Organ shortage is the greatest challenge facing the field of organ transplantation in Korea. There are no reports of patients who have undergone endovascular aneurysm repair being considered as kidney donors. We successfully performed kidney transplant procedures in a 62-year-old man and a 57-year-old man using kidneys recovered from a 67-year-old female brain-dead donor who underwent endovascular aneurysm repair 6 months before organ retrieval. To the best of our knowledge, this is the first report of transplants performed with organs from a donor who previously underwent endovascular aneurysm repair.
Key words : Aneurysm, Brain death, Renal transplant
Kidney transplant is a superior treatment for patients with end-stage renal disease compared with long-term hemodialysis or peritoneal dialysis.1 The major rate-limiting factor in kidney transplant is the shortage of donor organs. Several efforts have been made to extend the donor pool, including the use of living donors, donations after cardiac death, and the use of expanded criteria donor (ECD) grafts.2-4
Currently, endovascular aneurysm repair (EVAR) is a major treatment option for abdominal aortic aneurysm (AAA). In Korea, increasing numbers of EVARs are being performed, owing both to an aging society and to the availability of better technology. Herein, we present a case of a brain-dead kidney donor who previously underwent EVAR for AAA. This case presents another potential option to extend the donor pool for patients with end-stage renal disease awaiting kidney transplant.
A 67-year-old unconscious female victim of a road traffic accident was transferred to our hospital. The referring hospital had diagnosed her as having sustained subdural and subarachnoid hemorrhage. After brain death was suspected, her family indicated that they wanted to donate her organs. At admission, her blood pressure, pulse rate, and body temperature were 90/51 mm Hg, 70 beats/min, and 36.5ºC, respectively, and she was intubated and received ventilator therapy. Her initial creatinine level was 4.5 mg/dL (reference value, 0.6-1.5 mg/dL). The brain death determination committee confirmed that she was brain dead.
She had undergone EVAR for AAA at our hospital 6 months before this presentation (Figure 1) and was on regular follow-up for management of her hypertension and type 2 diabetes mellitus. Her previous creatinine level, recorded 2 months earlier at our hospital, was normal.
We decided to recover her liver and kidneys for transplant. During organ retrieval, in view of her EVAR stent, we had to insert the infusion catheter into the right external iliac artery instead of the aorta. We clamped the aorta at the supraceliac area and both of the external iliac arteries distally. The left internal iliac artery was embolized during her EVAR; therefore, the right internal iliac artery was clamped during perfusion (Figure 2A and Figure 3). The liver was transferred to another hospital, whereas our hospital performed the kidney transplant procedures.
The first recipient was a 62-year-old man who underwent dialysis for 5 years. He received the left kidney, which had a cold ischemic time of 28 minutes. The second recipient was a 57-year-old man who underwent hemodialysis for 15 years. The right kidney was supplied by 2 arteries, and the lower polar artery was excluded by the EVAR stent graft (Figure 3). The cold ischemic time of the right kidney was 3 hours and 28 minutes. We established the patency of the lower polar artery and reconstructed the 2 right renal arteries. Both of the recipients were prescribed antithymocyte globulin (1.5 g/kg for 3 days) and triple therapy with tacrolimus, prednisolone, and mycophenolate mofetil for immune suppression. Postoperatively, both recipients had stable kidney function, with creatinine levels in the range of 0.9 to 1.4 mg/dL. Both recipients have remained well for 2 years without any evidence of kidney dysfunction or rejection.
The greatest challenge in organ transplantation is to increase the number of allografts available for transplant. An important strategy for increasing the number of allografts is to expand the deceased donor pool utilizing ECDs and donors after cardiac death.2 The main concerns with ECDs are delayed graft function or primary nonfunction of the graft and worse long-term results.5 We selected the oldest recipients among the patients on our wait list as a measure to address possible poor long-term outcomes in this scenario.
Currently, EVAR is a popular procedure for patients with AAA. Owing to the low risk of EVAR, there has been an increase in the performance of this interventional procedure. In Korea, the rate of EVAR has exceeded that of open surgical repair for AAA.6 Organ procurement from donors who have undergone EVAR appears to be difficult compared with the general population. However, allografts from such donors may be suitable for selected patients in times of organ shortage, especially in Korea. To the best of our knowledge, this is the first report of kidney transplants performed with allografts from a donor who underwent EVAR. This case presents a possible option to further expand the donor pool for organ transplant.
DOI : 10.6002/ect.2018.0037
From the Department of Surgery, Ulsan University Hospital, University of Ulsan
College of Medicine, Ulsan, Korea
Acknowledgements: The authors have no sources of funding for this study and have no conflicts of interest to declare.
Corresponding author: Sang Jun Park, Department of Surgery, Ulsan University Hospital, 877 Bangeojinsunhwan-doro, Dong-gu, Ulsan 44033, Republic of Korea
Phone: +82 52 250 8862
Figure 1. Computed Tomography Scan With 3-Dimensional Reconstruction Following Endovascular Aneurysm Repair
Figure 2. Infusion of Preservative Solution
Figure 3. Lower Polar Artery in Donor’s Right Kidney