Does kidney transplantation with multiple arteries affect graft survival?

A Retrospective Analysis of the 1-Year Graft Survival Rate in Indonesian Renal Transplant Recipients With Multiple Renal Arteries

BACKGROUND

Renal transplantation is the preferred treatment for end-stage renal disease because of its association with improved survival and quality of life. The debate over multiple renal arteries (MRA) vs a single renal artery regarding kidney function, posttransplant complications, and graft and patient survival remains ongoing. Our goal was to determine the 1-year graft survival rate among renal transplant recipients with MRA at Cipto Mangunkusumo Hospital in Jakarta.

METHODS

A retrospective study was conducted between January 2012 and December 2020, including all kidney transplant candidates with MRA. Data on graft survival, patient demographics, previous renal transplantation, duration of hemodialysis, and delayed graft function were collected and analyzed using SPSS 24. Kaplan-Meier plots and Cox regression analyses were used to determine risk factors for 1-year survival.

RESULTS

Among 752 renal transplant recipients, 104 cases had MRA. The majority were men (71.5%), and the median age of recipients was 47 years. One-year graft survival was observed in 96% of cases, whereas patient survival was 97.7%. No significant difference was found in graft survival based on the number of arteries (single renal artery vs MRA), length of hemodialysis, or previous renal transplantation. However, delayed graft function was significantly associated with graft survival.

CONCLUSION

This study highlights that 1-year graft survival in renal transplant recipients with MRA is not significantly affected by the length of hemodialysis before surgery or previous renal transplantation.

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.

Transplanting a left or right donor kidney into the left or right iliac fossa: importance of laterality and site of venous anastomosis

Data on the impact of donor-to-recipient laterality on kidney transplantation are lacking. This study evaluated the impact of donor-to-iliac fossa laterality and the site of venous anastomosis on operating time and surgical outcome. This retrospective single-center study analyzed 1262 deceased donor adult kidney transplants into pristine iliac fossa. Multivariable linear and logistic regression analyses were used to identify variables with an impact on operating time and surgical complications. Operating time was shorter by 11 min in median for transplantations into the right iliac fossa compared to the left iliac fossa (p < 0.001). Operating time in left-to-right donor-to-recipient combination was shorter by 17 min in median if venous anastomoses were performed on the caval vein or common iliac vein as compared to anastomoses to the external iliac vein (p < 0.001). Overall, the shortest operating times (median 112.5 min) were achieved in left-to-right donor-to-recipient combinations with venous anastomosis to the caval or common iliac vein, without an increase in surgical complications. Kidney transplantation into the right iliac fossa with anastomosis to the caval vein or the common iliac vein saves operating time and reduces thrombotic complications. Acceptance of a left donor kidney is likely to further reduce operating time.

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.

Clinical Outcomes Following Single vs. Multiple Vessel Living-Donor Kidney Transplantation: A Retrospective Comparison of 210 Patients

Background: The use of living-donor kidney allografts with multiple vessels continues to rise in order to increase the donor pool. This requires surgeons to pursue vascular reconstructions more often, which has previously been associated with a higher risk of developing early post-transplant complications. We therefore wanted to investigate the prognostic role of using living-donor renal allografts with a single artery (SA) vs. multiple arteries (MA) at the time of transplant.

Methods: We retrospectively analyzed a cohort of 210 consecutive living-donor kidney transplants performed between January, 2008 and March, 2019, and compared the incidence of developing postoperative complications and other clinical outcomes between SA vs. MA recipients.

Results: No differences were observed between SA (N = 161) and MA (N = 49) kidneys in terms of the incidence of developing a postoperative (or surgical) complication, a urologic complication, hospital length of stay, delayed graft function, estimated glomerular filtration rate at 3 or 12 mo post-transplant, and graft survival.

Conclusions: The use of live-kidney allografts with MA requiring vascular reconstruction shows excellent clinical outcomes and does not increase the risk of developing postoperative complications or other adverse outcomes when compared with SA renal allografts.

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.

Double Single-Side Kidney Transplants With Bench Vascular Reconstruction: A Further Challenge Beyond the Marginality Without Future Preclusions

BACKGROUND

Double kidney transplantation allows the use of marginal kidneys with a significant improvement in the recovery of renal function expected after transplantation, although with a greater anesthesiologic and surgical risk. One-sided positioning, more cautious in the event of functional exhaustion, can be complex due to vascular anomalies.

MATERIALS AND METHODS

We report the case of 2 double unilateral kidney transplants with vascular reconstructions. The first is a double kidney transplant from a 83-year-old donor. Both kidneys (score 5) had 2 arteries and the arterial patch was not usable. A cryopreserved arterial graft was used for the packaging of an arterial axis with which a single T-L anastomosis was performed; the 2 veins were also joined with the packaging of a single anastomosis. The second case is a double kidney transplant from a cadaveric donor performed on a recipient suffering from severe diffuse atheromasia. The right kidney had 2 arteries and the left kidney had 3 arteries (both score 5). The aortic patches and veins of the 2 kidneys were joined together and a single arterial and venous anastomosis was performed.

RESULTS

The course has been uneventful. In both cases there were no perioperative vascular complications.

CONCLUSIONS

The use of marginal organs is an increasingly common reality. Bench vascular reconstructions can further increase donation resources, safely enhancing the transplantation of already marginal organs that would otherwise not be usable and allowing the contralateral vascular axis to be kept intact.

Evaluation of Vascular Structures of Living Donor Kidneys by Multislice Computed Tomography Angiography before Transplant Surgery: Is Arterial Phase Sufficient for Determination of Both Arteries and Veins?

Objectives

The aim of our study was to determine the efficacy of preoperative early arterial Computed tomography angiography (CTA) in donor nephrectomy, to assess the renal arterial and venous structures of donor kidneys.

Materials and Methods

Seventy living donor candidates were included to this study, who had CTA for the assessment of their renal vessels in our hospital between January 2011 and January 2015. Only early arterial phase images were obtained to avoid exposing the patients from high dose of radiation. Scans were reported by two radiologists independently. The number of renal arteries, veins and their tributaries were documented. The donor kidneys were removed by two consultant surgeons, and after back-table perfusion the same details were recorded and taken as the reference findings for the operation side.

Results

A total of 70 potential live kidney donors underwent renal CTA, among them fifty five patients had donor nephrectomy. A total of 140 kidneys were evaluated by CTA and the vessels of 55 harvested kidneys were compared with CTA findings. There were 40 kidneys that had at least one accessory or polar artery. There were 5 early branching renal arteries, two retroaortic and two circumaortic renal veins. Three kidneys had multiple renal veins. Operation findings were totally consistent with CTA findings in patients who underwent donor nephrectomy.

Conclusion

Arterial phase CTA is sufficient for evaluation of both arterial and venous vessels of kidneys, and precontrast, venous or late phase imaging should be preserved only for chosen circumstances to avoid high radiation exposure.

Morphological and clinical aspects of the occurrence of accessory (multiple) renal arteries

Renal vascularization variants vastly differ between individuals due to the very complex embryogenesis of the kidneys. Moreover, each variant may have implications for clinical and surgical interventions. The number of operating procedures continues to grow, and includes renal transplants, aneurysmorrhaphy and other vascular reconstructions. In any surgical technique, unawareness of the presence of multiple renal arteries may result in a fatal outcome, especially if laparoscopic methods are used. The aim of this review is to comprehensively identify the variation within multiple renal arteries and to highlight the connections between the presence of accessory renal arteries and the coexistence of other variants of vascularization. Another aim is to determine the potential clinical implications of the presence of accessory renal arteries. This study is of particular importance for surgeons, intervention radiologists, nephrologists and vascular surgeons.

Risk Balancing of Cold Ischemic Time against Night Shift Surgery Possibly Reduces Rates of Reoperation and Perioperative Graft Loss

Background. This retrospective cohort study evaluates the advantages of risk balancing between prolonged cold ischemic time (CIT) and late night surgery. Methods. 1262 deceased donor kidney transplantations were analyzed. Multivariable regression was used to determine odds ratios (ORs) for reoperation, graft loss, delayed graft function (DGF), and discharge on dialysis. CIT was categorized according to a forward stepwise pattern ≤1h/>1h, ≤2h/>2h, ≤3h/>3h,…, ≤nh/>nh. ORs for DGF were plotted against CIT and a nonlinear regression function with best R² was identified. First and second derivative were then implemented into the curvature formula k(x) = f′′(x)/(1 + f′(x)²)^3/2 to determine the point of highest CIT-mediated risk acceleration. Results. Surgery between 3 AM and 6 AM is an independent risk factor for reoperation and graft loss, whereas prolonged CIT is only relevant for DGF. CIT-mediated risk for DGF follows an exponential pattern f(x) = A · (1 + k · e^{(I · x)}) with a cut-off for the highest risk increment at 23.5 hours. Conclusions. The risk of surgery at 3 AM–6 AM outweighs prolonged CIT when confined within 23.5 hours as determined by a new mathematical approach to calculate turning points of nonlinear time related risks. CIT is only relevant for the endpoint of DGF but had no impact on discharge on dialysis, reoperation, or graft loss.

Surgical complications and graft survival in pediatric kidney transplant recipients treated with a steroid-free protocol: experiences from a Danish university hospital

BACKGROUND

The outcome of pediatric kidney transplantation depends on several factors, among these are the complications, which occur in relation to the surgical procedure. In this study, we present our experience with pediatric kidney transplantation in a steroid-free immunosuppression regimen, from a surgical point of view.

METHODS

Patient charts of pediatric kidney transplantations in the period 1998-2011 were reviewed. Surgical complications, acute rejection, and patient and graft survivals were recorded.

RESULTS

Sixty-one renal transplantations were performed in 58 patients. Thirty patients (49.1%) experienced a surgical complication, of which 11 (18%) required an explorative laparotomy. Overall the five-year Kaplan-Meier patient survival rate was 96.2% and the graft survival rate was 88.6%. Nine patients (14.7%) had an acute rejection episode within the first year after transplantation. No correlation was observed between surgical complications and acute rejection episodes or graft loss.

CONCLUSIONS

This study indicated a high incidence of surgical complications among pediatric kidney transplantations when using a steroid-free immunosuppression regimen. Despite this, we observed high overall patient and graft survival, supporting the trend toward steroids avoidance in pediatric kidney transplantation.

Meticulous use of techniques for reconstruction of multiple renal arteries in live donor kidney transplantation

BACKGROUND

The aims of this study were to provide an overview of techniques for renal artery reconstruction and to introduce a novel technique using the gonadal vein as a "Carrel patch."

MATERIALS AND METHODS

From January 2005 to December 2011, we performed 128 live donor kidney transplantations. All donor nephrectomies used laparoscopic surgery, yielding 23 grafts with 2 and 3 with 3 renal arteries. The reconstruction technique was based on the length and caliber of the arteries. For 3 renal arteries, we used the gonadal vein as a "Carrel patch". The gonadal vein was harvested with the ureter as a bundle during nephrectomy. The recipients were 1.5 to 71 years old (average, 43.9).

RESULTS

All laparoscopic donor nephrectomies were performed successfully with preservation of the multiple arteries. The reconstructions were satisfactory; all grafts functioned immediately. There was no arterial infarction on postoperative Doppler ultrasound and renal nuclear scan. Renal artery stenosis occurred in 2 cases, in which the interventional balloon dilatation was first used; 1 case required subsequent stent insertion.

CONCLUSION

In cases of multiple renal arteries, the live donor kidney can be recovered safely by laparoscopic surgery. Our technique to reconstruct multiple renal arteries uses the gonadal vein as a "Carrel patch." The gonadal vein is readily available during laparoscopic donor nephrectomy.

A novel technique for reconstruction of multiple renal arteries in live donor kidney transplantation: a case report and literature review

BACKGROUND

Reconstruction for three renal arteries from a living donor becomes a real challenge as the limited material can be used when compared with deceased donors. Therefore, in this report we introduce a novel technique by using the gonadal vein as a Carrel patch for reconstruction with three renal arteries. The other techniques will also be reviewed in this report.

METHODS

The living donor is a 51-year-old woman with three renal arteries on the left side and one renal artery on the right side, but with early branching 15 mm from the origin. The recipient is her husband, a 56-year-old with end-stage kidney disease secondary to type II diabetes. A left laparoscopic donor nephrectomy was performed successfully. The three renal arteries were anastomosed to the gonadal vein patch in a parallel fashion. Thereafter, the gonadal vein patch was anastomosed to the side of external iliac artery. The renal vein was anastomosed to the side of external iliac vein.

RESULTS

The kidney was reperfused rapidly and uniformly. The kidney functioned immediately. Doppler ultrasound and renal nuclear scans revealed that the perfusion of the kidney was normal. The creatinine level was 158 umol/L at day 7 and stable at 140 umol/L during the 2-month follow-up examination.

CONCLUSIONS

The gonadal vein can be used as a Carrel patch for multiple renal artery reconstruction, in particular, for more than two renal arteries. This technique provides a new approach for the reconstruction of multiple renal arteries in living donor kidney transplantations.