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

Robotic Versus Laparoscopic Donor Nephrectomy: A Retrospective Bicentric Comparison of Learning Curves and Surgical Outcomes From 2 High-volume European Centers

BACKGROUND

Although laparoscopic donor nephrectomy (LDN) represents the gold-standard technique for kidney living donation, robotic donor nephrectomy (RDN) settled as another appealing minimally invasive technique over the past decades. A comparison between LDN and RDN outcomes was performed.

METHODS

RDN and LDN outcomes were compared, focusing on operative time and perioperative risk factors affecting surgery duration. Learning curves for both techniques were compared through spline regression and cumulative sum models.

RESULTS

The study analyzed 512 procedures (154 RDN and 358 LDN procedures) performed between 2010 and 2021 in 2 different high-volume transplant centers. The RDN group presented a higher prevalence of arterial variations (36.2 versus 22.4%; P  = 0.001) compared with the LDN cohort. No open conversions occurred; operative time (210 versus 195 min; P  = 0.011) and warm ischemia time (WIT; 230 versus 180 s; P  < 0.001) were longer in RDN. Postoperative complication rate was similar (8.4% versus 11.5%; P  = 0.49); the RDN group showed shorter hospital stay (4 versus 5 d; P  < 0.001). Spline regression models depicted a faster learning curve in the RDN group ( P  = 0.0002). Accordingly, cumulative sum analysis highlighted a turning point after about 50 procedures among the RDN cohort and after about 100 procedures among the LDN group.Higher body mass index resulted as an independent risk factor for longer operative time for both techniques; multiple arteries significantly prolonged operative time in LDN, whereas RDN was longer in right kidney procurements; both procedures were equally shortened by growing surgical experience.

CONCLUSIONS

RDN grants a faster learning curve and improves multiple vessel handling. Incidence of postoperative complications was low for both techniques.

Barriers to the donation of living kidneys for kidney transplantation

Since the waiting time for deceased donor kidney transplantation continues to increase, living donor kidney transplantation is an important treatment for end stage kidney disease patients. Barriers to living kidney donation have been rarely investigated despite a growing interest in the utilization of living donor transplantation and the satisfaction of donor safety. Here, we retrospectively analyzed 1658 potential donors and 1273 potential recipients who visited the Seoul National University Hospital for living kidney transplantation between 2010 and 2017 to study the causes of donation discontinuation. Among 1658 potential donors, 902 (54.4%) failed to donate kidneys. The average number of potential donors that received work-up was 1.30 ± 0.66 per recipient. Among living donor kidney transplant patients, 75.1% received kidneys after work-up of the first donor and 24.9% needed work-up of two or more donors. Donor-related factors (49.2%) were the most common causes of donation discontinuation, followed by immunologic or size mismatches between donors and recipients (25.4%) and recipient-related factors (16.2%). Interestingly, withdrawal of donation consent along with refusal by recipients or family were the commonest causes, suggesting the importance of non-biomedical aspects. The elucidation of the barriers to living kidney donation could ensure more efficient and safer living kidney donation.

Long-term outcomes of left versus right laparoscopic living donor nephrectomy with multiple renal arteries

OBJECTIVES

The objective of this study is to compare the long-term graft outcomes of left versus right donor nephrectomy with multiple renal arteries, and therefore creating a reference for the expansion of the potential living kidney donor pool.

METHODS

Laparoscopic live donor nephrectomy cases between May 2010 and October 2020 were included in this retrospective cross-sectional study. The data relating to donor and recipient demographics, surgical and anatomical characteristics, recipient and graft status were retrieved and compared using nonparametric statistical methods and multivariate regression. Analyses were fit for survival factors.

RESULTS

A total of 1009 recipients were included in this retrospective cross-sectional study with their donors. 16.7% of the donors had been discovered to have more than one renal artery supplying the donated kidney. The acute rejection rate was 12.8%. Death-censored graft survival at post-operative year 5 for single renal artery transplants was 89.6%, 89.5% for left-sided multiple renal arteries, and 88.2% for right-sided ones.

CONCLUSIONS

Both right donor nephrectomy and left donor nephrectomy are safe procedures with no significant negatively impacted rates for neither survival nor complications of the recipients in the long-term, compared to single renal artery ones.

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.

Hypertension and renal outcomes in normotensive kidney donors with multiple renal arteries

Having multiple renal arteries (MRA) has been linked to hypertension development. Whether kidney donors who are left with MRA in the nondonated kidney incur a higher risk of hypertension has not been studied. We compared the development of hypertension, reduced estimated glomerular filtration rate (eGFR), cardiovascular disease, and mortality in 2624 normotensive kidney donors with MRA in the nondonated kidney and to 2624 propensity score matched normotensive donor controls with a single renal artery. In total, 35% of donors had MRA. Donors with MRA were less likely to have undergone a left nephrectomy (51% vs. 83%). Postdonation hypertension was associated with age, male gender, non-White ethnicity, obesity, and family history of hypertension. Having MRA was not associated with risk of hypertension; aHR 0.92 (95% CI 0.82-1.03), P = 0.16. After 17 ± 11 years from donation, a similar proportion of donors with and without MRA developed cardiovascular disease, proteinuria and eGFR <30, <45 and <60 mL/min/1.73 m² and the multivariable risks of developing these outcomes were similar in the two groups. Our study did not show increased risk for hypertension, reduced eGFR, proteinuria or cardiovascular disease in donors with MRA in the remaining kidney and without hypertension at donation.

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.

Management of Multiple Renal Arteries and Unusual Venous Anatomy During Kidney Transplant: From a Simple Technical Problem to a Graft-Saving Procedure

OBJECTIVES

Incidence of vascular anomalies in donor kidneys varies from 18% to 30% and presents a challenge for a transplant surgeon in kidney transplant. Here we present our personal experience for man - agement of the complicated and unexpected cases.

MATERIALS AND METHODS

A total of 250 kidney transplants (226 living, 24 deceased) were performed in a period of 24 years; mean donor age was 55 years (range, 25-86 years), and mean recipient age was 38.6 years (range, 14-66 years). We analyzed the surgical techniques, complications and outcomes, rejection episodes, kidney function, and graft and patient survival rates.

RESULTS

Of 250 nephrectomies, 209 had a single artery (83.6%), 34 had 2 arteries (13.6%), and 7 had 3 arteries (2.8%). Of 34 double arteries, 14 had 2 main arteries, 15 had a main and a polar artery, and 5 had an aortic Carrel patch after deceased donation. According to the size, type, and position, the anastomoses were performed with branches of hypogastric, epigastric inferior, iliac external, and main renal artery, intracorporeally or in bench surgery. Regarding veins, 1 double inferior vena cava, 1 left-side inferior vena cava, 4 retroaortic, 2 circumaortic, 10 large lumbar veins draining into the left renal veins, and 8 cases with 2 or more different size renal veins were managed. In 9 cases with short right renal vein, an extension with vena cava (a "Barry cavoplasty") was performed in deceased donor organs. No serious surgical complications related to vascular anomalies were observed. There were no statistical differences in 1-, 6-, and 12-month graft survival rates between the groups with or without vascular anomalies.

CONCLUSIONS

Vascular anomalies should no longer be considered a contraindication for transplant, if careful anastomosis is performed in every case to avoid ischemia and further complications. Therefore, management of vascular anomalies could be a graftsaving procedure.

Unenhanced magnetic resonance angiography as an accurate alternative in the preoperative assessment of potential living kidney donors with contraindications to computed tomography angiography and to contrast-enhanced magnetic resonance angiography

Objective

To evaluate the accuracy of steady-state free precession (SSFP) unenhanced magnetic resonance angiography (MRA) at 1.5 T for the identification of multiple renal arteries, using computed tomography angiography (CTA) as the reference standard.

Materials and Methods

This was a prospective study involving 39 patients (26 males; mean age, 62.6 years) who underwent CTA and unenhanced MRA to evaluate the proximal and middle segments of the renal arteries. The analysis was performed in two phases: the quality of unenhanced MRA images was classified as diagnostic or nondiagnostic for the presence of multiple renal arteries by two independent readers; two other independent readers then evaluated the images previously classified as being of diagnostic quality. The sensitivity, specificity, and overall accuracy of unenhanced MRA were calculated, CTA being used as the reference standard. The kappa statistic was used in order to calculate interobserver agreement.

Results

The image quality of unenhanced MRA was considered diagnostic in 70-90% of the extrarenal arterial segments. The CTA examination revealed 19 multiple renal arteries (8 on the right and 11 on the left). The accuracy of unenhanced MRA for the identification of multiple renal arteries was greater than 90%, with a sensitivity of 72.7-100% and a specificity of 96.3-100%.

Conclusion

Unenhanced MRA provides high quality imaging of the extrarenal segments of renal arteries. This method may be used as an alternative for the evaluation of the renal arteries, given that it has an accuracy comparable to that of CTA.

Perioperative antithrombotic therapy does not increase the incidence of early postoperative thromboembolic complications and bleeding in kidney transplantation - a retrospective study

Perioperative antithrombotic therapy could play a role in preventing thromboembolic complications (TEC) after kidney transplantation (KTx), but little is known on postoperative bleeding risks. This retrospective analysis comprises 2000 single‐organ KTx recipients transplanted between 2011 and 2016 in the two largest transplant centers of the Netherlands. TEC and bleeding events were scored ≤7 days post‐KTx. Primary analyses were for associations of antithrombotic therapy with incidence of TEC and bleeding. Secondary analyses were for associations of other potential risk factors. Mean age was 55 ± 14 years, 59% was male and 60% received a living donor kidney. Twenty‐one patients (1.1%) had a TEC. Multiple donor arteries [OR 2.79 (1.15–6.79)] and obesity [OR 2.85 (1.19–6.82)] were identified as potential risk factors for TEC. Bleeding occurred in 88 patients (4.4%) and incidence varied significantly between different antithrombotic therapies (P = 0.006). Cardiovascular disease [OR 2.01 (1.18–3.42)], pre‐emptive KTx [OR 2.23 (1.28–3.89)], postoperative heparin infusion [OR 1.69 (1.00–2.85)], and vitamin K antagonists [OR 6.60 (2.95–14.77)] were associated with an increased bleeding risk. Intraoperative heparin and antiplatelet therapy were not associated with increased bleeding risk. These regimens appear to be safe for the possible prevention of TEC without increasing the risk for bleeding after KTx.

Reconstruction of Multiple Renal Arteries During Simultaneous Pancreas and Kidney Transplantation: A Case Report

We present a case of a multiple renal artery reconstruction during simultaneous pancreas and kidney transplantation. The kidney graft had 6 renal arteries, the aorta patch was 10 cm long, and there were two renal veins. To perform anastomoses to the left external iliac vessels we had to reconstruct the renal arterial and venal patches. The results of the transplantation were very good. Both grafts had satisfactory function, even though a control computed tomography performed a year after transplantation revealed infarction of a lower renal pole. Anatomical anomalies should not be a contraindication for transplantation, although transplants involving a multiplicity of vessels is a challenge for surgeons and requires both knowledge and microsurgical skills.

Attitudes among transplant professionals regarding shifting paradigms in eligibility criteria for live kidney donation

BACKGROUND

The transplant community increasingly accepts extended criteria live kidney donors, however, great (geographical) differences are present in policies regarding the acceptance of these donors, and guidelines do not offer clarity. The aim of this survey was to reveal these differences and to get an insight in both centre policies as well as personal beliefs of transplant professionals.

METHODS

An online survey was sent to 1128 ESOT-members. Questions were included about several extended donor criteria; overweight/obesity, older age, vascular multiplicity, minors as donors and comorbidities; hypertension, impaired fasting glucose, kidney stones, malignancies and renal cysts. Comparisons were made between transplant centres of three regions in Europe and between Europe and other countries worldwide.

RESULTS

331 questionnaires were completed by professionals from 55 countries. Significant differences exist between regions in Europe in acceptance of donors with several extended criteria. Median refusal rate for potential live donors is 15%. Furthermore, differences are seen regarding pre-operative work-up, both in specialists who perform screening as in preoperative imaging.

CONCLUSIONS

Remarkably, 23.4% of transplant professionals sometimes deviate from their centre policy, resulting in more or less comparable personal beliefs regarding extended criteria. Variety is seen, proving the need for a standardized approach in selection, preferably evidence based.