Living Donor Kidney Transplantation With Multiple Renal Arteries in the Laparoscopic Era

Laparo-Endoscopic Single-Site Left Donor Nephrectomy In Patients With Uncommon Renal Vascular Anatomy: Does the Technique Make a Difference?

BACKGROUND

To compare donor and recipient outcomes in patients with renal artery and ante-aortic renal vein vs unusual renal vascular anatomy undergoing laparoendoscopic single-site donor nephrectomy (LESSDN).

METHODS

A retrospective chart review of the comparative study of donor and recipient outcomes of LESSDN in donors with venous abnormality (n = 28, group A), arterial abnormality (n = 74, group B), and standard donors (n = 248, group C).

RESULTS

From September 2016 to August 2022, 350 left LESSDN were performed. The most common anomalies in group A were the retro-aortic and 2 renal veins in 12 patients each. In group B, 72 and 2 patients had 2 and 3 renal arteries, respectively. Operative and warm ischemia times were significantly longer in donors with vascular anomalies. Moreover, patient creatinine on discharge was significantly higher in arterial anomalies; it was 1.61 ± 0.22 compared with 1.26 ± 0.43 and 1.25 ± 0.32 mg/dL for patients with no anomalies and venous anomalies, respectively (P < .001). However, serum creatinine levels recovered after 1 month and were comparable between the study groups. Recipients, operative time, and vascular anastomosis time were significantly longer in recipients with vascular anomaly. Slow graft function was higher in group B (6.9%) than in the other groups. One-year graft survival rates were 96.4%, 94.6%, and 97.1% (P = .496).

CONCLUSION

With increased experience, LESSDN in multiple renal arteries and uncommon venous anatomy cases is feasible and safe. Moreover, it does not influence donor or recipient outcomes.

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.

Recommendations for living donor kidney transplantation

This Guide for Living Donor Kidney Transplantation (LDKT) has been prepared with the sponsorship of the Spanish Society of Nephrology (SEN), the Spanish Transplant Society (SET), and the Spanish National Transplant Organization (ONT). It updates evidence to offer the best chronic renal failure treatment when a potential living donor is available. The core aim of this Guide is to supply clinicians who evaluate living donors and transplant recipients with the best decision-making tools, to optimise their outcomes. Moreover, the role of living donors in the current KT context should recover the level of importance it had until recently. To this end the new forms of incompatible HLA and/or ABO donation, as well as the paired donation which is possible in several hospitals with experience in LDKT, offer additional ways to treat renal patients with an incompatible donor. Good results in terms of patient and graft survival have expanded the range of circumstances under which living renal donors are accepted. Older donors are now accepted, as are others with factors that affect the decision, such as a borderline clinical history or alterations, which when evaluated may lead to an additional number of transplantations. This Guide does not forget that LDKT may lead to risk for the donor. Pre-donation evaluation has to centre on the problems which may arise over the short or long-term, and these have to be described to the potential donor so that they are able take them into account. Experience over recent years has led to progress in risk analysis, to protect donors' health. This aspect always has to be taken into account by LDKT programmes when evaluating potential donors. Finally, this Guide has been designed to aid decision-making, with recommendations and suggestions when uncertainties arise in pre-donation studies. Its overarching aim is to ensure that informed consent is based on high quality studies and information supplied to donors and recipients, offering the strongest possible guarantees.

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.

Safety and Intraoperative Results in Live Kidney Donors with Vascular Multiplicity After Hand-Assisted Laparoscopy Living Donor Nephrectomy

Background and Purpose

Vascular multiplicity is the most frequent anatomic variation in kidney donors. Despite concerns about risks, these allografts are increasingly used to overcome the shortage of kidney donors. The safety and clinical outcomes in living kidney donors were evaluated with vascular multiplicity after hand-assisted laparoscopic living donor nephrectomy (HALDN).

Patients and Methods

Data from all living kidney donors who underwent HALDN from 2008 to 2021 was retrospectively reviewed. Patients were divided into two groups as single (SRV) and multiple renal vessels (MRV), and a comparative analysis was done. The primary outcomes include operating room time (ORT), days of hospital stay, estimated blood loss, complications, conversion, and re-operations.

Results

MRV were present in 166 out of 612 donors (27.1%). Among those, 10 (1.6%) donors had simultaneous multiple arteries and veins. Additionally, the prevalence of artery and vein multiplicity was 21.8% (n = 134) and 3.5% (n = 22), respectively. Warm ischemia time was significantly different among the two groups but not clinically important. The number of conversions to open technique, the mean ORT, the median blood loss, and days of hospital stay were similar between the SRV and MRV groups, without significant differences. According to the modified Clavien-classification system, no differences were found in the complication rates between the two groups (p = 0.29). Complication rates were 3.3% and 3.6% for the SRV and MRV groups, respectively.

Conclusion

HALDN is a procedure with safe intraoperative results, even with vascular multiplicity. The presence of multiple renal arteries or veins has no negative impact on the outcome of the donor after living donor nephrectomy.

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.

Description and Outcomes of Three Different End-to-Side Microsurgical Techniques for the Anastomosis of Accessory Renal Artery With the Dominant Renal Artery in Kidney Transplantation

BACKGROUND

In this study, we compared the outcomes of three different surgical microscope-assisted end-to-side anastomosis techniques between the dominant and accessory renal arteries during living donor kidney transplant.

METHODS

The demographics, serum creatinine levels, warm and cold ischemia times, rate of complications, and incidence of delayed graft function of 135 kidney recipients were analyzed according to the type of arterial anastomosis. Group A (n = 98) had one dominant renal artery (DRA) with one end-to-side anastomosis to the external iliac artery (EIA) using a surgical microscope. Group B (n = 17) had one DRA plus one accessory renal artery (ARA) with two separate end-to-side anastomoses to the EIA using a surgical microscope. Group C (n = 20) had one DRA with end-to-side anastomosis to the EIA and one ARA with an ex vivo on-bench end-to-side anastomosis to the DRA using a surgical microscope.

RESULTS

Compared with groups A and B, the cold ischemia time and the rate of delayed graft function were significantly higher in group C (P ≤ .001). At 6 months after transplant, group B demonstrated a higher creatinine value (2.40 ± 3.41 mg/dL) than group A and group B (P = .032). Also, the decrease in creatinine at postoperative month 6 was limited in group B as compared with groups A and C.

CONCLUSIONS

An end-to-side anastomosis between ARA (group B) and DRA (group A) of the kidney graft using a surgical microscope on the bench ex vivo results in superior outcomes. Single arterial anastomosis techniques are associated with a better function in a 6-month follow-up than two separate arterial anastomoses.

Sequential analysis of single-center experience of living donor kidney transplants with several vascular anastomosis techniques

Background and aim

Vascular variations of grafts are handled with various reconstruction techniques in renal transplantation. We aimed to analyze the effects of these reconstruction techniques and sites on patient/graft outcomes.

Materials and methods

Renal transplantation cases at the Transplantation Unit of the General Surgery Department, İstanbul Uni- versity Cerrahpaşa Medical Faculty between January 1st, 2000 and December 31st, 2012 were analyzed retrospectively. Postoperative duplex ultrasound results, urea-creatinine reduction rates, and complications were evaluated.

Results

There were 228 living-donor transplantation cases evaluated. For single-renal-artery living-donor transplantations, there were 45 end-to-side external iliac artery, 15 end-to-side internal iliac artery, 152 end-to-end internal iliac artery, and 3 end-to-side common iliac artery anastomoses performed. In cases with double-arteries, 3 had end-to-side external iliac artery anastomoses, and 10 had end- to-end internal iliac artery anastomoses. No statistically significant differences were found between reconstruction techniques with regard to complications or urea-creatinine reduction rates.

Conclusion

Internal, external, and common iliac arteries can be safely used for anastomoses. The presence of more than one renal artery creates no short or long-term problems when a side-to-side anastomosis is initially performed.

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 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.

Surgical Technique Notes of Arterial Vascular Reconstruction During Kidney Transplantation: Personal Experience and Literature Review

BACKGROUND

Arterial vascular anomalies in patients undergoing kidney transplantation (KT) are correlated with a higher incidence of early surgical complications, potentially causing graft loss. Arterial reconstruction allows patients to overcome these surgical challenges, thus minimizing the risk of poor outcomes. The aim of the present study is to retrospectively investigate the safety and effectiveness of the multiple arterial reconstruction technique with a Teflon patch in case of an unavailable aortic patch: to do so, surgical complications, graft function, and patient survival were evaluated.

METHODS

During the period January 2009 to August 2016, 202 adult deceased-donor KTs were performed at our center. Group A (n = 27; reconstruction of multiple arteries) and Group B (n = 175; control group) were compared.

RESULTS

No differences were observed between the 2 groups in terms of early postoperative course, with no vascular complication observed in Group A. No vascular patch infections were reported, nor longer cold ischemia time rates. Similarly, long-term survival rates were similar between the 2 groups.

CONCLUSIONS

The Teflon-patch arterial reconstruction technique appears to be safe and effective, with an acceptable balance of benefits and potential risks of using a prosthetic material. Studies based on larger series are needed to further validate this approach.

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.

Vascular Multiplicity Should Not Be a Contra-Indication for Live Kidney Donation and Transplantation

BACKGROUND

Whether vascular multiplicity should be considered as contraindication and therefore 'extended donor criterion' is still under debate.

METHODS

Data from all live kidney donors from 2006-2013 (n = 951) was retrospectively reviewed. Vascular anatomy as imaged by MRA, CTA or other modalities was compared with intraoperative findings. Furthermore, the influence of vascular multiplicity on outcome of donors and recipients was studied.

RESULTS

In 237 out of 951 donors (25%), vascular multiplicity was present. CTA had the highest accuracy levels regarding vascular anatomy assessment. Regarding outcome of donors with vascular multiplicity, warm ischemia time (WIT) and skin-to-skin time were significantly longer if arterial multiplicity (AM) was present (5.1 vs. 4.0 mins and 202 vs. 178 mins). Skin-to-skin time was significantly longer, and complication rates were higher in donors with venous multiplicity (203 vs. 180 mins and 17.2% vs. 8.4%). Outcome of renal transplant recipients showed a significantly increased WIT (30 vs. 26.7 minutes), higher rate of DGF (13.9% vs. 6.9%) and lower rate of BPAR (6.9% vs. 13.9%) in patients receiving a kidney with AM compared to kidneys with singular anatomy.

CONCLUSIONS

We conclude that vascular multiplicity should not be a contra-indication, since it has little impact on clinical outcome in the donor as well as in renal transplant recipients.

Complex kidneys for complex patients: the risk associated with transplantation of kidneys with multiple arteries into obese patients

Conflicting evidence surrounds clinical outcomes in obese individuals after transplantation; nonetheless, many are denied the opportunity to receive a transplant. Allografts with complex vascular anatomy are regularly used in both deceased and living donor settings. We established the risk of transplanting kidneys with multiple renal arteries into obese recipients. A retrospective analysis of data from 1095 patients undergoing renal transplantation between January 2004 and July 2013 at a single centre was conducted. Of these, 24.2% were obese (body mass index >30 kg/m(2)), whereas 25.1% of kidneys transplanted had multiple arteries, thereby making the transplantation of kidneys of complex anatomy into obese recipients a relatively common clinical occurrence. Vessel multiplicity was associated with inferior 1-year graft survival (85.8.% vs 92.1%, P = .004). Obese patients had worse 1-graft survival compared to those of normal BMI (86.8% vs 93.8%, P = .001). The risk of vascular complications and of graft loss within a year after transplantation were greater when grafts with multiple arteries were transplanted into obese recipients as compared to their nonobese counterparts (RR 2.00, CI 95% 1.07-3.65, and RR 1.95, CI 95% 1.02-3.65). Additionally, obese patients faced significantly higher risk of graft loss if receiving a kidney with multiple arteries compared to one of normal anatomy (RR 1.97, 95% CI 1.02-3.72). Thus, obese patients receiving complex anatomy kidneys face poorer outcomes, which should be considered when allocating organs, seeking consent, and arranging for aftercare.

Shifting paradigms in eligibility criteria for live kidney donation: a systematic review

As the organ shortage increases, inherently the demand for donor kidneys continues to rise. Thus, live kidney donation is essential for increasing the donor pool. In order to create successful expansion, extended criteria live kidney donors should be considered. This review combines current guidelines with all available literature in this field, trying to seek and establish the optimal extended criteria. Comprehensive searches were carried out in major databases until November 2013 to search for articles regarding older age, overweight and obesity, hypertension, vascular anomalies/multiplicity, nulliparous women, and minors as donors. Of the 2079 articles found, 152 fell within the scope of the review. Five major guidelines were included and reviewed. Based on the literature search, live kidney donation in older donors (up to 70 years of age) seems to be safe as outcome is comparable to younger donors. Obese donors have comparable outcome to lean donors, in short- and mid-term follow-up. Since little literature is available proving the safety of donation of hypertensive donors, caution is advised. Vascular multiplicity poses no direct danger to the donor and women of childbearing age can be safely included as donors. Although outcome after donation in minors is shown to be comparable to adult donors, they should only be considered if no other options exist. We conclude that the analyzed factors above should not be considered as absolute contraindications for donation.

Multiple renal arteries with renal cell carcinoma: Preoperative evaluation using computed tomography angiography prior to laparoscopic nephrectomy

Objective

To investigate anatomical variations in the renal arteries of patients with renal cell carcinoma (RCC) using computed tomography angiography (CTA).

Methods

Patients diagnosed with RCC were evaluated using CTA prior to undergoing laparoscopic nephrectomy. Any anatomical variations of the renal arteries on the side affected by the RCC were recorded. The CTA results were compared with the observations made during surgery and those produced by conventional digital subtraction angiography.

Results

A total of 107 patients with RCC were enrolled in the study. Multiple renal arteries were found in 11 patients (10.3%). Accessory renal inferior polar arteries were the most common type of multiple renal arteries. Multiple renal arteries acting as the feeding arteries to the RCC were found in five patients (4.7%).

Conclusion

CTA can be used as part of the preoperative evaluation prior to laparoscopic nephrectomy to provide anatomical information about the presence of multiple renal arteries in the affected kidney of patients with RCC. This could help with planning the surgery and reducing surgical complications.

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.

Long-term outcomes of living donor kidney transplants in pediatric recipients following laparoscopic vs. open donor nephrectomy

We compared long-term outcomes of LDKT in pediatric recipients following either laparoscopic (LDN) or ODN. In our retrospective single-center study, we compared 38 pediatric LDKT recipients of a laparoscopically procured kidney with a historic ODN group comprising 17 pediatric recipients. In our center, the first pure laparoscopic non-hand-assisted LDN for a pediatric LDKT recipient was performed in June 2001. Demographic data of donors and recipients were comparable between groups. Mean follow-up was 64 months in the LDN group and 137 months in the ODN group. Patient survival was comparable between groups. Graft survival at one and five yr was 97% (LDN) vs. 94% (ODN) and 91% (LDN) vs. 88% (ODN; p = n.s.), respectively. Serum creatinine at one and five yr was 1.16 ± 0.47 mg/dL (LDN) vs. 1.02 ± 0.38 mg/dL (ODN) and 1.38 ± 0.5 mg/dL (LDN) vs. 1.20 ± 0.41 mg/dL (ODN), respectively. The type and frequency of surgical complications did not differ between groups. DGF and acute rejection rates were similar between groups. In the ODN group, a higher proportion of right donor kidneys was used. In the ODN group, all kidneys had singular arteries, whereas in the LDN group five kidneys had multiple arteries. Arterial multiplicity was associated with a higher incidence of DGF. In our experience, LDN does not compromise long-term graft outcomes in pediatric LDKT recipients. Arterial multiplicity of the donor kidney may be a risk factor for impaired early graft function in the pediatric population.

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.

Expanded Criteria Living Donors: How Far Can We Go?

In an effort to expand the deceased donor pool, transplant centers have accepted expanded criteria donors as appropriate for many of the patients in the deceased donor pool. Translating this into the living donor pool is more complex. One must consider not only the quality of the organ procured but the consequences that the nephrectomy might have on the living donors for the rest of their lives. This review examines the available data on higher risk donors and the appropriateness, or lack thereof, of accepting them as kidney donors.