High resolution ultrasound characterization of early allograft hemodynamics in pediatric living related renal transplantation

PURPOSE: Allograft vascular thrombosis occurs in 5% to 10% of pediatric renal transplants. The hemodynamics of renal allograft immediately after implantation is unclear. High resolution Doppler ultrasound of the renal allograft performed in the operating room after incision closure is an effective and objective method to advance our understanding of baseline renal allograft hemodynamics, and identify unsuspected vascular complications early enough to ensure prompt surgical repair. MATERIALS AND METHODS: Between September 1998 and July 2000 high resolution, color power Doppler ultrasound was prospectively performed on 21 living related renal transplants in the operating room immediately after incision closure. Each ultrasound described allograft anastomotic blood flow, direction of diastolic flow, parenchymal perfusion and resistive indexes. RESULTS: There were 20 (95%) allografts with good power Doppler perfusion that had satisfactory immediate function with no vascular complications at 9 to 26-month followup. Initially, anastomotic turbulence was described in 15 (71%) allografts, and resistive indexes were abnormal in 8 (38%). Turbulence and abnormal resistive index normalized in all allografts by 1-month followup. Ultrasound of 1 allograft identified unsuspected poor perfusion and reversal of diastolic flow in the operating room after incision closure. In another allograft in which a 4-hour post-transplant ultrasound was compared with the baseline study in the operating room an unsuspected thrombosis of the right common iliac vein was confirmed. CONCLUSIONS: Good parenchymal perfusion and forward diastolic flow after renal reperfusion correlated well with immediate graft function. Initial turbulence and abnormal resistive index in the presence of favorable perfusion are misleading and not independent predictors of graft function. Ultrasound performed in the operating room identified 2 unsuspected major vascular complications facilitating prompt surgical correction.     

Should the indications for laparascopic live donor nephrectomy of the right kidney be the same as for the open procedure? Anomalous left renal vasculature is not a contraindiction to laparoscopic left donor nephrectomy

BACKGROUND: The left kidney is preferred for live donation. In open live donor nephrectomy, the right kidney is selected if the left kidney has multiple renal arteries or anomalous venous drainage. With laparoscopic live donor nephrectomy (LLDN), there is reluctance to procure the right kidney because of the more difficult exposure and further shortening of the right renal vein (RRV) after a stapled transection. An experience with LLDN is reviewed to determine whether the right kidney should be procured laparoscopically. METHODS: From February 1995 to November 1999, 227 patients underwent live donor renal transplants with allografts procured by LLDN. The results of these transplants were analyzed. RESULTS: Of the 227 kidneys transplanted, 17 (7.5%) were right kidneys. In the early experience, three (37.5%) of the eight right renal allografts developed venous thrombosis, two of which had duplicated RRV. Based on these initially unacceptable results, donor evaluation and LLDN techniques were modified. Spiral computerized tomography (CT) replaced conventional angiography to define better the venous anatomy. LLDN was modified in one of three ways: (1) changing the stapler port placement such that the RRV was transected in a plane parallel to the inferior vena cava, (2) relocation of the incision for open division of RRV, or (3) lengthening of the donor RRV with a panel graft constructed of recipient greater saphenous vein. Finally, the recipient operation enjoined complete mobilization of the left iliac vein with transposition lateral to the iliac artery. With these modifications, there were no vascular complications with the subsequent nine right renal allografts (P<0.05). Of the left kidneys transplanted, 31 had multiple renal arteries, 14 had retroaortic or circumaortic veins, 4 had both multiple arteries and venous anomalies, and 1 had a duplicated IVC draining the left renal vein. There were no vascular complications with left renal allografts that had multiple arteries or venous anomalies. CONCLUSIONS: LLDN of the left kidney is technically easier. Left kidneys with multiple arteries or anomalous venous drainage are not problematic. The right kidney can be procured with LLDN; however, a rational approach to preoperative angiographic imaging, donor operation, and recipient operation is crucial.     

Short- and long-term outcomes of kidney transplants with multiple renal arteries.

OBJECTIVE: The authors determined whether the use of kidney allografts with multiple renal arteries adversely effects post-transplant graft and patient outcome or increases the incidence of vascular and urologic complications. BACKGROUND: Kidney grafts with multiple renal arteries have been associated with an increased incidence of early vascular and urologic complications. Kidney transplants with single versus multiple renal arteries have not been compared in regard to long-term graft and patient outcome or post-transplant incidence of hypertension, acute tubular necrosis, rejection, and late vascular and urologic complications. METHODS: We analyzed 998 adult kidney transplants done from December 1, 1985 through June 30, 1993, in which only the recipient's external or internal iliac artery was used for anastomosis. We divided the study population into 3 groups: Group A-1 renal artery, 1 arterial anastomosis (n = 835), Group B-->1 renal artery, 1 arterial anastomosis (n = 112), Group C-->1 renal artery, > 1 arterial anastomosis (n = 51). We compared the incidence of post-transplant hypertension, acute tubular necrosis, acute rejection, and vascular and urologic complications; mean creatinine levels at 1, 3, and 5 years post-transplant; and patient and graft survival. Univariate and multivariate analyses were done to identify risk factors for vascular complications. RESULTS: We found no significant differences among the three groups for the following variables: post-transplant hypertension, acute tubular necrosis, acute rejection, creatinine levels, early vascular and urologic complications, and graft and patient survival. In kidneys with single arteries, the presence (vs. absence) of an aortic patch and the type of the arterial anastomosis (end-to-end to the hypogastric vs. end-to-side to the external iliac artery) did not have an impact on the incidence of early or late vascular complications. In kidneys with multiple arteries, only the rate of late renal artery stenosis was higher, the rate of early vascular and urologic complications was not different. Our multivariate analysis identified acute tubular necrosis as a risk factor for renal artery and vein thrombosis; graft placement on the left side for arterial thrombosis; and preservation time > or = 24 hours and multiple renal arteries for renal artery stenosis. CONCLUSIONS: Results of kidney transplants using allografts with multiple versus single arteries are similar.     

Renal transplantation in allografts with multiple versus single renal arteries

Allograft with multiple renal arteries (MRA) is considered to have an increased post-transplantation risk due to vascular and urologic complications. The aim of this study is to investigate the outcome of living donor kidney transplantation using allograft with a single artery and recipients of allografts with multiple arteries. Seven hundred and eighteen consecutive adult kidney transplants done between 1998 and 2007, with living unrelated kidney donors, were enrolled in this retrospective analysis. Data from the group with MRA (n = 60) were compared with those from the group with single renal artery (SRA) (n = 658). Delayed graft function (DGF) was more frequent in recipients' allografts with more than 2 arteries when compared with SRA recipients (Odds Ratio: 1.2; 95% CI:1.08-1.9, P = 0.02), but there was no difference between SRA and allograft with two arteries. The incidence of acute rejection (AR) was not statistically greater in recipients with MRA. Renal artery stenosis (RAS) occurred more frequently in patients with MRA (8.3% vs. 5.9% and P = 0.02), but other vascular complications such as renal artery thrombosis and hematoma revealed no differences (P > 0.05). Urologic complications such as UVJ obstruction, urinary leakage and ureteropelvic obstruction were not statistically different between the groups. The actuarial 1-year allograft survival rate was comparable in both groups (93.6% vs 96.8%, P = 0.22). Allografts with more than two arteries were associated with increased DGF and RAS, but no surgical or urological complications were detected in our series. Our findings demonstrate that renal allograft transplantation with multiple arteries could be performed with reasonable complications and acceptable outcomes.     

En Bloc Liver Kidney Transplantation Using Donor Splenic Artery as Inflow to the Kidney: Report of Two Cases

The number of simultaneous liver–kidney transplants has been increasing. This surgery is associated with an increased risk of complications, longer duration of surgery and longer ischemia time for the renal allograft. Two patients listed for liver–kidney transplant at our center underwent en bloc combined liver–kidney transplantation using donor splenic artery as inflow. Patient 1 previously underwent cardiac catheterization that was complicated by a bleeding pseudoaneurysm of the right external iliac artery that required endovascular stenting of the external iliac artery and embolization of the inferior epigastric artery. Patient 2 was on vasopressor support and continuous renal replacement therapy at the time of transplant. In this paper, we described a novel technique of en bloc liver–kidney transplant with simultaneous reperfusion of both allografts using the donor splenic artery for renal inflow. This technique is useful for decreasing cold ischemia time and total operative time by simultaneous reperfusion of both allografts. It is a useful technical variant that can be used in patients with severe disease of the iliac arteries.     

The use of the inferior epigastric artery for accessory lower polar artery revascularization in live donor renal transplantation

Purpose This study describes the surgical technique and outcomes of live donor renal allografts with multiple arteries in which the lower polar artery was anastomosed to the inferior epigastric artery after declamping. Materials and methods Between 1988 and 2004, 477 consecutive live donor renal transplants were performed, including 429 with single and 48 with multiple arteries. Anastomosis of the lower polar artery to the inferior epigastric artery was used for 15 grafts with multiple arteries. Results Successful revascularization of all areas of the transplanted graft was confirmed by Doppler ultrasonography in most patients and radionuclide renal scanning ± MRA in some patients. Conclusions In live donor renal transplantation with multiple arteries, the anastomosis of the lower polar artery to the inferior epigastric artery after declamping avoids prolongation of the ischemia time that occurs with other surgical and microsurgical techniques of intracorporeal and ex vivo surgeries.     

Multiple arteries in live donor renal transplantation: surgical aspects and outcomes

PURPOSE: This retrospective study describes the surgical techniques and outcomes of live donor renal allografts with multiple arteries. MATERIALS AND METHODS: Between 1976 and 2000, 1,200 consecutive live donor renal transplants were done, including 1,087 with single (group 1) and 113 with multiple (group 2) arteries. Intracorporeal in situ anastomotic techniques were used for 94 grafts with multiple arteries, while ex vivo techniques were used for 19. During in situ surgery each one of the multiple arteries was anastomosed separately to an individual artery. In ex vivo surgery 2 or more arteries were joined together on the bench to form a common stem, which was then anastomosed to an iliac artery or the aorta. RESULTS: Patient and graft survival were comparable in groups 1 and 2. The 2 groups were comparable regarding complications, including arterial bleeding, hematoma, renal artery stenosis, acute rejection, new onset hypertension, acute tubular necrosis and urological complications. Mean serum creatinine +/- SD at 1 year was 1.4 +/- 0.5 and 1.5 +/- 0.6 mg./dl., and at 5 years it was 1.8 +/- 1 and 2.1 +/- 1.4 mg./dl. for the 2 groups, respectively. The difference was only significant at 1 year (p = 0.02). Graft and patient survival, and the incidence of the described complications were comparable for the ex vivo bench anastomotic techniques and intracorporeal in situ techniques in the group with multiple renal arteries. CONCLUSIONS: The use of multiple arteries in renal allografts does not adversely affect patient or graft survival. It is not associated with an increased rate of complications except for significantly higher mean serum creatinine at 1 year. Extracorporeal bench surgery was as effective as intracorporeal surgery for the anastomosis of multiple renal arteries with no increase in the incidence of relevant complications.     

Multiple-artery renal transplantation: emphasis on extracorporeal methods of donor arterial reconstruction.

The operative techniques to transplant kidneys with multiple renal arteries and our recent experience with them are reviewed. The preferred methods are anastomosis with a Carrel aortic patch and extracorporeal arterial repair before transplantation. These are simple and effective methods that avoid subjecting the kidney to prolonged ischemia. Revascularization of all renal arteries is important to obviate ischemic allograft complications.     

Extracorporeal microvascular arterial reconstruction in donor kidneys prior to transplantation

Revascularization of all renal arteries is important to the prevention of ischemic allograft complications. Extracorporeal arterial repair prior to transplantation was performed on 41 donor kidneys. Three extracorporeal reconstructive techniques are described that are applicable to most of the anatomic variants presented by multiple renal arteries and those that are damaged or diseased. These are simple and effective methods that avoid subjecting the kidney to prolonged ischemia.     

Chronic rejection of rat renal allografts. II. The impact of prolonged ischemia time on transplant histology.

The effect of prolonged ischemia time on the generation of chronic rejection was investigated in long-surviving rat renal allografts. Three groups of rats were compared: allografts with a 30-min ischemia time, allografts with a 60-min ischemia time, and syngeneic grafts with a 60-min ischemia time. All transplants were initially immunosuppressed with 5 mg/kg/day of cyclosporine i.m. for 3 weeks postoperatively. The CsA trough levels were similar in the three rat groups. All groups demonstrated an initial rise and fall in serum creatinine; a simultaneous biopsy confirmed acute CsA toxicity. Thereafter the serum creatinine level remained on the normal control level both in the 30-min ischemia allografts and in the 60-min ischemia syngeneic grafts. After the initial decline, the serum creatinine level steadily increased in the 60-min ischemia allograft group and was 181 +/- 64 mumol/L at the end of the observation period, 12 weeks postoperatively, compared with 85 +/- 21 mumol/L in the 30-min ischemia allografts and 89 +/- 25 mumol/L in the 60-min ischemia syngeneic grafts. Quantitative histology that was performed upon autopsy demonstrated that the 60-min ischemia allografts showed persistent inflammation, inflammatory cell pyroninophilia, vascular arteriosclerosis and obliteration, and glomerular sclerosis, which were significantly stronger than in similarly immunosuppressed syngeneic transplants. Reduction of the ischemia time from 60 to 30 min significantly ameliorated the vascular and glomerular changes in the allografts but not the inflammatory alterations. This experimental study confirms previous clinical observations and demonstrates that prolonged ischemia contributes to chronic rejection in renal allografts. The results suggest that the effect of prolonged ischemia on chronic rejection is directed primarily to the parenchymal components of the graft, possibly to the graft vascular endothelium. As prolonged ischemia did not significantly affect the inflammation in the transplants, we conclude that the effect is not directed to the intensity of the host antigraft immune response.     

Management of pararenal aneurysms of the abdominal aorta

The operative treatment of 77 patients with atherosclerotic aneurysms of the pararenal aorta (54 juxtarenal and 23 suprarenal) is analyzed. Repair of these complex lesions is formidable because of difficult exposure, renal ischemia and myocardial strain as a result of proximal aortic occlusion, and associated renal atherosclerosis with secondary renal functional impairment. Nineteen (25%) patients were normotensive with normal renal function. Sixteen patients (21%) had hypertension alone and 42 (54%) were hypertensive with abnormal renal function. There were multiple renal arteries in 22% of patients. Aortic reconstruction involved infrarenal graft in 27 patients (35%), infrarenal graft plus pararenal aortic endarterectomy (TEA) in 26 (34%), and infra- and pararenal aortic graft in 24 (31%). Twenty-two patients (30%) had normal renal arteries and therefore no renal reconstruction. Of the 55 patients who required combined aortic and renal artery repair, 24 required renal artery repair because of involvement of the renal arteries by the aneurysm and 31 because of atherosclerotic renal artery disease. TEA was the most common technique of renal artery repair (54 of 93 arteries, 58%), followed by reimplantation (18 arteries) and prosthetic graft (13). The perioperative mortality rate was 1.3%. The perioperative morbidity rate was 28% and consisted principally of renal insufficiency (23%). This was usually transient (44%) and (89%) mild. Renal morbidity was adversely affected by renal ischemia status, severity of renal artery disease and extent of renal revascularization. Following reconstruction, hypertension was cured or improved in 77% of patients and abnormal renal function was cured or improved in 46% and stabilized in an additional 39% of patients. These results show that combined aortic aneurysm repair and renal artery reconstruction can be performed with minimal mortality and an acceptable morbidity. Aggressive intraoperative monitoring is necessary to minimize myocardial complications. Careful attention must be paid to the technical details of the reconstruction, especially in minimizing renal ischemia, to reduce the subsequent incidence of renal function deterioration.     

Lactated Ringer as Preservation Solution in Living Donor Renal Transplantation

BackgroundOptimal organ preservation remains a critical hallmark event in renal transplantation as it is the supply line. Previous studies have shown that the choice of preservation solution may affect transplant outcomes. In this study, we aimed to present the early follow-up results of the graft and patients, using lactated Ringer to preserve kidney allografts with living donors.MethodsThe results of 97 living donor transplant operations performed in Sanko University Hospital were evaluated retrospectively. The patient's evaluation included demographics, dialysis time duration, renal replacement method, primary disease, comorbidity, surgical and clinical complications in the acute period, graft functions, blood levels of calcineurin inhibitor drugs, anastomotic renal artery, warm ischemia, and cold ischemia times.ResultsDonor (49 men, 50.5%) and recipient (58 men, 59.7%) demographics, HLA compatibility (mismatch), hospitalization days, and length of warm and cold ischemic time are summarized in Table 1. Primary nonfunction was not defined in any patients, but delayed graft function was observed during the follow-up of 3 patients (3.09%), who were all hypotensive in the post-transplantation period, and positive inotropic infusion was needed for hemodynamic stability.ConclusionsLactated Ringer demonstrated efficacy in terms of patient and graft survival, and its lower cost represents a financial advantage, so it can be used in living donor kidney transplantation because it is safe, effective, and inexpensive. Standard preservation solutions may still be recommended in cases with long cold ischemia times, such as paired exchange transplants and cadaveric transplants. Thus, randomized controlled studies are needed for further investigation.     

Graft and patient outcomes among recipients of renal grafts with multiple arteries

Anastomosis of multiple renal arteries in living donor kidney transplantation is technically demanding. Previously this condition was considered a relative contraindication to use of the donor, due to an increased risk of vascular and urologic complications. We conducted this retrospective study to determine the prevalence of multiple renal arteries in kidney transplants and their relation to graft and patient survival acute tubular necrosis, as well as vascular and urologic complications for comparison with the outcomes of recipients of single-artery grafts. Among the 1425 patients who underwent renal transplantation at our center, between November 1975 and March 2003 the present analysis concerned the most recent 1095 recipients. Seventy-nine (7.2%) cases required multiple-artery anastomoses (group I) and 1016 (92.8%) a single-artery anastomosis (group II). There were no significant differences between groups I and II with respect to creatinine clearance at 1 year, cold ischemia time at 1 year, or serum creatinine values at 1, 2 or 5 years (P <.05 for all). There were also no significant differences between the groups with respect to rate of posttransplantation hypertension (P =.67), acute tubular necrosis (P =.55), or number of acute rejection episodes (P =.34). The respective graft survival rates at 1 and 5 years posttransplantation were 95.1% and 73.2% in group I and 95.0% and 79% in group II. The corresponding patient survival rates were 95% and 88% for group I and 97.1% and 83.1% for group II. These findings indicate that kidney grafts with multiple arteries may be used with excellent results.     

Does kidney transplantation with multiple arteries affect graft survival?

Introduction

We compared short- and long-term outcomes of renal transplants with single versus multiple arteries.

Patients and methods

We retrospectively analyzed data from kidney transplants from 208 living donors performed between 1994 and 2010. Renal grafts were divided into two groups: single renal artery (n = 164) versus multiple renal arteries (n = 44). The groups were compared regarding early and late vascular and urological complications. Patient and graft survivals were compared using Kaplan-Meier survivorship curves with comparisons using the log-rank test.

Results

Both groups were comparable regarding acute rejection episodes, posttransplant hypertension, postsurgery renal artery stenosis, and urologic complications. Only hemorrhagic complications and renal artery thrombosis were significantly higher in the multiple renal arteries group (P = .027 and .03, respectively). Warm ischemia time was significantly longer in the multiple renal arteries group without any influence on the incidence of acute tubular necrosis (P = .2). Mean creatinine clearance at 1 year was 65 versus 50 mL/min/1.73 m² (P = .5) and at 5 years, 60 versus 55 mL/min/1.73 m² (P = .1) for the single versus multiple renal arteries groups, respectively. Return to hemodialysis was necessary for 18.8% of the single and 16.1% of the multiple renal arteries group.

Conclusion

The use of an allograft with multiple renal arteries is a safe, successful surgical procedure, that does not influence patient or graft survivals or increase surgical complication rates provided the surgical team is evolved with technical skill.     

Management of renal allografts with multiple renal arteries resulting from laparoscopic living donor nephrectomy

Laparoscopic living donor nephrectomy (LLDN) has become an accepted procedure in many transplant centers. The placement of laparoscopic vascular staples can result in multiple short, small-caliber renal arteries that the recipient surgeon must deal with to restore perfusion to all parts of the kidney. The incidence of multiple renal arteries resulting from LLDN, surgical management of multiple renal arteries, and the short- and long-term graft functions were studied in 73 consecutive kidney recipients at a single center. Various techniques used for reconstruction are described, including the use of recipient internal iliac artery for the extension and reconstruction of small-caliber, short renal vessels. Single-artery allografts were compared with those with multiple arteries, with length of renal artery, warm ischemia time, hospital length of stay, operating time, creatinine levels, and 1 yr survival rates not found to be significantly different. The presence of multiple renal arteries should not exclude the possibility of using the left kidney for LLDN.     

Renal transplant arterial thrombosis: association with cyclosporine

Of 136 patients who received a renal transplant between January 1984 and August 1988, there were six cases (4.4%) of allograft arterial thrombosis (AAT) occurring a mean of 23 days after transplantation. All were maintained on cyclosporine A(CsA) in addition to prednisone and azathioprine. All transplants were performed by the same transplant surgeon. Five of the six episodes (83%) were in allografts that had multiple renal arteries (MRA), giving an incidence of AAT in that group of 36%. Only one of 122 (0.8%) allografts with a single renal artery experienced thrombosis. CsA was started a mean of 9 days after transplantation (range, 16 to 33 days). There was no correlation of AAT to CsA levels. AAT appears to be an early complication of allografts with MRA in patients maintained on CsA.     

Activation of mitochondrial apoptotic pathways in human renal allografts after ischemiareperfusion injury

BACKGROUND: Ischemia-reperfusion injury in cadaveric (CAD) kidney allografts is associated with tubular cell injury, delayed graft function, and an increased incidence of acute and chronic rejection. We tested the hypothesis that activation of specific apoptotic pathways represents a mechanism for tubular cell death after CAD kidney transplantation. METHODS: Serial tissue sections from paraffin-embedded needle biopsy specimens obtained at approximately 1 hr of reperfusion after transplantation of 13 CAD and 12 living-related donor (LRD) renal allografts were examined by using the terminal deoxynucleotide transferase-mediated dUTP nick-end labeling assay to detect apoptosis and by immunohistochemistry for expression of key pro-apoptotic molecules (Bax, Bak, tumor necrosis factor receptor [TNFR]-1, Fas, and cytochrome c). RESULTS: Apoptosis was detected primarily in tubular cells, with a mean+/-standard deviation of 6.8+/-2.2 apoptotic cells per 100 cells examined in CAD renal allografts compared with 1.8+/-2.7 cells per 100 in LRD (P<0.001) renal allografts. There was a significant correlation between apoptosis rate and cold ischemia time in CAD (r=0.86, P<0.001) renal allografts. Bax was expressed in 100% of CAD versus 17% of LRD renal allografts (P<0.001), Bak in 92% of CAD versus 17% of LRD renal allografts (P<0.001), and TNFR-1 in 100% of CAD versus 58% of LRD renal allografts (P<0.05). Fas was expressed in only a small number of samples (23% of CAD and 17% of LRD renal allografts, P=not significant). Bax and Bak were expressed predominantly in apoptotic cells. Cytochrome c was detected as a mitochondrial pattern in LRD renal allografts, but in a diffuse cytosolic distribution in CAD renal allografts. CONCLUSIONS: Ischemia-reperfusion injury in CAD kidney transplants is associated with a duration-dependent increase in tubular cell apoptosis, mediated at least in part by activation of mitochondrial pathways.     

The Outcomes of Living Donor Renal Transplants With Multiple Renal Arteries: A Large Cohort Study With a Mean Follow-Up Period of 10 Years

Background

Living donor kidney transplants with multiple arteries are presumed to be associated with an increased risk of complications.

Objectives

The aim of the study was to compare the outcomes in living donor transplantation with the specific intention of comparing long-term outcomes in which the donor kidney had 1 or more renal arteries. The study was undertaken in 2 large transplant centers.

Methods

A retrospective analysis of 201 living donor kidney transplants with multiple arteries that were performed between January 1985 and December 2004 was undertaken. We recorded patient and graft survivals, urological and vascular complications. Kaplan-Meier survival estimates were calculated, and 2-tailed Student t-test was used to compare outcomes. P < .05 was considered statistically significant.

Results

Graft and patient survival at 1 year were 93% and 97% and at 5 years were 87% and 92%. The most common complications were vascular (8.9%), followed by urological (6%), acute tubular necrosis (5.5%), and posttransplant hypertension (4.0%). There was significantly higher incidence of acute tubular necrosis (ATN) in multiple-artery transplants.

Conclusion

In this large cohort of patients studied, apart from a higher incidence of ATN and vascular complications, it appears that the number of renal arteries did not have any adverse impact on the outcomes. The findings from this study suggest that live donor kidneys with multiple renal arteries can be safely utilized for renal transplantation.     

亲属活体供肾移植中副肾动脉的重建

目的 探讨亲属活体供肾移植中利用受者腹壁下动脉(IEA)重建供肾副肾动脉(ARA)的临床效果.方法 存在ARA的亲属活体供肾16个,其中单支型15个,多支型1个.5个供肾的ARA位于上极,1个位于中部,9个位于下极,1个供肾的中部和下极各有一支ARA,其开口直径为1.5～3.5 mm.供肾热缺血时间为1～6.5 min,冷缺血时间为15 90 min.除多支型1例的中部ARA与肾动脉主干行端侧吻合外,其余16支ARA均与受者的IEA重建.ARA位于上极的5个供肾中,3个由于ARA过短,而供肾因为输尿管原因又不适于颠倒以与IEA重建,遂切取一段长3～6cm的供者生殖腺静脉,对ARA进行延长,再将ARA与IEA进行重建.术后采用多普勒超声检查移植肾血流,监测血清肌酐(Cr).结果 所有IEA与ARA的吻合均一次完成,吻合时间为(4.9±1.4)min,开放IEA后,见IEA和ARA均搏动良好,吻合口通畅.仅2例术中发生吻合口漏血,经热盐水纱布轻压局部2～3 min后出血停止.术后第3天,多普勒超声检查显示,16例移植肾的ARA供血区域血流丰富,局部动脉阻力指数正常(<0.7).所有肾脏均在恢复血液供应后10 min内开始泌尿,术后血清Cr均迅速下降至正常.16例未发现下肢血管并发症的发生.术后随访6个月,未见局部动脉栓塞,也无输尿管坏死发生.结论 对于存在ARA的供肾,可利用受者的IEA进行重建,此术式适用于ARA与肾动脉主干或其他动脉吻合存在困难者.     

Sequential anastomosis of accessory renal artery to inferior epigastric artery in the management of multiple arteries in live related renal transplantation: a critical appraisal

In live related renal transplant program, management of multiple renal arteries (MRA) is technically demanding and used to be considered a relative contraindication because of increased risk of vascular and urologic complications. We present a retrospective analysis of the outcome of grafts with MRA and suggest certain guidelines. Of the 680 live related kidney transplantations done, 53 allografts had MRA. Cases were grouped according to the reconstruction technique: group A, MRA reconstructed ex vivo into a single renal artery (n=27); group B, MRA with multiple anastomoses in vivo (n =13); group C, MRA with sequential revascularization using inferior epigastric artery (n=11). We compared serum creatinine, acute tubular necrosis, rejection rates and the rewarm ischemia time between the three groups. Overall patient survival and graft survival were excellent (100 and 96%). Mean serum creatinine at 1 yr did not differ significantly between the three groups. Rewarm ischemia time was significantly less in group C (p<0.01). Incidence of acute tubular necrosis and rejection episodes was also less in group C although the difference was statistically significant only between group C and group B. We conclude that allografts with MRA can be used successfully in a live related renal transplantation program. Bench reconstruction should be done whenever possible. For reconstruction of an accessory vessel, inferior epigastric artery with sequential revascularization is recommended.