PTFE Mesh in Renal Allograft Compartment Syndrome

Local Renal Treatments for Acute Kidney Injury: A Review of Current Progress and Future Translational Opportunities

Acute kidney injury (AKI) constitutes a significant public health concern, with limited therapeutic options to mitigate injury or expedite recovery. A novel therapeutic approach, local renal treatment, encompassing pharmacotherapy and surgical interventions, has exhibited positive outcomes in AKI management. Peri-renal administration, employing various delivery routes, such as the renal artery, intrarenal, and subcapsular sites, has demonstrated superiority over peripheral intravenous infusion. This review evaluates different drug delivery methods, analyzing their benefits and limitations, and proposes potential improvements. Renal decapsulation, particularly with the availability of minimally invasive techniques, emerges as an effective procedure warranting renewed consideration for AKI treatment. The potential synergistic effects of combined drug delivery and renal decapsulation could further advance AKI therapies. Clinical studies have already begun to leverage the benefits of local renal treatments, and with ongoing technological advancements, these modalities are expected to increasingly outperform systemic intravenous therapy.

Introducing a New Technique for Fascial Closure to Avoid Renal Allograft Compartment Syndrome in Pediatric Recipients: The Use of Tutoplast® Fascia Lata

Introduction

Renal allograft compartment syndrome (RACS) is a complication that infrequently occurs after renal transplantation. Tight muscle closure may lead to RACS due to compression of renal parenchyma or kinking of the renal vessels. Many techniques have been proposed in an attempt to achieve tension-free closure, which can be specially challenging in child recipients. We present our experience with Tutoplast^® Fascia Lata (RTI Surgical Tutogen Medical GmbH Industriestrasse 6, 91077 Neunkirchen am Brand, Germany) closure.

Methods

All pediatric patients who underwent renal transplantation in our center between 2012 and 2021 were reviewed. Eight patients with Tutoplast^® Fascia Lata placed at the time of initial transplantation were identified. Donor and recipient characteristics, Doppler ultrasound findings, and overall patient and graft survival rates were analyzed.

Results

Doppler ultrasound was performed intra-operatively after abdominal wall closure. If any sign of vascular compromise was seen, the abdominal wall was opened and the graft was revised. The Tutoplast^® Fascia Lata implant was used to perform tension-free fascia closure and, afterwards, a Doppler ultrasound was performed to confirm the optimal renal artery perfusion and venous patency. Three of the renal transplantations were from a cadaver donor, with two of them en bloc. Living donor transplantation was performed in four cases. Among which, there was a case of auto-transplantation due to bilateral renal artery stenosis. None of the patients presented any complications of either short or long term that was derived from the abdominal closure with Tutoplast^® Fascia Lata. There was also no record of graft failure till datum.

Conclusions

Restricted volume of the recipient pelvic cavity and the size discrepancy between the recipient pelvic cavity space and the donor adult kidney may lead to RACS. Other situations that occur more infrequently, i.e., as en bloc or auto-transplantation, are prone to suffer the same problem. Tutoplast^® Fascia Lata is a safe option for these patients.

Abdominal wall complications after kidney transplantation: A clinical review

Introduction

Abdominal wall complications are common after kidney transplantation, and although they have a minor impact on patient and graft survival, they increase the patient's morbidity and may have an impact on quality of life. Abdominal wall complications have an overall incidence of 7.7–21%.

Methods

This review will explore the natural history of abdominal wall complications in the kidney transplant setting, with a special focus on wound dehiscence and incisional herni, with a particular emphasis on risk factors, clinical characteristics, and treatment.

Results

Many patient‐related risk factors have been suggested, including older age, obesity, and smoking, but kidney transplant recipients have an additional risk related to the use of immunosuppression. Wound dehiscence usually does not require surgical intervention. However, for deep dehiscence involving the fascial layer with concomitant infection, surgical treatment and/or negative pressure wound therapy may be required.

Conclusions

Incisional hernia (IH) may affect 1.1–18% of kidney transplant recipients. Most patients require surgical treatment, either open or laparoscopic. Mesh repair is considered the gold standard for the treatment of IH, since it is associated with a low rate of postoperative complications and an acceptable rate of recurrence. Biologic mesh could be an attractive alternative in patients with graft exposition or infection.

Complications of surgical mesh patches after kidney transplantation in children-A case series

BACKGROUND

Abdominal compartment syndrome after kidney transplantation in pediatric recipients is a recognized complication relating to size discrepancy requiring abdominal wall closure over a large adult allograft. In order to circumvent this problem, our center implemented use of a surgical mesh, Surgisis^® (Cook Surgical, Bloomington, IN), for abdominal wall closure in very small children to increase the surface covering over the organ and prevent compression. In this article, we report on the complications encountered following the use of these mesh patches.

METHODS

A retrospective case review was conducted of all pediatric kidney transplants from September 2006 to December 2018 and divided into abdominal wall closure with and without implantation of Surgisis^® mesh patch. Review of clinical notes was performed to identify information with respect to clinical course and post-operative outcomes.

RESULTS

A surgical mesh patch was used in 7 pediatric recipients, of which 5 (71%) presented with post-operative complications. Three recipients were found to have bowel obstruction related to the surgical patch, necessitating bowel resection in one child. In addition, three children developed large serous fluid collections between the subcutaneous layers and the surgical mesh, requiring surgical drainage in two.

CONCLUSIONS

In view of these findings, we recommend close surveillance for potential complications in this cohort. Future research is needed to explore the safety of different approaches to achieve abdominal wall closure in this group.

Renal Allograft Compartment Syndrome: A Case Report and Review of the Literature

Kidney transplantation is the treatment of choice for patients with ESRD. One rare complication after transplantation is the development of renal allograft compartment syndrome (RACS). We present a case of 1 patient who developed RACS due to compression of the transplant vein, which was then treated by salvaging the kidney transplant using urgent decompression surgery with mesh fascial closure. We postulate that this technique is safe and should be the treatment of choice for patients with RACS.

Laparoscopic Repair of Boundary Incisional Hernia in a Kidney Transplant Patient: A Safe Tacks-Fibrin Glue Combined Mesh Fixation Technique

BACKGROUND

Incisional hernia in renal transplant patients is a complication that negatively affects the global outcome of transplant and quality of life. The repair of this condition was classically made by open repair with mesh. Increasing evidence suggests that laparoscopic repair could be advocated as the technique of choice in these patients with optimal results. However, the fixation of mesh should be performed by a mixed combination of fibrin sealant (lateral margin of wall defect) and tacks (medial margin). The tacks fixation of the mesh along the lateral margin of the wall defect, close to the graft, is generally difficult for the small size of the remaining aponeurotic plane and dangerous for the underlying presence of the graft.

MATERIALS AND METHODS

A case of incisional hernia in a kidney transplant recipient was repaired by laparoscopic mesh technique. The polypropylene-polyglycolic acid composite mesh was fastened with a mixed technique of absorbable tacks for medial margin of the defect and fibrin sealant for the lateral side in contiguity with graft surface.

RESULTS

The patient was discharged after 4 days. The 6-month follow-up did not show mesh displacement or recurrence of hernia.

CONCLUSIONS

The laparoscopic mesh repair may become the criterion standard for kidney transplant patients affected by incisional hernia. The difficulties of mesh fixation close to the graft can be overcome by the combination of fibrin sealant glue and absorbable tacks at different margins of the wall defect. This technique may offer advantages for this population of patients.

Abdominal compartment syndrome: an underrated complication in pediatric kidney transplantation

The transplantation of a large kidney in small children can lead to many complications, including an underrated complication known as abdominal compartment syndrome (ACS), which is defined as intra-abdominal pressure (IAP)≥20 mm Hg with dysfunction of at least one thoracoabdominal organ. Presenting signs of ACS include firm tense abdomen, increased peak inspiratory pressures, oliguria, and hypotension. Between June 1, 1985, and September 30, 2013, our center performed 420 kidney transplants (deceased/living related donors: 381/39) in 314 pediatric recipients (female/male: 147/167). ACS occurred in 9 pediatric patients (weight<15 kg) who received a large kidney from adult donors. In 1 case, the patient underwent abdominal decompression with re-exploration and closure with mesh in the immediate postoperative period. In a second case, the patient developed a significant respiratory compromise with hemodynamic instability necessitating catecholamines, sedation, and assisted ventilation. For small children transplanted with a large kidney, an early diagnosis of ACS represents a critical step. From 2005 we have measured IAP during transplantation via urinary bladder pressure, and immediately after wound closure we use intraoperative and postoperative duplex sonography to value flow dynamics changes. We recommend that bladder pressure should be routinely checked in small pediatric kidney recipients who are transplanted with a large graft.

Salvaging kidneys with renal allograft compartment syndrome

Renal allograft compartment syndrome is an under recognized cause of early allograft dysfunction which can be reversed by early intervention. It occurs early after renal transplantation where closure of the anterior abdominal wall seems to compress the transplant in the limited retroperitoneal space. The literature about this syndrome in renal transplantation is sparse. Our report describes the diagnostic criteria and the management of two renal transplant recipients with this syndrome. Its diagnosis depends upon duplex vascular scan findings of reversed or absent diastolic flow in the renal vasculature in the absence of any perigraft collection or severe acute tubular necrosis. In our hands emergency laparotomy, decompression of the transplant and closure with interposition mesh salvaged these kidneys.

Use of intraperitoneal ePTFE Gore dual-mesh plus in a giant incisional hernia after kidney transplantation: a case report

We evaluated the incidence of and predisposing factors for an incisional hernia after kidney transplantation. Numerous techniques have been used to repair postoperative fascial dehiscences or simple incisional hernias, but no clear treatment exists for giant hernias. Our aim was to obtain (1) a safe procedure to repair a large abdominal defect and reinforce the surrounding, fragile zones and (2) a simple, rapid technique to reduce the operative time. Herein we have described the surgical repair of a giant incisional hernia using intraperitoneal Gore ePTFE dual-mesh plus (Gore-Tex; W. L. Gore, Flagstaff, Ariz, USA) in a 55-year-old man status-post renal transplantation. Total necrosis of distal graft ureter had caused a giant urinoma. The patient was reexplored on day 2 posttransplantation with a primary fascial approximation. Thirty days after transplantation we discovered a large incisional hernia and performed a repair. No drain was used. The patient continued immunosuppressive therapy (cyclosporine, mycophenolate mofetil, prednisolone) and was discharged on postoperative day 4 with no complications. An ultrasonographic follow-up at 1 year revealed the prosthesis to be correctly positioned. Incisional hernia is not rare after renal transplantation but the real incidence is unknown. Immunosuppressive therapy, prolonged pretransplantation dialysis, obesity, and diabetes are probably the major causes of incisional hernias in these patients. Surgical complications of renal transplantation surgery, such as wound hematoma, urinoma, and lymphocele, are the most important predisposing factors for an incisional hernia. The use of intraperitoneal ePTFE dual-mesh is feasible, safe, and easy to repair a large incisional hernia in a kidney transplant patient.