Retrospective analysis of the perioperative outcome in living donor kidney transplantation with multiple renal arteries: does accessory vessel ligation affect the outcome?

PURPOSE

Accurate surgical reconstruction of arterial vascular supply is a crucial part of living kidney transplantation (LDKT). The presence of multiple renal arteries (MRA) in grafts can be challenging. In the present study, we investigated the impact of ligation versus anastomosis of small accessory graft arteries on the perioperative outcome.

METHODS

Clinical and radiological outcomes of 51 patients with MRA out of a total of 308 patients who underwent LDKT with MRA between 2011 and 2020 were stratified in two groups and analyzed. In group 1 (20 patients), ligation of accessory arteries (ARAs) and group 2 (31 patients) anastomosis of ARAs was performed.

RESULTS

Significant differences were observed in the anastomosis-, surgery-, and warm ischemia time (WIT) in favor of group 1. Students t-test showed comparable serum creatinine levels of 2.33 (± 1.75) to 1.68 (± 0.83) mg/dL in group 1 and 2.63 (± 2.47) to 1.50 (± 0.41) mg/dL in group 2, were seen from 1 week to 1 year after transplant. No increased rates of Delayed graft function (DGF), primary transplant dysfunction and transplant rejection were seen, but graft loss and revision rates were slightly higher when the ARAs were ligated. Analysis of Doppler sonography revealed that segmental perfusion deficits tend to regenerate during the clinical course.

CONCLUSION

Ligation of smaller accessory renal arteries may not affect the outcome of living kidney transplantation, except for a minor increase in the reoperation rate. Segmental perfusion deficits of the graft seem to regenerate in most cases as seen in Doppler sonography.

ALDH2 rs671 and MTHFR rs1801133 polymorphisms are risk factors for arteriosclerosis in multiple arteries

BACKGROUND

Arteriosclerosis in multiple arteries has long been associated with heightened cardiovascular risk. Acetaldehyde dehydrogenase 2 (ALDH2) and methylenetetrahydrofolate reductase (MTHFR) play an important role in the pathogenesis of arteriosclerosis by participating in the oxidation and reduction reactions in vascular endothelial cells. The purpose was to investigate the relationship of ALDH2 and MTHFR gene polymorphisms with arteriosclerosis in multiple arteries.

METHODS

410 patients with arteriosclerosis in single artery and 472 patients with arteriosclerosis in multiple arteries were included. The relationship between ALDH2 rs671 and MTHFR rs1801133 polymorphisms and arteriosclerosis in single artery and arteriosclerosis in multiple arteries was analyzed.

RESULTS

The proportion of ALDH2 rs671 A allele (35.6% vs. 30.9%, P = 0.038) and MTHFR rs1801133 T allele (32.6% vs. 27.1%, P = 0.012) in patients with arteriosclerosis in multiple arteries was significantly higher than that in arteriosclerosis in single artery, respectively. The proportion of history of alcohol consumption in patients with ALDH2 rs671 G/G genotype was higher than those in ALDH2 rs671 G/A genotype and A/A genotype (P < 0.001). The results of logistic regression analysis indicated that ALDH2 rs671 A/A genotype (A/A vs. G/G: OR 1.996, 95% CI: 1.258-3.166, P = 0.003) and MTHFR rs1801133 T/T genotype (T/T vs. C/C: OR 1.943, 95% CI: 1.179-3.203, P = 0.009) may be independent risk factors for arteriosclerosis in multiple arteries (adjusted for age, sex, smoking, drinking, hypertension, and diabetes).

CONCLUSIONS

ALDH2 rs671 A/A and MTHFR rs1801133 T/T genotypes may be independent risk factors for arteriosclerosis in multiple arteries.

Renal transplantation using vascular conduit reconstruction in deceased kidneys with multiple renal arteries and short renal veins

BACKGROUND

Transplantation of kidneys with vascular anatomical variants remains a challenge. Due to its varying success in regard to graft function after transplantation, these organs have been frequently discarded assuming in advance an unaffordable rate of vascular complications.

PATIENTS AND METHODS

We performed three kidney transplants using organs from deceased donors harboring vascular variants (multiple arteries and short veins), including an unsplittable horseshoe kidney. Different grafts harvested from the same donor aorta, common iliac artery, and inferior vena cava, were used to reconstruct the initial vascular configuration by creating single arterial and venous conduits aimed to simplify the vascular anastomoses in the recipient.

RESULTS

No post-operative complications were recorded. Warm ischemia times remained comparable to single artery renal allografts. No delayed graft function was noted in any case, and every patient regained normal renal function after transplantation.

CONCLUSIONS

Vascular reconstruction using arterial and venous grafts harvested from the same deceased donor may result a helpful tool to simplify vascular anastomoses during transplantation surgery, thus avoiding their discard in advance, minimizing perioperative complications, and enabling normal graft function rates in the long-term follow-up. The successful outcome obtained by using this approach would help to expand the donor criteria for the inclusion of organs containing vascular anatomical variants.

Arterial reconstruction using the donor's gonadal vein in living renal transplantation with multiple renal arteries: a case report and a literature review

Background

Arterial reconstruction is one of the paramount procedures in kidney transplantation (KT) and greatly important if the procured kidney has multiple renal arteries (MRA). Despite various established techniques for arterial reconstruction, sometimes, the surgeon finds performing arterial anastomoses challenging in case of MRA. In our case, the donor’s gonadal vein and recipient’s internal iliac artery graft were used for arterial anastomoses, and 3 years after KT, the allograft did not present vascular complications.

Case presentation

A 34-year-old man underwent ABO-incompatible preemptive living KT. The allograft had three renal arteries and four renal veins. After donor nephrectomy, arterial reconstruction was performed on a back table. These arteries were reconstructed into one piece using the recipient’s internal iliac artery graft. The two arteries at the middle of the renal hilum were reconstructed using the conjoined method. As the superior renal artery was too short to anastomose, the donor’s gonadal vein was used for extension. The internal iliac artery graft was anastomosed to the original internal iliac artery. Intraoperative Doppler ultrasonography revealed that the blood flow in each renal artery was adequate, resulting in sufficient blood flow throughout the allograft. The allograft function was maintained with a serum creatinine level of approximately 0.9 mg/dL without vascular complications 3 years after KT.

Conclusions

The donor’s gonadal vein can be a candidate for extension of the renal artery in the allograft with MRA. Further follow-up is needed for the assessment of long-term outcomes.

Maximizing Nephron Mass in Horseshoe Kidney Transplantation Using Inferior Epigastric Artery: Case Report

Due to the progressive shortage of donors, kidneys with congenital anomalies are considered for transplantation. We report a successful transplantation of a split horseshoe kidney from a deceased donor by using the inferior epigastric artery with an end-to-end anastomosis, supplying the isthmus. Thus, we preserved as much as possible the functional parenchyma for a good long-term outcome. The learning point is that the use of the right inferior epigastric artery seems to be a good solution to perfuse the lower artery in order to avoid its ligation, thus reducing the nephron mass of the graft.

Long-term outcome of grafts with multiple arteries in live-donor renal allotransplantation: Analysis of 2100 consecutive patients

Purpose

To analyse the long-term outcome in relation to multiple graft arteries (MGA) in live-donor renal transplantation, and assess its effect on graft and patient survival.

Patients and methods

Between March 1976 and November 2009, a total of 2100 live-donor renal transplants were carried out at our centre. Patients were stratified according to the number of graft arteries into two groups, i.e. MGA (two or more arteries; 237 patients) and single-graft artery (SGA; 1863 patients). Variables assessed included patient demographics, site of vascular anastomosis, ischaemia time, onset of diuresis, delayed graft function, acute tubular necrosis (ATN), acute rejection, vascular and urological complications. Moreover, long-term patient and graft survival were compared among both groups. Patients were followed up for a mean (SD) of 112 (63) months.

Results

Grafts with MGA were associated with a prolonged ischaemia time (P = 0.001) and ATN (P = 0.005). Vascular thrombosis (arterial and venous) had a higher incidence in MGA (2.5%) than SGA (0.6%) (P = 0.01). Both groups were not significantly different for the onset of diuresis, acute rejection and urological complications (P = 0.16, 0.23 and 0.85, respectively). Graft and patient survival were comparable in both groups. The mean (SD) 1-, 5-, 10- and 20-year graft survival rates (%) for MGA were 96.1 (1.26), 86.6 (2.39), 61.3 (4.42) and 33.8 (7.23), and 97.5 (0.36), 86.8 (0.84), 66.0 (1.35) and 37.3 (2.76) for SGA (P = 0.54).

Conclusions

Although there was a higher incidence of prolonged ischaemia time, ATN and vascular thrombosis in live-donor renal transplants with MGA, it did not adversely affect patient or graft survival. The early, intermediate- and long-term follow-up showed an outcome comparable to that in patients with SGA.