En bloc and dual kidney transplantation: two initial cases from a new kidney transplantation center

Successful Pediatric Kidney Transplantation Into an Adult Recipient: A Case Report

BACKGROUND

The constant shortage of kidney donors prompts exploration into new strategies of transplantation. One of these strategies is the use of pediatric donors aged up to 5 years whose kidneys can be transplanted into adult recipients, mainly en bloc. This involves retrieving kidneys en bloc with aorta and inferior vena cava and anastomosing them to the recipient's external iliac vessels.

CASE PRESENTATION

In our hospital, kidneys from a 3-year-old child were transplanted to a 30-year-old man. The recipient with end-stage renal failure, due to glomerular nephritis, was dialyzed for 12 years and had 1 failed transplantation with consequent graftectomy. In 2009, kidneys were transplanted to the external iliac artery and vein with reconstruction of the renal vessels. Shortly after transplantation the patient had normal renal measures. Three months later a critical stenosis of 1 renal artery was detected. Angioplasty was performed but technical reasons did not allow for effective dilatation of the vessel. Further, 6 months after kidney transplantation (KTx) nephrotic proteinuria appeared and features of membranous nephropathy were detected in a renal biopsy. The proteinuria subsided after administration of ramipril and losartan. Doppler ultrasound revealed that 1 artery remained 90% stenotic with a peak systolic velocity of 377 cm/sec. Despite reported complications, renal function appeared normal over 7 years of observation.

CONCLUSIONS

A transplantation of 2 pediatric kidneys into an adult recipient has very high efficacy. The survival of both graft and recipient is similar to the results obtained after living donor kidney transplantation.

Graft Growth and Podocyte Dedifferentiation in Donor-Recipient Size Mismatch Kidney Transplants

Background

Kidney transplantation is the treatment choice for patients with end-stage renal diseases. Because of good long-term outcome, pediatric kidney grafts are also accepted for transplantation in adult recipients despite a significant mismatch in body size and age between donor and recipient. These grafts show a remarkable ability of adaptation to the recipient body and increase in size in a very short period, presumably as an adaptation to hyperfiltration.

Methods

We investigated renal graft growth as well as glomerular proliferation and differentiation markers Kiel-67, paired box gene 2 and Wilms tumor protein (WT1) expression in control biopsies from different transplant constellations: infant donor for infant recipient, infant donor for child recipient, infant donor for adult recipient, child donor for child recipient, child donor for adult recipient, and adult donor for an adult recipient.

Results

We detected a significant increase in kidney graft size after transplantation in all conditions with a body size mismatch, which was most prominent when an infant donated for a child. Podocyte WT1 expression was comparable in different transplant conditions, whereas a significant increase in WT1 expression could be detected in parietal epithelial cells, when a kidney graft from a child was transplanted into an adult. In kidney grafts that were relatively small for the recipients, we could detect reexpression of podocyte paired box gene 2. Moreover, the proliferation marker Kiel-67 was expressed in glomerular cells in grafts that increased in size after transplantation.

Conclusions

Kidney grafts rapidly adapt to the recipient size after transplantation if they are transplanted in a body size mismatch constellation. The increase in transplant size is accompanied by an upregulation of proliferation and dedifferentiation markers in podocytes. The different examined conditions exclude hormonal factors as the key trigger for this growth so that most likely hyperfiltration is the key trigger inducing the rapid growth response.

En bloc kidney transplantation from a 24 month-old donor to an adult recipient: case presentation and literature review

Paediatric kidney transplantation into adult recipients is a well-recognised technique. However, there are different opinions regarding two methods of transplantation. These two opinions are single kidney transplantation (SKT) and en bloc kidney transplantation (EBKT) from donors up to 20 kg. We are reporting the first successful en bloc kidney transplantation from a small, paediatric donor into an adult recipient in our institution and discussing the appropriate recent literature regarding possible concerns using this technique. Despite the fact that paediatric donors are uncommon and surgical experiences are limited, en bloc kidney transplantation can be performed successfully and could be used to expand the donor pool.

Dual Kidney Transplantation From Pediatric Donors to Adult Recipients

BACKGROUND

The organ shortage is a global problem. A potential approach to expanding the deceased donor pool is to harvest organs from pediatric patients.

METHODS

Seven cases of dual kidney transplantation from pediatric donors to adult recipients were performed between 2012 and 2014 in our center. The proximal end of the donor aorta (AO) was anastomosed to the right common iliac artery or external artery. The proximal end of the donor inferior vena cava (IVC) was anastomosed to the right external iliac vein. Recipients received basiliximab or antithymocyte globulin as induction therapy, followed by tacrolimus, mycophenolate mofetil, and prednisone. Prophylactic anticoagulation was not universal in our study.

RESULTS

During the 21-month study period, both patient and graft survivals were 100%. No patient showed thrombotic complications. Complications included an acute rejection episode in 1 patient, urine leakage in 2, and anticoagulation related hemorrhage in 1. All recipients had excellent graft function with normal serum creatinine ranging from 0.49 to 1.45 mg/dL and estimated glomerular filtration rate ranging from 56.89 to 145.27 mL/min/1.73 m(2).

CONCLUSIONS

Dual kidney transplantation from pediatric donors to adult recipients is a promising way to expand the donor pool. Using the proximal end of the AO/IVC for anastomosis brings satisfactory results.

Preemptive Kidney Transplantation: The Initial Experience of a Single Center

BACKGROUND

Kidney transplantation is the best treatment method for end-stage renal disease. Outcomes of the preemptive kidney transplantation are better than non-preemptive kidney transplantation. Preemptive kidney transplantation is performed as a small percentage of kidney transplantations worldwide. We performed 15 preemptive kidney transplantations from living donors between November 2010 and April 2014. We present our experiences and outcomes for these 15 preemptive kidney transplantations.

METHODS

We performed 110 kidney transplantations between November 2010 and April 2014. Fifteen of the kidney transplantations were performed from living related donors to preemptive recipients. These 15 preemptive recipients and their donors' data were collected and retrospectively analyzed.

RESULTS

The mean age of recipients and donors was 37.2 years (range, 4-60) and 50.6 years (range, 28-64), respectively. The male-female ratios were 10:5 in the recipients and 8:7 in the donors. Nine left kidneys and 6 right kidneys were recovered. Nine kidneys had a single artery; the other 6 kidneys had 2 renal arteries. The mean warm ischemic time was 219.5 seconds (range, 90-480). The mean hospitalization times were 5.9 days (range, 4-10) and 4.9 days (range, 3-9) for the recipients and the donors, respectively. The mean follow-up time was 20.3 months (range, 0.5-37) for recipients. Graft survival was 100% in this period. BK virus nephropathy occurred in only 1 pediatric recipient. One patient had a recurrent disease that was the cause of the renal failure. They graft functions were stable. No kidney was lost from rejection, technical causes, infection, or recurrent disease. The donors live their lives with no problems.

CONCLUSIONS

Preemptive kidney transplantation is a better therapeutic option than is non-preemptive kidney transplantation for patients with chronic renal failure. Kidney transplantation should be performed if possible before beginning dialysis for these patients.

En bloc kidney transplant from an 18-month-old donor to an adult recipient: Case report and literature review

INTRODUCTION

There is an ever-increasing need for organ donations globally. Paediatric kidney transplantation into adult recipients is a well-recognised technique to expand the donor pool. The transplantation can be done either via en bloc kidney transplant (EBKT) or as single kidney transplantation (SKT).

PRESENTATION OF CASE

An EKBT from a 18-month-old (15 kg) male patient was transplanted in a 35-year old, 85 kg male with end stage renal failure (ESRF), secondary to Focal Segmental Glomerulosclerosis (FSGS) on haemodialysis. Post-operative recovery was uneventful. Immuno-suppressant drugs used were tacrolimus, basiliximab and prednisolone. Doppler ultrasound scans performed post-operatively showed normal renal resistive indices in both kidneys. Serum creatinine decreased from 1200 to 170 μmol/L 57 with eGFR improving from 4 to 38 mL/min/1.73 m² at four weeks post-transplant.

DISCUSSION

Given the low incidence of paediatric donors, EBKTs are relatively uncommon and subsequently published series tend to be centre specific with small numbers. The graft survival rates tell us that paediatric kidney donors should not be considered as marginal transplants. The difficulty is in determining when it is more appropriate to perform a paediatric EBKT as opposed to splitting and performing two SKT. Unfortunately there are no widely accepted guidelines to direct clinicians.

CONCLUSION

This case report highlights the first EKBT performed at our institution. The current literature demonstrates that paediatric donors are excellent resources that should be procured whenever available.