Is Severe Atherosclerosis in the Aortoiliac Region a Contraindication for Kidney Transplantation?

Aortobifemoral Bypass in Kidney Transplant Candidates: A Ten-Year Experience

In patients with severe aorto-iliac calcifications, vascular reconstructions can be performed in order to allow kidney transplantation. The aim of this study was to analyze the outcomes of kidney transplant candidates who underwent an aortobifemoral bypass (ABFB) for aorto-iliac calcifications. A retrospective study including all kidney transplant candidates who underwent an ABFB between 2012 and 2022 was performed. Primary outcome was 30-day morbidity-mortality after ABFB. Secondary outcome was accessibility to kidney transplant waiting list. Twenty-two ABFBs were performed: 10 ABFBs in asymptomatic patients presenting severe aorto-iliac circumferential calcifications without hemodynamic consequences, and 12 ABFBs in symptomatic patients in whom aorto-iliac calcifications were responsible for claudication or critical limb threatening ischemia. Overall 30-day mortality was 0%. Overall 30-day morbidity was 22.7%: 1 femoral hematoma and 1 retroperitoneal hematoma requiring surgical drainage in the asymptomatic group, and 2 digestive ischemia requiring bowel resection and 1 femoral hematoma requiring surgical drainage in the symptomatic group. Among the 22 patients, 20 patients could access to kidney waiting list and 8 patients underwent a kidney transplantation, including 3 living-donor transplantations. Aorto-iliac revascularization can be an option to overcome severe calcifications contraindicating kidney transplantation.

Kidney Transplant Outcomes in Elderly Population: A Systematic Review and Meta-analysis

Context

Owing to population ageing, a growing number of kidney transplants (KTs) in elderly population are being performed. KT is the best treatment for patients with end-stage renal disease (ESRD). However, in older patients, the decision between dialysis and KT can be difficult due to potential inferior outcomes. Few studies have been published addressing this issue, and literature outcomes are controversial.

Objective

To conduct a systematic review and meta-analysis to appraise the evidence about outcomes of KT in elderly patients (>70 yr).

Evidence acquisition

A systematic review and meta-analysis (PROSPERO registration: CRD42022337038) was performed. Search was conducted on PubMed and LILACS databases. Comparative and noncomparative studies addressing outcomes (overall survival [OS], graft survival [GS], complications, delayed graft function [DGF], primary nonfunction, graft loss, estimated glomerular filtrate rate, or acute rejection) of KT in people older than 70 yr were included.

Evidence synthesis

Of the 10 357 yielded articles, 19 met the inclusion criteria (18 observational studies, one prospective multicentre study, and no randomised controlled trials), enrolling a total of 293 501 KT patients. Comparative studies reporting enough quantitative data for target outcomes were combined. There were significant inferior 5-yr OS (relative risk [RR], 1.66; 95% confidence interval [CI], 1.18-2.35) and 5-yr GS in the elderly group (RR, 1.37; 95% CI, 1.14-1.65) to those in the <70-yr group. Short-term GS at 1 and 3 yr was similar between groups, and similar findings occurred with DGF, graft loss, and acute rejection rates. Few data about postoperative complications were reported.

Conclusions

Elderly recipients have worse OS at all time points and long-term GS compared with younger recipients (<70 yr). Postoperative complications were under-reported and could not be assessed. The DGF, acute rejection, death with functioning graft, and graft loss were not inferior in elderly recipients. Geriatric assessment in this setting might be useful for selecting better elderly candidates for KT.

Patient summary

Compared with younger population, kidney transplant in elderly patients has inferior patient and graft survival outcomes in the long term.

KDIGO Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation

The 2020 Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation is intended to assist health care professionals worldwide who evaluate and manage potential candidates for deceased or living donor kidney transplantation. This guideline addresses general candidacy issues such as access to transplantation, patient demographic and health status factors, and immunological and psychosocial assessment. The roles of various risk factors and comorbid conditions governing an individual's suitability for transplantation such as adherence, tobacco use, diabetes, obesity, perioperative issues, causes of kidney failure, infections, malignancy, pulmonary disease, cardiac and peripheral arterial disease, neurologic disease, gastrointestinal and liver disease, hematologic disease, and bone and mineral disorder are also addressed. This guideline provides recommendations for evaluation of individual aspects of a candidate's profile such that each risk factor and comorbidity are considered separately. The goal is to assist the clinical team to assimilate all data relevant to an individual, consider this within their local health context, and make an overall judgment on candidacy for transplantation. The guideline development process followed the Grades of Recommendation Assessment, Development, and Evaluation (GRADE) approach. Guideline recommendations are primarily based on systematic reviews of relevant studies and our assessment of the quality of that evidence, and the strengths of recommendations are provided. Limitations of the evidence are discussed with differences from previous guidelines noted and suggestions for future research are also provided.

Application of homograft for intraoperative severe atherosclerotictic iliac vessel finding in renal transplantation: A case report

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Severe atherosclerosis is a complicated condition in patients with CKD and as the number of waiting list for renal transplantation rose, the rate is increasing.

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Surgeons should not omit artherosclerosis even pre-operative results did not suggest it.

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One-stage approach (renal transplantation and vascular reconstruction altogether) is a feasible and safe method for treating the conditions.

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The role of the surgeon’s skills and experiences, and especially tissue bank should be highlighted.

Introduction

Severe atherosclerosis is a complicated condition in chronic kidney disease (CKD) and could lead to the operation’s failure, when it was not detectable by pre-operative diagnostic imaging. Several methods including two-stage approach, synthetic graft, stent… have been reported, but complications (i.e. infection, graft rejection) are a matter of concern. The aim of this case is to provide the one-stage approach, in which renal transplantation and vascular reconstruction using fresh homografts from one brain-dead donor were used.

Presentation of case

We reported a case of a 33-year-old male, who was diagnosed with CKD caused by chronic glomerulonephritis since the age of 28 and had been on hemodialysis. Not until did the transplantation take place that the operation team spotted the atherosclerotic external iliac artery, and vessel graft from the same donor was used and the renal was transplanted. The patient was discharged 14 days after the surgery without any complications.

Discussion

Kidney transplantation has revolutionized the life of patients with end-stage renal disease (ESRD). Around 6% of patients have severe atherosclerosis and the figure is increasing. Vascular degradation in ESRD might lead to unsuccessful operation. One-stage approach (including renal transplantation and external iliac artery replacement) using homograft from one doner is feasible to handle the situation.

Conclusion

Severe atherosclerosis often accompanies with CKD. The difficulties of doing arterial anastomosis increases, which requires advanced techniques to deal with. Surgeons should be prepared about this circumstance. One-stage approach using one donor’s homografts, is a possible and safe procedure.

Impact of Aortoiliac Stenosis on Graft and Patient Survival in Kidney Transplant Recipients Using the TASC II Classification

BACKGROUND

Patients with end-stage renal disease and aortoiliac stenosis are often considered ineligible for kidney transplantation, although kidney transplantation has been acknowledged as the best therapy for end-stage renal disease. The clinical outcomes of kidney transplantation in patients with aortoiliac stenosis are not well-studied. This study aimed to assess the impact of aortoiliac stenosis on graft and patient survival.

METHODS

This retrospective, single-center study included kidney transplant recipients transplanted between January 1, 2000, and December 31, 2016, who received contrast-enhanced imaging. Patients with aortoiliac stenosis were classified using the Trans-Atlantic Inter-Society Consensus (TASC) II classification and categorized as having TASC II A/B lesions or having TASC II C/D lesions. Patients without aortoiliac stenosis were functioning as controls.

RESULTS

A total number of 374 patients was included in this study (n = 88 with TASC II lesions, n = 286 as controls). Death-censored graft survival was similar to the controls. Patient and uncensored graft survival was decreased in patients with TASC II C/D lesions (log-rank test P < 0.001). Patients with TASC II C/D lesions had a higher risk of 90-day mortality (hazard ratio, 3.96; 95% confidence interval, 1.12-14.04). In multivariable analysis, having a TASC II C/D lesion was an independent risk factor for mortality (hazard ratio, 3.25; 95% confidence interval, 1.87-5.67; P < 0.001). Having any TASC II lesion was not a risk factor for graft loss (overall P = 0.282).

CONCLUSIONS

Kidney transplantation in patients with TASC II A/B is feasible and safe without increased risk of perioperative mortality. TASC II C/D decreases patient survival. Death-censored graft survival is unaffected.

Simultaneous recipient external iliac endarterectomy and renal transplant - a propensity score matched analysis

Patients with end-stage renal disease and severe iliac atherosclerosis are frequently denied renal transplant due to technical challenges, and risk of potential steal syndrome in the allograft, or ipsilateral limb. Few studies have evaluated the safety and efficacy of performing an endarterectomy in this setting. A single-center retrospective review of renal transplant patients from 1/2013 to 12/2017 was performed. Patients requiring endarterectomy at the time of transplant were matched to a nonendarterectomized cohort in a 1:2 fashion using propensity score matching. Patients were followed for a minimum of 12 months. Simultaneous endarterectomy and renal transplant were performed in 23 patients and subsequently matched to 42 controls. Ankle-brachial index was lower in the endarterectomized group (P = 0.04). Delayed graft function (26.1% vs. 19%, P = 0.54), graft loss (8.7% vs. 7.1%, P = 0.53), 1-year mortality (8.7% vs. 4.8%, P = 0.53), and renal function at 12 months were comparable in both groups. There were no incidents of ipsilateral limb loss in the endarterectomized population. This is the first matched study investigating endarterectomy and renal transplant. Long-term follow-up of limb and graft function is indicated. Despite the small sample size, our findings suggest that a combined procedure can safely provide renal transplantation access to a previously underserved population.

Chimney-Patch Arterial Graft in Kidney or Pancreas Transplantation for Recipients with Heavily Calcified Iliac Arteries

Iliac artery calcification is a common phenomenon complicating renal transplantation, particularly in those with diabetes. The potential for vascular clamp injury can threaten the renal allograft, ipsilateral lower extremity, or both. Utilization of internal balloon occlusion can allow for placement of a "Chimney Patch" graft, fashioned from a deceased donor artery, to the calcified vessel, eliminating the risk of clamp injury and minimizing warm ischemic time. We present a series of 6 patients transplanted with internal balloon occlusion with successful renal and pancreatic allograft function and no ipsilateral vascular complications. Internal balloon occlusion is a safe and effective adjunct for renal or pancreas transplant to prevent clamp injury with no adverse effect on allograft function.

Patient Selection for Kidney Transplant

The incidence of end-stage renal disease has continued to increase. Similarly, the number of patients living with a functioning renal allograft has also increased. Transplantation has improved with advances in surgical techniques, immunosuppression, and better control of comorbid conditions. Transplantation is transformative and offers the greatest potential for restoring a healthy, productive, and durable life to appropriately selected patients. This article describes factors to address in selection of renal transplant candidates and discusses commonly encountered perioperative events. Paramount to selecting appropriate candidates is the collaboration between a multidisciplinary team focused on a systematic process guided by protocols and common practices.

Renal Transplantation with Simultaneous Aortoiliac Reconstruction Using a Polytetrafluoroethylene Vascular Graft for Severe Atherosclerosis

Studies on aortoiliac reconstruction for severe atherosclerosis with renal transplantation are limited. Here, we report a rare experience of the simultaneous reconstruction of the external iliac artery caused by severe atherosclerosis with polytetrafluoroethylene vascular graft and renal transplantation in a 55-year-old female; she was unable to undergo standard renal artery anastomosis to the right external iliac artery because of severe atherosclerosis, which would result in complete occlusion. Next, we directly anastomosed the donor renal artery to the polytetrafluoroethylene graft. After transplantation, delayed graft function occurred; therefore, the patient had to undergo hemodialysis. On day 7 after transplantation, her creatine level started to decrease. She was discharged from the hospital on the 14th day after transplantation. After 1 month, her serum creatinine level reduced to 1.12 mg/dL. After 3 years of transplantation, her serum creatinine level was 1.2 mg/dL. The simultaneous implantation of the polytetrafluoroethylene graft and renal transplantation was feasible as well as safe, with no infectious complications and stable renal function noted on long time follow-up. Although our case was rare, it emphasizes the need for transplant surgeons to gain surgical skills for vascular surgery using vascular grafts.

Surgical Techniques and Procedures for Kidney Transplant Recipients With Severe Atherosclerosis

OBJECTIVES

Atherosclerosis is becoming a more common problem for dialysis patients. Therefore, transplant surgeons are faced with the need to develop surgical techniques and procedures for severe atherosclerosis. This study aimed to clarify the clinical features, the usefulness of examinations, and operative procedures for kidney transplant recipients with the complication of severe atherosclerosis.

MATERIALS AND METHODS

Among 220 kidney transplant candidates, 13 patients (severe atherosclerosis group) were predicted complications due to arterial calcification in the bilateral iliac arterial system using a computed tomographic scan. They were compared with the remaining 207 patients (mild atherosclerosis group) based on patient characteristics. The severe atherosclerosis group was evaluated by additional examination, anastomosis procedure of the graft artery, and patient outcome.

RESULTS

The severe atherosclerosis group had significantly higher rates of mean recipient age, glycosylated hemoglobin A1c, past smoking, and administration of antithrombotics. Past vascular surgery related to atherosclerosis in the aortoiliac region had been performed in 8 patients from the severe atherosclerosis group. A three-dimensional computed tomography angiography and an intraoperative periarterial echography were useful to determine the kidney transplant site. A balloon catheter effectively blocked blood flow. A polytetrafluoroethylene vascular graft was used for bypass between the graft artery and abdominal aorta. All kidney grafts of the severe atherosclerosis group were functioning well.

CONCLUSIONS

Kidney transplant for patients with severe atherosclerosis can be achieved successfully by additional examinations and vascular surgical techniques.

Outcomes of Endovascular Aortic Aneurysm Repair in Kidney Transplant Recipients: Results From a National Quality Initiative

Contrast-induced nephropathy after endovascular aortic aneurysm repair (EVAR) in kidney transplant recipients (KTRs) can have devastating consequences. The Vascular Quality Initiative (VQI) database was queried to select all KTRs who underwent EVAR between January 2003 and December 2014. Our primary outcome was renal dysfunction, defined as acute kidney injury (AKI; elevation of serum creatinine >0.5 mg/dL from baseline) or new postoperative hemodialysis requirement. Within the EVAR VQI dataset, 40 patients were KTRs (40 of 17 213, or 0.2%). Renal dysfunction occurred in five of 40 patients in the KTR group in comparison to 779 of 17 173 patients in the nontransplanted group (12.5% versus 4.5%, p < 0.01). Emergent EVAR was required in 2 (5%) patients, one of whom required dialysis after surgery and subsequently died. One-year survival after EVAR was similar in the two groups (92.9% versus 93.1%, p = 0.73). KTRs who developed renal dysfunction had significantly lower preoperative estimated glomerular filtration rates (eGFRs) (29.5 versus 54.7, p = 0.007) and a significantly higher iodine:eGFR ratio (0.78 versus 0.39, p = 0.02) despite receiving a similar volume of contrast (70.0 versus 68.8, p = 0.97). Renal dysfunction is 3 times more frequent in KTRs treated with EVAR, though overall survival did not differ between the groups. Decreased preoperative eGFR and a higher iodine:eGFR ratio are associated with postoperative renal dysfunction.

Thoracic aorta to femoral artery bypass allows secondary kidney transplantation in case of major iliac artery disease

Iliac artery major calcifications can compromise kidney graft. First-performed prosthetic arterial bypass from the thoracic aorta to the femoral artery allows secondary kidney transplantation. Four patients were submitted to this procedure. No patient died during the postoperative period or the follow-up. The median time to receive a kidney graft after the arterial surgery was 24 months (4-52). The normalization of the sera creatinine level was 6.4 days (2-15). The median follow-up was 38 months (7-79). In our experience, using lateral side clamping of the descendant thoracic aorta during the proximal implantation of the arterial graft avoids bleeding and visceral abdominal ischemia. The secondary performed kidney graft is safe on a very available arterial conduit.