolute terms, for each 100 kidney pairs of DD kidneys transplanted there are 2.72 (1.67-3.78, p < .00001) excess episodes of DGF in right kidneys. Graft thromboses and graft loss due to technical failure was also significantly more likely in right kidneys, in both DD and LD settings. There was no evidence that laterality alters long term graft survival in LD or DD.

CONCLUSION

Right kidneys have inferior early outcomes, with higher rates of DGF, technical failure and graft thrombosis. However, these differences are small in absolute terms, and long-term graft survival is equivalent.

Complex Surgical Reconstruction of Upper Pole Artery in Living-Donor Kidney Transplantation

Background

The use of allografts with multiple renal arteries has increased in the era of laparoscopic donor nephrectomy. Although several studies recommend reconstructing lower pole arteries (LPAs) to reduce risk of urologic complications, it is common opinion to ligate upper pole arteries (UPAs) with a diameter less than 2 mm because of increased risk of thrombosis related to their reconstruction. This retrospective study evaluates the feasibility and safety of reconstructing thin UPAs during living-donor kidney transplantation, with the goal of maintaining the integrity of the graft and assuring its maximal function.

Material/Methods

Data from 922 living-donor kidney transplants performed between 2009 and 2019 were reviewed. Six cases with UPAs were identified (0.65%). The study endpoints were incidence of allograft vascular and urologic complications, slow graft function, delayed graft function, graft failure, and graft and patient survival.

Results

The UPAs had a mean diameter of 1.8±0.28 mm. Methods of reconstruction included: interposition graft (n=2), end-to-side anastomosis inside the renal hilum to a branch of the main renal artery (n=3), and side-to-side anastomosis with the main renal artery (n=1). Additional reconstruction of LPAs (n=2) and main renal arteries (n=2) was performed. During a median (range) follow-up of 14.5 (9–49) months no complications were observed.

Conclusions

Ex vivo reconstruction of UPAs with a diameter less than 2 mm is worth attempting, particularly in the setting of living-donor kidney transplantation.

Recipient outcomes in total laparoscopic live donor nephrectomy with multiple renal vessels

Introduction:

In kidney transplantation, total laparoscopic live donor nephrectomy (TLLDN) in the presence of multiple renal arteries (MRA) is technically challenging and has traditionally been associated with higher complication rates. We report our experience of using MRA grafts procured by TLLDN.

Materials and Methods:

Patients undergoing TLLDN at our center (2004–2014) was identified from a prospectively maintained database and divided into single renal arteries (SRA) or MRA groups. Recipient perioperative parameters, postoperative complications, and long-term graft survival were analyzed.

Results:

Of 465 patients, 106 had MRA and 359 had an SRA. There were six vascular complications in the SRA group and two in the MRA group (1.7% vs. 1.8%). There were eight ureteric complications requiring intervention in the SRA group compared to three in the MRA group (4% vs. 3%; P = 0.45). Acute rejection was observed in 12% of the SRA group compared to 9% in the MRA group (P = 0.23). One-, 5- and 10-year graft survivals were 98.2%, 91.3%, and 89.8% in the MRA group versus 98.0%, 90.4%, and 77.5% in the SRA group (log-rank P = 0.13).

Conclusion:

The use of MRA grafts procured by TLLDN has comparable complication rates to SRA grafts and should not preclude selection for renal transplantation.

Grafts With Multiple Renal Arteries in Kidney Transplantation

BACKGROUND

Renal grafts with multiple renal arteries (MRA) are a compelling issue in surgery of kidney transplantation. Transplantations using "grafts with MRA" have conflicting results. Here, we present our experiences on the issue.

METHOD

This is a single-center, observational, descriptive study. One hundred ninety-nine patients with end-stage renal disease received a kidney graft from their living- or deceased-related donors in our center between July 2016 and May 2017. We included all recipients to the study. Patients were divided into the following 2 groups: Group 1, recipients who received a renal graft with single renal artery, and Group 2, recipients who received a renal graft with MRA. Groups were compared for estimated glomerular filtration rates (months 1-3 and 12), delayed graft function, and graft survival. Data were analyzed by using SPSS for Windows version 15.

RESULTS

One hundred ninety-five recipients with all documented data were analyzed. Graft function was compared between 2 groups in months 1, 3, and 12 and found both to have similar outcomes. MRA has been indicated to have no impact on delayed graft function, higher risk for vascular injury, and biopsy-proven acute tubular necrosis. Also, anastomosis sides have been found to have no importance on graft function in recipients with MRA (P > .05 between all sides).

CONCLUSION

Our study indicates grafts with MRA and grafts with a single renal artery have comparable results in the first post-transplant year.

Inferior Long-Term Graft Survival of Suboptimal Kidneys After Living Donor Kidney Transplantation

BACKGROUND

In living donors, if both kidneys are considered to be of equal quality, the side with favorable anatomy for transplant is usually selected. A "suboptimal kidney" is a kidney that has a significant abnormality and is chosen to maintain the principle of leaving the better kidney with the donor. We hypothesized that the long-term outcome of suboptimal kidney is inferior to that of the normal kidney.

METHODS

In a retrospective analysis of 1744 living donor kidney transplantations performed between 1999 and 2015 at our institution, 172 allografts were considered as a suboptimal kidney (9.9%). Median length of follow-up after living donor kidney transplantation was 59.5 months (interquartile range 26.3-100.8). This study strictly complied with the Helsinki Congress and the Istanbul Declaration regarding donor source.

RESULTS

The reasons for suboptimal kidneys were cysts or tumors (46.5%), arterial abnormalities (22.7%), inferior size or function (19.8%), and anatomic abnormalities (11.0%). Suboptimal kidneys showed worse long-term overall graft survival regardless of the reasons (5-year: control vs suboptimal kidney; 88.9% vs 79.3%, P = .001 and 10-year: 73.6% vs 63.5%, P = .004). Suboptimal kidneys showed a 1.6-fold higher adjusted hazard ratio (aHR) of all-cause graft loss (95% confidence interval [CI]: 1.1-2.5, P = .025) and had the same impact as older donor age (≥ 54 years old, aHR: 1.6, 95% CI: 1.1-2.4, P = .008).

CONCLUSIONS

The impact of suboptimal kidney should be factored into the donor selection process.

Which One Is the Best for Living Donation: A Multiple-Artery Left Kidney Nephrectomy or a Right Kidney Nephrectomy?

INTRODUCTION

The current approach in living-donor kidney transplant is to preserve the best kidney for the donor and harvest the contralateral one. Due to a shorter renal vein and a greater incidence of venous thrombosis, left kidneys are more frequently elected. Notwithstanding, arterial anatomy may be complex and thus render the transplantation procedure more difficult and prone to complications.

OBJECTIVES

To analyze the outcomes after multiple-artery left kidney nephrectomy (MALKN) and right kidney nephrectomy (RKN).

RESULTS

Seventy-three cases were performed from 1999 to 2017 in our institution: 34 MALKN and 39 RKN. The mean operative time was significantly longer in MALKN. Warm ischemia time, donor and receptor hospital stay, and postoperative complications did not differ between groups. There was a positive correlation between renal arteries' ostia distance in MALKN and the duration of warm ischemia period. There was no significant difference in the incidence of acute tubular necrosis, first-year variations in serum creatinine, and glomerular filtration rate between groups. Long-term graft survival did not significantly differ between groups. Three cases of vein thrombosis after RKN were reported with graft loss.

CONCLUSION

The safety and efficacy of MALKN does not differ from RKN, although there appears to be a higher incidence of vein thrombosis after right kidney transplantation. Despite being technically more demanding, particularly in cases with distant artery ostia, MALKN could be a better option than RKN for living donation, expanding the available donor pool, although more studies are needed to affirm this conclusion.

Inferior long-term graft survival after end-to-side reconstruction for two renal arteries in living donor renal transplantation

Living donor kidneys with two arteries can be revascularized using various techniques depending on anatomy. We hypothesized that the revascularization technique could impact long-term outcomes. We retrospectively analyzed 1714 living donor renal transplants at our institution between 1999 and 2015. Three hundred and eleven kidneys had dual arteries, and these were categorized into 5 groups; end-to-side (n = 18), inferior epigastric artery (n = 21), direct anastomosis (n = 65), side-to-side (n = 126) and ligated (n = 81). We then compared the outcomes with that of a control group (single artery, n = 1403) using Kaplan-Meier and Cox regression analyses. Cox regression was adjusted by age, sex and race/ethnicity of donor and recipient, side of kidney, transplant period and recipient surgeon. Compared to the control group, the end-to-side group had increased all-cause graft loss (10 years: 77.2% vs 24.5%, adjusted hazard ratio [aHR] 3.02, 95% confidence interval [CI] 1.30–7.03, p = 0.010) and death-censored graft loss (10 years: 82.0% vs 55.9%, aHR 4.17, 95% CI 1.63–10.68, p = 0.003), whereas the other groups did not. Our study shows that 10-year overall survival and death-censored graft survival were significantly worse for end-to-side arterial reconstruction than for other techniques. Alternative techniques to the end-to-side method should be used for accessory arteries that require revascularization.

Novel surgical techniques, regenerative medicine, tissue engineering and innovative immunosuppression in kidney transplantation

On the 60th anniversary of the first successfully performed renal transplantation, we summarize the historical, current and potential future status of kidney transplantation. We discuss three different aspects with a potential significant influence on kidney transplantation progress: the development of surgical techniques, the influence of regenerative medicine and tissue engineering, and changes in immunosuppression. We evaluate the standard open surgical procedures with modern techniques and compare them to less invasive videoscopic as well as robotic techniques. The role of tissue engineering and regenerative medicine as a potential method for future kidney regeneration or replacement and the interesting search for novel solutions in the field of immunosuppression will be discussed. After 60 years since the first successfully performed kidney transplantation, we can conclude that the greatest achievements are associated with the development of surgical techniques and with planned systemic immunosuppression.

Evaluation of postoperative lymphocele according to amounts and symptoms by using 3-dimensional CT volumetry in kidney transplant recipients

Purpose

To analyze the risk factors for postoperative lymphocele, for predicting and preventing complications.

Methods

We evaluated 92 kidney transplant recipients with multidetector CT (MDCT) at 1-month posttransplantation. From admission and 1-month postoperative records, data including diabetes, dialysis type, immunosuppressant use, steroid pulse therapy, and transplantation side were collected. Lymphocele volume was measured with 3-dimensional reconstructed, nonenhanced MDCT at one month postoperatively. The correlations between risk factors and lymphocele volume and between risk factors and symptomatic lymphocele (SyL) were analyzed. The cutoff was calculated by using the receiver operating characteristic (ROC) curve for SyL volume.

Results

Among 92 recipients, the mean volume was 44.53 ± 176.43 cm³ and 12 had SyL. Univariable analysis between risk factors and lymphocele volume indicated that donor age, retransplantation, and inferiorly located lymphocele were statistically significant. The ROC curve for SyL showed that 33.20 cm³ was the cutoff, with 83.3% sensitivity and 93.7% specificity. On univariable analysis between risk factors and SyL, steroid pulse, inferiorly located lymphocele, and >33.20 cm³ were statistically significant. Multivariable analysis indicated that steroid pulse, >33.20 cm³, and serum creatinine level at one month were significant factors.

Conclusion

Risk factors including donor age, retransplantation, steroid pulse therapy, and inferiorly located lymphocele are important predictors of large lymphoceles or SyL. In high-risk recipients, careful monitoring of renal function and early image surveillance such as CT or ultrasound are recommended. If the asymptomatic lymphocele is >33.20 cm³ or located inferiorly, early interventions can be considered while carefully observing the changes in symptoms.

Is the Reluctance for the Implantation of Right Donor Kidneys Justified?

Background

The lengths of right renal veins are shorter when compared to their left counterparts. Since the implantation of kidneys with short renal veins is considered more challenging, many surgeons prefer left kidneys for transplantation. Therefore, our hypothesis is that the implantation of right kidneys from living and deceased donors is associated with more technical graft failures as compared to left kidneys.

Methods

Two consecutive cohorts of adult renal allograft recipients of living (n = 4.372) and deceased (n = 5.346) donor kidneys between January 1, 2000 and January 1, 2013 were analyzed. Data were obtained from the prospectively maintained electronic database of the Dutch Organ Transplant Registry. Technical graft failure was defined as failure of the renal allograft within 10 days after renal transplantation without signs of acute rejection.

Results

In the living donor kidney transplantation cohort, the implantation of right donor kidneys was associated with a higher incidence of technical graft failure (multivariate analysis p = 0.03). For recipients of deceased donor kidneys, the implantation of right kidneys was not significantly associated with technique-related graft failure (multivariate analysis p = 0.16).

Conclusions

Our data show that the implantation of right kidneys from living donors is associated with a higher incidence of technique-related graft failure as compared to left kidneys.

Renal retransplantation after kidney and pancreas transplantation using the renal vessels of the failed allograft: pitfalls and pearls

Renal retransplantation after a failed prior kidney and pancreas transplant is being increasingly performed. In these complex cases, both iliac fossae have been used for prior transplants, and the placement of the new allograft can be problematic. We describe our experience with an alternative technique for renal retransplantation (RRTx) in the setting of severe bilateral aortoiliac atherosclerosis or scarring and fibrosis on the iliac vessels. Nephrectomy of the failed allograft is performed, and the renal vessels of the failed allograft (RVFA) are preserved. The new kidney is implanted on RVFA at the same operative time. This technique was attempted and successfully accomplished in a total of six patients (mean operative time = 240 ± 63 min). One postoperative complication occurred: poor arterial inflow to the allograft, being corrected reoperatively. Hospitalizations ranged from five to eight d. Five of the six patients were alive with a functioning allograft at last follow-up (a single graft failure occurred 21 months postoperatively in the setting of post-transplant lymphoproliferative disease that also led to patient death). Renal vessels of the failed allograft seem to be suitable alternative vascular conduits for renal retransplantation after prior kidney and pancreas transplants.