Begin typing your search above and press return to search.
EPUB Before Print

FULL TEXT

ARTICLE
A Single-Center Experience With Third and Fourth Kidney Transplants and Second Kidney Transplant After Pancreas-Kidney Transplant: Surgical Aspects and Outcomes

Objectives: Overall, 25% to 33% of patients on kidney transplant wait lists present with prior graft loss. In addition, the number of patients who require a retransplant seems to be increasing. Here, we describe our experience with patients who had a second kidney transplant after a previous pancreas-kidney transplant or a third or fourth kidney transplant. We focused specifically on the technical aspects and outcomes related to this patient group.

Materials and Methods: A single-center retrospective study was performed. The cohort included 15 patients > 18 years old who had received a second kidney graft after pancreas-kidney transplant or a second or greater kidney graft between 2013 and 2019.

Results: Median age of recipients was 45 years (range, 20-58 y). In 10 patients, the transperitoneal approach was selected. In 5 patients, the retroperitoneal heterotopic kidney retransplant technique was used. Early surgical complications (≤ 30 days posttransplant) were reported in 4 patients. Three patients had late ureteral stenosis (> 90 days posttransplant). All grafts were functioning at time of patient discharge. Mean creatinine level was 2.69 mg/dL (range, 1.23-6.26 mg/dL). The 1-year and 2-year graft survival rates were 85% and 75%, respectively. No grafts were lost because of surgical complications.

Conclusions: Retransplant of a second graft after pancreas-kidney transplant or retransplant of a third or fourth renal graft is challenging but feasible, with evidence of reasonably positive outcomes after retransplant.


Key words : Renal retransplantation, Surgical technique, Surgical complications

Introduction

Kidney transplant is the best treatment option for patients with end-stage renal disease.1 Despite the advances made with regard to donor and recipient selection and matching and improvements in immunosuppression therapy, long-term graft survival remains moderate (37% graft survival at 15 years).2 Patients who lost their graft function may consider returning to dialysis or may consider retransplant.

Overall, among 1 of 4 and up to 1 of 3 patients on kidney transplant wait lists present with prior graft loss.3 Additionally; the number of patients who require a retransplant seems to be rising.4

Retransplant is associated with lower mortality rates compared with dialysis treatment.5 Moreover, the latest advances on pretransplant screening, donor-recipient immune matching,6 surgery techniques, and posttransplant follow-up have led us to consider retransplant as the best presently available option.

There are different surgical options for these patients, including orthotopic kidney transplant, transperitoneal kidney retransplant, and retro­peritoneal kidney retransplant. However, none of these are exempt from technical difficulties and complications.7-9 Here, our aim was to describe our experience with patients who have had a second kidney transplant after a previous pancreas-kidney transplant or a third or fourth kidney transplant.

Materials and Methods

Cohort
A single-center retrospective study was conducted. Data from patients > 18 years old who had received a second kidney graft after pancreas-kidney transplant (pancreas graft placed on right iliac fossa and kidney graft placed on left iliac fossa)10 or who had received greater than a second kidney graft between 2013 and 2019 were collected. Data were exacted from our authorized transplant prospective database. Informed consent was obtained from all patients included in the study.

For inclusion on a wait list for retransplant, multidisciplinary team approval was needed. Vascular patterns were assessed by an angio-computed tomography scan and evaluated by experienced interventional radiologists.

Surgical technique
A lower midline laparotomy was performed using the transperitoneal approach.7 If an extraperitoneal technique was found to be feasible, the retrope­ritoneal heterotopic retransplant technique7 was applied, which was carried out with hockey-stick incision.

The vascular anastomosis and implantation techniques were performed based on the patient’s vascular patterns; if the patient had undergone a previous transplantectomy, the technique depended on the cause and time of surgery.

The modified Lich-Gregoir technique of extra­vesical ureteral reimplantation11 was the preferred option for urinary tract reconstruction. A ureteral stent, which was scheduled to be withdrawn 4 weeks after implant surgery, was placed in all cases.

Immunosuppressive regimens
Standard immunosuppressive induction therapy consisted of tacrolimus, mycophenolate mofetil, and prednisolone. On the basis of the patient’s previous immunosensitive state, induction with thymo­globulin or basiliximab was added.

Statistical analyses
Descriptive analyses of clinical and operative variables and outcomes were carried out by calculating the average range of quantitative variables and the absolute frequencies and percentages of qualitative variables. Kidney graft survival was analyzed and summarized by using Kaplan-Meier curves. All analyses were performed using SPSS software version 17.0 (SPSS Inc., Chicago, IL, USA).

Results

Our study included 15 deceased-donor kidney transplant patients (3 patients had second graft implantation after previous pancreas-kidney transplant). The median recipient age was 45 years (range, 20-58 y). The median duration of follow-up was 24 months (range, 2-71 mo) (Table 1).

Previous surgery of transplantectomy (due to thrombosis or rejection) was performed in 13 patients. Transplantectomy was carried out simultaneously in another patient to achieve optimal requirements for implantation.

Ten patients underwent the transperitoneal approach. Anastomosis was performed to the iliac arteries in 9 patients. For venous anastomosis, the inferior cava vein was selected for 3 patients and the iliac veins for 7 patients (Table 2).

Five patients underwent the retroperitoneal heterotopic kidney retransplant technique. Iliac vessels were selected in all cases for anastomosis. Early transplantectomy was carried out previously in 4 patients (Table 2).

Four patients had early surgical complications (≤ 30 days postoperatively). One patient experienced postoperative bleeding that required urgent surgery. Another patient had wound dehiscence after discharge, which also required urgent surgery. One patient had wound infection, and one patient had a limited episode of hematuria due to previous BK virus infection.

Late complications (> 30 days postoperatively) were shown in 3 patients who had late ureteral stenosis (> 90 days postoperatively).12

All grafts were functioning at discharge with mean creatinine level of 2.69 mg/dL (range, 1.23-6.26 mg/dL). The average hospital stay was 12 days (range, 9-62 d).

The 1-year and 2-year graft survival rates were 85% and 75%, respectively. No grafts were lost due to surgical complications (Figure 1).

Discussion

Despite advances in immunosuppressive treatment, survival of the kidney graft remains limited. This fact implies that some patients with renal transplant must return to dialysis programs. Kidney transplant is considered the best treatment option for patients with end-stage renal disease,1 even in cases of retransplant.5,13

With advances in immunotherapy and surgery, transplants involving a third or fourth kidney allograft have become more common, which have increased patient quality of life and survival rates.6,14,15

Recipients of a third or fourth renal graft have many risk factors that make retransplant more challenging. Among these factors are access to vascular tissues, which become more difficult due to numerous surgical interventions, a long history of immunosuppression, and subsequent multiple comorbidities that may affect recipients.7,8,14

Numerous surgical techniques have been reported with different rates of surgical complications and graft loss.7-9,14,16 Therefore, no specific surgical technique has been established.

Our group prefers the transperitoneal approach due to more extensive bilateral vascular access. However, the retroperitoneal heterotopic transplant approach is used in cases where an early (< 1 mo) previous graft nephrectomy had proven successful and the external iliac vessels had not deteriorated.

Ureteral stenosis is one of the most common late surgical complications, with an incidence of up to 15% in some patient cohorts.17 In our study, 3 patients developed late ureteral stenosis, with 2 of them presenting with BK virus colonization.18

Despite the surgical challenges posed by retransplant, retransplant is feasible and safe when conducted at experienced centers.14 Hence, patients with loss of a previous graft should not be dismissed from undergoing retransplant, even on a previously used surgical field.7

Limitations of our study include the low number of cases and the retrospective nature of data collection of select cases.

Conclusions

Retransplant of a second graft after pancreas-kidney transplant and retransplant of third or fourth renal grafts are challenging but feasible procedures, which have shown evidence of reasonably positive outcomes.


References:

  1. Wolfe RA, Ashby VB, Milford EL, et al. Comparison of mortality in all patients on dialysis, patients on dialysis awaiting transplantation, and recipients of a first cadaveric transplant. N Engl J Med. 1999;341(23):1725-1730.
    CrossRef - PubMed
  2. Gomez EG, Hernandez JP, Lopez FJ, et al. Long-term allograft survival after kidney transplantation. Transplant Proc. 2013;45(10):3599-3602.
    CrossRef - PubMed
  3. Marcen R, Fernandez A, Fernandez Lucas M, Teruel JL, Perez-Flores I, Sanchez-Fructuoso A. [Retransplant]. Nefrologia. 2009;29 Suppl 1:62-71.
    CrossRef - PubMed
  4. Gentil Govantes MA, Rodriguez-Benot A, Sola E, et al. Trends in kidney transplantation outcome: the Andalusian Kidney Transplant Registry, 1984-2007. Transplant Proc. 2009;41(5):1583-1585.
    CrossRef - PubMed
  5. Rao PS, Schaubel DE, Wei G, Fenton SS. Evaluating the survival benefit of kidney retransplantation. Transplantation. 2006;82(5):669-674.
    CrossRef - PubMed
  6. Horovitz D, Caumartin Y, Warren J, et al. Outcome of third renal allograft retransplants versus primary transplants from paired donors. Transplantation. 2009;87(8):1214-1220.
    CrossRef - PubMed
  7. Halawa A. The third and fourth renal transplant; technically challenging, but still a valid option. Ann Transplant. 2012;17(4):125-132.
    CrossRef - PubMed
  8. Mazzucchi E, Danilovic A, Antonopoulos IM, et al. Surgical aspects of third and subsequent renal transplants performed by the extraperitoneal access. Transplantation. 2006;81(6):840-844.
    CrossRef - PubMed
  9. Musquera M, Peri LL, Alvarez-Vijande R, Oppenheimer F, Gil-Vernet JM, Alcaraz A. Orthotopic kidney transplantation: an alternative surgical technique in selected patients. Eur Urol. 2010;58(6):927-933.
    CrossRef - PubMed
  10. Campos Hernandez JP, Gomez E, Carrasco Valiente J, et al. Influence of surgical complications on kidney graft survival in recipients of simultaneous pancreas kidney transplantation. Transplant Proc. 2015;47(1):112-116.
    CrossRef - PubMed
  11. Campos Freire J, de Goes GM, de Campos Freire JG. Extravesical ureteral implantation in kidney transplantation. Urology. 1974;3(3):304-308.
    CrossRef - PubMed
  12. Rodriguez Faba O, Boissier R, Budde K, et al. European Association of Urology Guidelines on Renal Transplantation: Update 2018. Eur Urol Focus. 2018;4(2):208-215.
    CrossRef - PubMed
  13. Arce J, Rosales A, Caffaratti J, et al. [Renal retransplantation: risk factors and results]. Actas Urol Esp. 2011;35(1):44-50.
    CrossRef - PubMed
  14. Loupy A, Anglicheau D, Timsit MO, et al. Impact of surgical procedures and complications on outcomes of third and subsequent kidney transplants. Transplantation. 2007;83(4):385-391.
    CrossRef - PubMed
  15. Loupy A, Anglicheau D, Suberbielle C, et al. Long-term outcome of third kidney transplants. Nephrol Dial Transplant. 2007;22(9):2693-2700.
    CrossRef - PubMed
  16. Gutierrez Banos JL, Rodrigo Calabia E, Rebollo Rodrigo MH, et al. [Surgical aspects in the third and fourth kidney retransplant]. Actas Urol Esp. 2005;29(2):212-216.
    CrossRef - PubMed
  17. Gil-Sousa D, Oliveira-Reis D, Teves F, et al. Ureteral stenosis after renal transplantation-a single-center 10-year experience. Transplant Proc. 2017;49(4):777-782.
    CrossRef - PubMed
  18. Pahari A, Rees L. BK virus-associated renal problems--clinical implications. Pediatr Nephrol. 2003;18(8):743-748.
    CrossRef - PubMed


DOI : 10.6002/ect.2019.0372


PDF VIEW [163] KB.

From the 1Urology Department, Reina Sofía University Hospital, Córdoba, Spain, the 2Nephrology Department, Reina Sofía University Hospital, Córdoba, Spain; and the 3Urology Department, The University of Navarra Clinic, Pamplona (Navarra), Spain
Acknowledgements: The authors have no conflicts of interest to report. This research did not receive any specific grants from funding agencies in the public, commercial, or not-for-profit sectors.
Corresponding author: Joseba Salguero Segura, Urology Department, Reina Sofía University Hospital, Menendez Pidal s/n Avenue, 14004, Córdoba, Spain
Phone: + 34 638252134
E-mail: josebasalguerosegura@gmail.com