Renal transplantation to the ovarian vein: a case report

How to Deal With Kidney Retransplantation-Second, Third, Fourth, and Beyond

Kidney transplantation is the best health option for patients with end-stage kidney disease. Ideally, a kidney transplant would last for the lifetime of each recipient. However, depending on the age of the recipient and details of the kidney transplant, there may be a need for a second, third, fourth, or even more kidney transplants. In this overview, the outcome of multiple kidney transplants for an individual is presented. Key issues include surgical approach and immunologic concerns. Included in the surgical approach is an analysis of transplant nephrectomy, with indications, timing, and immunologic impact. Allograft thrombosis, whether related to donor or recipient factors merits investigation to prevent it from happening again. Other posttransplant events such as rejection, viral illness (polyomavirus hominis type I), recurrent disease (focal segmental glomerulosclerosis), and posttransplant lymphoproliferative disease may lead to the need for retransplantation. The pediatric recipient is especially likely to need a subsequent kidney transplant. Finally, noncompliance/nonadherence can affect both adults and children. Innovative approaches may reduce the need for retransplantation in the future.

A cadaveric study of ovarian veins: variations, measurements and clinical significance

The literature showing information regarding ovarian venous variation, its diameter and termination distance from respective renal venous origin are limited. This information is important in various surgical and clinical procedures including venous embolization, vascular reconstruction during renal transplantation and localizing the source of origin of a pelvic mass. We examined 94 sides of 47 formalin fixed female cadavers and noted the course and termination of ovarian veins. We measured the diameter of ovarian veins at their termination point and the termination distance in respect to the termination point of renal veins at inferior vena cava (IVC) on respective sides. We found two cases of variations related to right ovarian vein -one, right ovarian vein joined the right renal vein; two, right ovarian vein duplicated and joined with IVC at two different points. We found one case of variation related to left ovarian vein-a partially duplicated left ovarian vein. All the variations were unilateral. The mean diameters of right and left ovarian veins were 3.66±1.18 and 4.20±0.96 mm, respectively. The distance of termination of ovarian veins ranged from 19-40 mm and 13-41 mm, respectively from termination points of right and left renal veins at IVC on respective sides. Our study presents a set of data regarding variation of ovarian veins, diameters and termination distances which could be useful for gynecologists, surgeons and radiologists.

Surgical Challenge in Pediatric Kidney Transplant Vascular Anastomosis

During pediatric kidney transplant, surgical challenges occasionally occur. In particular, vascular anastomosis should be considered for children with small body weight < 12 kg, multiple renal arteries, vascular anomaly, and inferior vena cava occlusion. In pediatric patients, a living-donor renal graft is usually donated from a parent. Therefore, the renal artery and vein are too large to be anastomosed with the recipient's internal iliac artery and external iliac vein. In children who are > 12 kg, the renal artery and vein could be anastomosed with the external iliac artery and the external iliac vein. In children who are < 10 kg, the renal artery and vein should be anastomosed directly with the aorta and inferior vena cava. A pediatric transplant surgeon should consider arterial and venous anastomosis sites before transplant surgery. In small children with partial or total inferior vena cava occlusion, the venous anastomosis site should be evaluated. If the graft is placed on the left side, a venous graft must be used as a bridge between the renal vein and inferior vena cava. In 13 kidney transplants in children with inferior vena cava occlusion, 7 were on the left and 6 were on the right side. A patent segment of the inferior vena cava, the left original renal vein, an ascending lumbar vein, an azygos vein, the first graft renal vein, and a portal vein were used for venous anastomosis in 6, 2, 2, 1, 1 and 1 recipient, respectively. One child had graft loss due to renal vein thrombosis and one died of hemorrhage immediately posttransplant. Three had grafts with relatively long-term function, but these were lost due to chronic allograft nephropathy 100, 122, and 137 months posttransplant. However, the other 8 recipients have so far maintained graft function from 6 to 138 months since transplant.

Kidney Transplantation Using Gonadal Vein for Venous Anastomosis in Patients With Iliac Vein Thrombosis or Stenosis: A Series of Cases

BACKGROUND

Kidney transplantation is the treatment of choice for patients with end-stage renal disease. The standard surgery uses the recipient's iliac vessels for vascular anastomosis. Thrombosis and/or stenosis of the iliac vein, which are possible complications of multiple vascular access points for dialysis, can be detected intraoperatively, constituting a surgical challenge. An infrequently reported option is the use of the gonadal vein.

OBJECTIVES

This study aims to evaluate the outcomes of venous anastomosis in the gonadal vein in patients with iliac vein thrombosis and/or stenosis submitted to kidney transplantation.

METHODS

We reviewed the records of five adult recipients with iliac vein thrombosis and/or stenosis detected intraoperatively during emergency kidney transplantation with deceased donor due to vascular access failure from February 2013 to December 2014. Antithrombotic prophylaxis was not performed. We evaluated the postoperative complications, length of stay, early graft echo-Doppler, and renal function during the first year postoperatively.

RESULTS

Delayed graft function occurred in three cases. Two patients developed postoperative infection requiring antibiotics. One patient required reoperation due to post-renal biopsy complications. The mean length of stay was 31.2 days and the mean serum creatinine levels at discharge, at 6 months, and at 12 months postoperatively were 1.42 mg/dL, 0.86 mg/dL, and 0.82 mg/dL, respectively. All patients had normal ultrasonography. There were no losses of graft or deaths during follow-up.

CONCLUSION

Venous anastomosis using the gonadal vein in kidney transplantation for patients with iliac vein thrombosis and/or stenosis showed good clinical and surgical results, showing this method to be a viable alternative to venous drainage in these complex patients.

Successful third renal transplantation in a child with an occluded inferior vena cava: A novel technique to use the venous interposition between the transplant renal vein and the infrahepatic inferior vena cava

A girl aged 11 years and 3 months with occlusion of the inferior vena cava had experienced two renal transplant graft failures since birth. The third renal transplant from a live donor was carried out. Preoperative evaluation showed that the arteries from the right common to the right external iliac artery were absent, and the ilio-caval vein was occluded below the level of the renal vein. The donor's renal artery was anastomosed to the aorta. The donor's ovarian and large saphenous veins were used to extend the transplant renal vein to the recipient's patent inferior vena cava. The present report concludes that the extension of a short donor renal vein using other donor veins is a viable therapeutic option for pediatric patients with vascular occlusions.

Case report of cadaveric kidney transplantation with renal-portal venous drainage: A feasible way for a venous drainage in a complex generalized thrombosed vessels setting

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One of the frequent complications suffered by patients with chronic renal failure is the lack of vascular access due to venous thrombosis.

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Patients with vascular structural alteration are technicaly challenging.

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Kidney transplant with portal venous drainage is an alternative in a general thrombosed vessels setting.

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The implant of the renal graft was undertaken via an anastomosis at the lateral side of the renal vein to the portal vein.

Introduction

One of the frequent complications suffered by patients with chronic renal failure is the lack of vascular access due to venous thrombosis. This means that the transplant surgeon must have a detailed knowledge of the intra-abdominal venous system, and other alternative surgeries, at the time of performing the renal graft implant, in order to ensure a good venous drainage.

Presentation of the case

This article provides a case report regarding a patient with no vascular access and with surgical difficulties at the time of the kidney transplant, in whom a renal-portal venous drainage was performed with very good outcome.

Discusion

Renal-portal venous drainage is a way to performe kidney transplant with good outcome. In Fundación Valle del Lili we have overcome the lack of vascular access in patients that need a renal transplant by new surgical technics that improve the patients quality of life and survival.

Conclusion

We can conclude that new surgical alternatives exist for those patients with chronic renal failure that have no vascular access. These patients are a priority for kidney transplants and the surgeon must take in to account the need for a new surgical assessment.

Successful Kidney Transplantation in Children With a Compromised Inferior Vena Cava

Background

Children with a compromised inferior vena cava (IVC) were previously considered unsuitable for kidney transplantation because of the technical difficulties and the increased risk of graft thrombosis secondary to inadequate renal venous outflow.

Methods

We conducted a retrospective study of 11 transplants in 9 patients with end-stage renal disease and thrombosed IVCs who received adult kidney allografts between 2000 and 2015. The mean age at transplantation was 7.5 ± 3.5 years. A pretransplant diagnosis of the IVC thrombosis was made in 7 patients by magnetic resonance imaging and computerized tomography, whereas there were 2 instances of intraoperative discovery of the IVC thrombosis.

Results

In the early cases, a kidney was placed intraperitoneally at the right iliac fossa with a venous anastomosis to the patent segment of the suprarenal IVC. After 2008, however, 6 adult-sized kidneys were subsequently placed in the left orthotopic position. Venous drainage was attained to the infrahepatic IVC (n = 3), left native renal vein (n = 2), and ascending lumbar vein (n = 1). Moreover, a venous bypass was created between the graft and the splenic vein in 2 children who showed high return pressure after the vessel was declamped.

The mean glomerular filtration rate of the functioning 8 grafts 1 year posttransplant was 73.4 ± 20.4 mL/min per 1.73 m². Of note, 6 of the grafts have been functioning well, with a mean follow-up of 66 months. Both 1- and 5-year graft survival were 81.8%.

Conclusions

Transplantation into the left orthotopic position and the revascularization methods are an effective set of surgical techniques that could potentially be adopted as safe and reliable transplant approaches in children with IVC thrombosis.

Renal Transplantation in a Patient With Unsuspected Inferior Vena Cava Obliteration

Vena cava thrombosis can represent a surgical challenge in the context of kidney transplantation. Selection of venous drainage in this setting should provide adequate venous outflow and minimize the risk of thrombosis and subsequent graft failure. We report the case of an adult female patient who presented for a deceased donor kidney transplant with incidental finding of complete inferior vena cava (IVC) and obliteration. After exploration of the retroperitoneal space up to the level of the obliterated IVC, a collateral venous branch was identified at the confluence of the right and left iliac veins. This was utilized as the site of the renal vein venous anastomosis. The patient recovered with immediate graft function. Follow-up ultrasound demonstrated patent vasculature without evidence of thrombosis or outflow obstruction. This report offers a surgical alternative to proceed in the case of an adult with unsuspected caval system obliteration.

Renal Transplantation With Size-Matched End-to-End Venous Anastomosis in Children With Inferior Vena Cava Thrombosis

Due to surgical technical difficulties, inferior vena cava (VCI) thrombosis is contraindicated for renal transplantation in pediatric patients. Of 287 pediatric renal transplantations, 3 patients (9, 12, and 19 kg, respectively) with end-stage renal failure, who had VCI thrombosis at the level of renal vein, underwent end-to-end anastomosis to the proximal aspect of VCI for venous drainage. The latest creatinine values of the patients, who were in the postoperative 56(th), 28(th), and 14(th) months, were 0.6, 0.4, and 0.3 mg/dL, respectively, with graft and patient survival rates of 100%. We think that end-to-end venous drainage into the proximal caval system is the most appropriate surgical approach in pediatric recipients, who have an open suprarenal VCI and a small intra-abdominal cavity, in the presence of an appropriate size-matched graft.

Reno-portal anastomosis as an approach to pediatric kidney transplantation in the setting of inferior vena cava thrombosis

In pediatric renal transplantation in the setting of IVC thrombosis, the retrohepatic IVC or gonadal veins are often used for outflow. However, if use of systemic venous outflow is unsuccessful, options become limited. We report the use of the portal vein for venous outflow in kidney retransplantation in the setting of IVC thrombosis. The patient is a 19-month-old male who developed end-stage renal failure at seven months of age secondary to hypotension after spontaneous rupture of an accessory renal vein. The IVC was occluded during emergent laparotomy, and the patient developed extensive IVC thrombosis. The first two transplant attempts used the retrohepatic IVC for venous outflow. Despite good initial flow, in both instances the renal vein thrombosed on post-operative day 1. In an unsuccessful salvage attempt of the second transplant, a reno-portal anastomosis was performed. With few options for vascular access, a third transplant was attempted. The reno-portal stump from the second transplant was used for outflow. The patient recovered well from his third transplant (creatinine 0.6 mg/dL 35 months post-surgery), demonstrating that the portal vein can be used for outflow in cases of extensive IVC thrombosis.

Abdominal wall phlebitis due to Prevotella bivia following renal transplantation in a patient with an occluded inferior vena cava

Pre-existing occlusion of the inferior vena cava may complicate renal transplantation. Suppurative abdominal wall phlebitis following renal transplantation was diagnosed in a patient with pre-existing thrombosis of the inferior vena cava of unknown cause. The phlebitis developed in the subcutaneous collateral veins of the abdominal wall contra-laterally to the renal transplant. Cultures from abdominal wall micro-abscesses yielded Prevotella bivia as the causative agent. This complication has not been described before in the context of renal transplantation. The pathogenesis and management of this serious complication are discussed in this paper.

Successful adult-to-child renal transplantation utilizing the ovarian vein in children with inferior vena cava/iliac vein thrombosis

IVC/iliac vein thrombosis has previously been considered to be a contraindication to renal transplantation because of the technical difficulties and the increased risk of graft thrombosis. We report two successful cases of adult-to-child kidney transplantation in which we anastomosed the graft renal vein to the recipient ovarian vein in the presence of IVC and/or iliac vein thrombosis, with no short or long term vascular complications. Our experience, which adds to the successful reports from several other centers, suggests that the inability to use the iliocaval axis should no longer be considered a contraindication to pediatric renal transplantation.