In renal transplant, multiple renal arteries in a donor require meticulous vascular reconstruction for successful allograft function in the recipient. Presence of more than 4 renal arteries is usually considered to be a relative contraindication for proceeding with renal donation. We report a living-donor renal transplant procedure where preoperative radiologic imaging of the donor showed 3 left renal arteries. Two additional arteries were identified intraoperatively. All 5 arteries were reconstructed during the back-table procedure, and the allograft was implanted in the recipient. At 3-month follow-up, computed tomographic imaging demonstrated patency of all 5 renal arteries, and the patient had a serum creatinine level of 0.8 mg/dL. Unidentified arteries on preoperative imaging may occasionally require complex reconstruction. A renal allograft with 5 renal arteries is usually a contraindication for renal donation. Here, we describe the first published case of successful kidney transplant after reconstruction of 5 renal arteries in the donor graft.
Key words : Laparoscopic surgery, Renal transplantation, Vascular surgical procedure
The reported incidence of multiple renal arteries (MRA) in donor kidneys is 8% to 30% unilaterally and 10% bilaterally.1 Meticulous reconstruction of multiple arteries is essential for successful allograft function in the recipient. Presence of more than 4 renal arteries is generally considered to be a contraindication for proceeding with renal donation. We report a case of a living-donor renal transplant where preoperative radiologic scan of the donor showed 3 renal arteries. However, 2 additional accessory arteries were identified during donor nephrectomy. Five graft arteries were reconstructed during the back-table procedure, and the allograft was successfully implanted in the recipient. This report describes the first published case of a successful kidney transplant after reconstruction of 5 renal arteries from the donor.
We report a kidney transplant procedure in which a 45-year-old male patient donated his left kidney to his 20-year-old son who had glomerulonephritis and end-stage renal disease. Preoperative imaging by computed tomographic angiography revealed 3 renal arteries bilaterally with a single vein on each side. Technetium Tc 99m diethylenetriaminepentaacetic acid nuclear scan showed a glomerular filtration rate of 93 mL/min/1.73 m2 with differential kidney function of 49% on the left and 51% on the right side. A decision was made to perform a laparoscopic left donor nephrectomy. Standard steps of left laparoscopic donor nephrectomy were followed.
During dissection, 4 renal arteries were identified arising from the aorta. After serial clamping and division of the ureter and vessels, the graft was retrieved from Pfannenstiel incision. The warm ischemia time was 7 minutes, and the total duration of donor surgical procedure was 150 minutes. The graft kidney was perfused with histidine tryptophan ketoglutarate solution and placed in a bowl of ice slush. On back-table dissection, another artery supplying the upper pole was identified in addition to the already identified 4 arteries, supplying about 15% of the graft kidney. All 5 arteries were of reasonable caliber and supplied a significant area of renal parenchyma. Two lower polar arteries were double-barreled, and the remaining 3 arteries were sutured on the bench to the branches of the internal iliac artery (IIA) graft obtained from the recipient. The double-barreled artery was anastomosed to the right external iliac artery in an end-to-side fashion, with the internal iliac graft anastomosed to the remaining stump of the IIA in an end-to-end fashion (Figure 1). The graft vein was sutured to the right external iliac vein, and ureterovesical anastomosis was done using the modified Lich-Gregoir technique. Adequate diuresis was observed after reperfusion. The total cold ischemia time was 180 minutes, and duration of the surgical procedure was 270 minutes.
The patient received 2500 units of heparin (unfractionated) intraoperatively, and a perinephric drain was placed. In the immediate postoperative period, the patient had a high hemorrhagic output from the drain, which resolved after heparin was discontinued. Postoperative day 0 urine output was 7300 mL, and the patient’s serum creatinine level progressively decreased to 1.2 mg/dL on day 4. Doppler ultrasonographic evaluation of the graft kidney showed normal vascularity with adequate perfusion of the whole graft kidney. The patient achieved a serum creatinine level of 1.0 mg/dL at discharge and 0.8 mg/dL at 3-month follow-up when a routine computed tomography scan showed patency of all 5 reconstructed vessels (Figure 2 and Figure 3).
In living-donor kidney transplant procedures, the left kidney is usually preferred because of anatomic reasons and technical ease. However, to avoid longer operating time associated with MRA grafts, a right kidney is preferentially used if there is a single artery on the right side.2 Thus presence of MRA plays a decisive role in selection of the donor’s kidney in living-donor kidney transplants. In cases of bilateral MRA, laparoscopic retrieval of kidneys with MRA can be technically challenging but is still considered safe and feasible.1,2 In addition, graft survival and function are not adversely affected by the presence of MRA in grafts procured laparoscopically.1 In the present case, the donor kidney had bilateral MRA, and a decision to undertake laparoscopic left donor nephrectomy was made. The donor and recipient surgical procedures were uneventful, and the recipient showed normal graft function at 3 months.
In deceased-donor renal transplantation, an aortic patch with multiple vessels can be utilized to have a single anastomosis in the recipient, but reconstruction can be challenging in living-donor transplantation where limited material for vascular reconstruction is available. Various surgical techniques for reconstruction of MRA have been described in the literature.3-6 The type of vascular reconstruction depends on the length, caliber, orientation, and distance between the vessels. This includes double-barreling or pantaloon anastomosis of vessels, end-to-side anastomosis of vessels, and use of internal iliac artery graft and inferior epigastric artery for vascular reconstruction.3-6 Synthetic grafts or venous grafts from the donor’s gonadal vein or recipient’s internal iliac vein graft have been rarely used as a Carrel patch for implanting multiple arteries.4 In the present case, an interposition graft of IIA with its branches was used to reconstruct 3 arteries and double-barrelling was used to reconstruct the other 2 arteries. Both the external iliac artery and IIA were utilized to implant the graft kidney. However, an IIA graft may not be available in patients with diabetes and smokers, where vessels can be severely atherosclerotic.7 Similarly, an IIA graft may not be electively used in patients undergoing second or third transplant for vascular reconstruction. Although the presence of MRA has not been shown to alter patient and graft survival after transplant, the incidence of vascular complications, including renal artery stenosis in the recipient, has been reported to be higher in MRA recipients because multiple arteries are more susceptible to torsion and kinking.8,9 Lower polar arteries always require meticulous reconstruction, as their occlusion can cause urologic complications, such as ureteral necrosis.9
The imaging techniques, done preoperatively, have a sensitivity of 98% in identifying the number of vessels.10 However, it is not uncommon for a transplant surgeon to encounter unexpected accessory renal arteries, as in the present case. This can happen with superimposition of visual images of the adjacent renal arteries, resulting in a reconstituted image that might not distinguish the multiplicity of vessels. In this context, laparoscopic donor nephrectomy provides a magnified view that can reduce the chances of vessel injury.
Renal allografts with 5 renal arteries can be successfully transplanted after back-table vascular reconstruction. Accessory renal arteries can sometimes be missed on preoperative radiologic imaging and can present as an unexpected finding for the surgeon.
Volume : 16
Issue : 6
Pages : 751 - 753
DOI : 10.6002/ect.2016.0102
From the 1Department of Renal Transplant Surgery and the 2Department
of Radiodiagnosis, Post Graduate Institute of Medical Education and Research,
Sector 12, Chandigarh, India
Acknowledgements: The contributing authors have no conflicts of interest, including specific financial interests or relations and affiliations relevant to the subject matter or materials discussed in the manuscript.
Corresponding author: Ashish Sharma, Department of Renal Transplant Surgery, Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh, India
Phone: +91 172 275 6643
Figure 1. Graft Kidney After Implantation Showing Adequate Perfusion and All 5 Reconstructed Arteries
Figure 2. Maximum Intensity Projection Computed Tomography Angio graphic Image in Coronal Plane Showing the 3 Renal Arteries Anastomosed to the Internal Iliac Artery, Along With the 2 Lower Polar Arteries Sutured to the External Iliac Artery
Figure 3. Maximum Intensity Projection Computed Tomography Angiographic Image in Oblique Axial Plane Showing the 3 Renal Arteries Anastomosed to the Internal Iliac Artery