Transplantation of en bloc pediatric kidneys with a partial bladder segment in an adult recipient

The success of transplantation of the urinary bladder en bloc with pediatric kidneys remains undetermined. We transplanted a large portion of the bladder with en bloc kidney allografts from a 13-month-old donor into a 45-year-old adult male. The recipient, who was on long-term hemodialysis, had a small urinary bladder consistent with long-standing anuria. Informed consent was given and bilateral kidneys were transplanted en bloc with both ureters and bladder. The patient's bladder was augmented with the donor bladder and bilateral ureteroneocystotomies of small ureters was avoided. At 3 and 18 months post-transplantation, cystoscopies revealed a viable bladder with new vessels and normal donor bladder. Cystogram revealed no reflux. The bladder segment was reperfused via blood supply from both ureters and then from the recipient's bladder. It seems that bladder transplantation en bloc with pediatric kidneys is a viable option for augmentation of a small recipient bladder that allows avoidance of very small bilateral ureteroneocystotomies.     

婴儿双供肾成人肾移植的改良简化术式四例

目的总结婴儿双供肾成人肾移植的改良简化术式的手术方式及临床效果。方法总结山西省第二人民医院肾移植透析中心2017年1月至2019年9月采用改良简化术式进行的4例婴儿双供肾成人肾移植资料。4例均为心死亡供者,男性3例,女性1例,年龄(54±22.69)d,体重为(5.6±0.79)kg。受者中男性1例,女性3例,年龄(41.5±5.97)岁,体重(45±3.56)kg。俢肾过程中将双侧供肾缝合固定,使双肾位置相对固定,行供肾腹主动脉瓣-受者髂外动脉、供肾下腔静脉瓣-受者髂外静脉端侧吻合,以降低手术难度、避免血流动力学紊乱。结果4例手术过程均顺利,供肾修整平均历时20 min,移植手术平均历时68.75 min。未出现血管及泌尿系统并发症,随访12个月移植肾功能恢复良好,受者及移植肾远期存活满意。结论改良简化婴儿双供肾成人整块肾移植优化了手术方式,操作简便且降低血管并发症,提高手术成功率,值得在临床实践中推广应用。     

En-bloc pediatric kidney transplantation together with a partial bladder segment: a case report

There is a continuing debate about the techniques of kidney transplantation from small donors because of the high vascular thromboses and ureteric leak rates. Transplantation of en-bloc pediatric kidneys with a partial bladder segment has potential benefits over established techniques. We transplanted cadaveric en-bloc kidneys together with a partial bladder segment from a 1.5-year-old donor to a 12-year-old boy with end-stage renal disease due to vesicoureteral reflux (VUR) of a solitary kidney. En-bloc kidneys were transplanted together with both ureters and a partial bladder segment. Using donor bladder segment augmented the recipient bladder. Thereby, potential complications of bilateral ureteroneocystostomies of small ureters were avoided. During the following 12 months, the clinical course was normal and there was no evidence of VUR. In conclusion, the technique of using en-bloc pediatric kidneys together with a partial bladder segment is feasible and safe as well as an efficient procedure to preserve the natural anti-reflux mechanism in childhood.     

Strategies for transplantation of cadaveric kidneys with congenital fusion anomalies

PURPOSE: The dire shortage of cadaveric kidneys has led to a gradual expansion of donor criteria in the transplant community. The use of kidneys with anatomical fusion anomalies is uncommon and has not been well defined in the literature. We evaluated the surgical strategies and postoperative outcomes of transplanting cadaveric kidneys with congenital fusion anomalies. MATERIALS AND METHODS: Three cadaveric kidneys with congenital fusion anomalies were procured and transplanted between May 1994 and November 1999. None of the 3 donors had any significant urological history. All fusion anomalies were identified during the organ procurement process. RESULTS: Anomalies included 1 L-shaped cross-fused ectopic and 2 horseshoe kidneys. All 3 kidneys were procured en bloc. One horseshoe kidney with a narrow isthmus was split and the 2 kidneys were transplanted into separate recipients, while the other horseshoe kidney was transplanted en bloc into a single recipient. The L-shaped kidney was transplanted en bloc into 1 patient. All transplants were successful with a serum creatinine of 1.1 to 1.9 mg/dl. CONCLUSIONS: To our knowledge we present the initial case of transplantation of an L-shaped kidney. Cadaveric kidneys with congenital fusion anomalies may be transplanted successfully using various individual technical strategies based on the specific renal anatomy. As such, these kidneys may be used to maximize the increasingly inadequate donor pool.     

马蹄铁肾移植的外科策略探讨(附二例报告)

目的 为避免供肾浪费，探讨马蹄铁肾移植的可行性和安全性。方法 对尸体马蹄铁肾采取原位灌注、整块切取法获取供肾。将马蹄铁肾离断峡部后，分成2个供肾，分别植入2例受者。结果 肾移植术中开放血管后，移植肾血供正常。1例随访至今(12个月)，肾功能正常，未发现与马蹄铁肾有关的并发症；另1例在移植后1．5个月死于感染。结论 在一定的外科策略指导下，马蹄铁肾移植是可行和安全的。     

Successful transplantation of pediatric en bloc kidneys with bilateral double ureters

We report a case in which en bloc kidneys with bilateral double ureters from a 5-month-old donor were successfully transplanted into a 25-year-old recipient. No stents were used. There were no complications after the transplant. The patient remains well at more than 1.5 years post-transplantation with serum creatinine 1.2 mg/dl. Received: 27 April 1998 Accepted: 24 June 1998     

Recovery and Utilization of Deceased Donor Kidneys from Small Pediatric Donors

The optimal use of kidneys from small pediatric deceased donors remains undetermined. Using data from the Scientific Registry of Transplant Recipients, 2886 small (< 21 kg) pediatric donors between 1993 and 2002 were identified. Donor factors predictive of kidney recovery and transplantation (1343 en bloc; 1600 single) were identified by logistic regression. Multivariable Cox regression was used to assess the risk of graft loss. The rate of kidney recovery from small pediatric donors was significantly higher with increasing age, weight and height. The odds of transplant of recovered small donor kidneys were significantly higher with increasing age, weight, height and en bloc recovery (adjusted odds ratio = 65.8 vs. single; p < 0.0001), and significantly lower with increasing creatinine. Compared to en bloc, solitary transplants had a 78% higher risk of graft loss (p < 0.0001). En bloc transplants had a similar graft survival to ideal donors (p = 0.45) while solitary transplants had an increased risk of graft loss (p < 0.0001). En bloc recovery of kidneys from small pediatric donors may result in the highest probability of transplantation. Although limited by the retrospective nature of the study, kidneys transplanted en bloc had a similar graft survival to ideal donors but may not maximize the number of successfully transplanted recipients.     

Pediatric En Bloc Dual Kidney-Pancreas Transplantation Into an Adult Recipient: a Simplified Technique. Benefits of the en bloc kidney-pancreas transplantation technique in pediatric donors

The lower age limit for pancreas donors is not well defined. Fear of inadequate islet beta-cell mass and of technical complications has hampered the use of pediatric donors. A surgical technique of 'en bloc' kidney-pancreas is described. Both kidneys and pancreas were removed en bloc from a 13-kg, 31-month-old child. During bench preparation, one anastomosis was performed between the portal vein and the inferior vena cava. The proximal end of the aorta was closed. The bloc was transplanted into a 36-year-old type I diabetic patient intraperitoneally in the right iliac fossa. The kidneys functioned immediately. Pancreatic graft function resumed after POD 15 but insulin therapy was maintained until POD 112. Currently, the patient retains excellent kidney and pancreas graft functions. Very young donors can be accepted as pancreas donors for adult recipients, although slow recovery of pancreatic function can be expected. Use of the en bloc technique is well suited for very small children, as it prevents potential vascular complications.     

Superiority of pediatric en bloc renal allografts over living donor kidneys: a long-term functional study

BACKGROUND: Growing waiting list for kidney transplantation in the United States makes it imperative to expand donor pool to use of pediatric kidneys. Because en bloc pediatric kidneys double nephron numbers, it would be interesting to learn how they fare compared to living donor kidneys long term. METHODS: Retrospective chart review was performed on all 72 pediatric en bloc and 75 live adult donor kidney recipients transplanted between January 1990 and December 2001. Long term graft function was assessed with glomerular filtration rate (GFR) using the abbreviated modification of diet in renal disease (MDRD) formula. RESULTS: Pediatric donor was 16.9 +/- 11.2 months old and weighed 10.7 +/- 3.8 kg. Nine en bloc kidneys thrombosed at a mean of 4.2 days posttransplantation. Proteinuria was detected later posttransplantation in en bloc group (45.6 +/- 33.6 months vs. 23.4 +/- 16.3 months, P = 0.002). Pediatric en bloc recipients had significantly higher GFR up to 8 years posttransplantation. One-year graft survival was significantly better in live donor group (93.3% vs. 81.9%, P = 0.041) but five-year graft survival rates were similar (86.7% vs. 76.3%, P = 0.125). One-year and five-year patient survival rates were similar between en bloc and live donor groups (97.3% vs. 98.6%, P = 0.585 and 94.6% vs. 93.0%, P = 0.688, respectively). CONCLUSION: Early postoperative graft thrombosis remain a challenge with pediatric en bloc renal transplants, but once the allografts survive early postoperative course, they provide better long-term function than living donor kidney transplants. In order to alleviate burden on waiting list, pediatric en bloc kidneys should be transplanted more often when available.     

The use of the portal system for the transplantation of a neonate kidney graft in a child with Wilms' tumor

A single an-encephalus neonate kidney graft was transplanted into the portal system of a 6-year-old recipient who had previously undergone removal of the right kidney and inferior vena cava because of Wilms tumor. The left kidney ceased to function shortly thereafter. The child was supported very poorly on hemodialysis, and showed repeated very high levels of cytotoxic antibodies in her serum. The first cross-negative kidney graft that was available harbored two main arteries and duplicate collecting system with two very thin ureters. These vascular anatomic and pathologic variations of both donor graft and recipient necessitated the use of the portal system for renal graft venous drainage and the aorta for the graft revascularization. The ureters that had pinpoint-like lumen were inserted together into the lumen of the native ureter stump and fixated. One year after the transplantation the serum creatinine level is 1.8 mg/dL.     

Combined pancreatic and kidney transplantation: en bloc retrieval and transplantation - a new surgical technique

Abstract We designed and performed on two patients a new surgical procedure of en bloc kidney and pancreatic transplantation. The liver, pancreas and kidneys were removed en bloc in the donor. On the bench, the liver and the left kidney were separated from the bloc, leaving the pancreas and the right kidney for combined kidney and pancreatic transplantation, The portal vein was divided near to the emergence of the splenic vein. The coeliac axis was taken with an aortic patch. The left renal vein was cut at its entrance to the inferior vena cava (IVC) and the left renal artery was taken with an aortic patch. Reconstruction of the pancreatic vessels was performed with a double anastomosis: the portal vein was anastomosed to the hole in the IVC resulting from the section of the left renal vein and the splenic artery was anastomosed to the hole in the aorta resulting from the section of the left renal artery. The proximal ends of the aorta and IVC were closed with running sutures. In the recipient, the iliac vessels on the right side were dissected. Anastomosis of the distal part of the aorta and the IVC was performed with the right iliac vessels. Duodenocystostomy and reimplantation of the ureter were done according to the usual techniques. This new surgical technique allowed an easy vascular reconstruction of the pancreatic vessels. In the recipient, only one side was used for renal and pancreatic transplantation. Moreover, the length of the transplant procedure was significantly reduced.     

门脉建立侧袖式大鼠肝/小肠整块联合移植模型

目的 建立大鼠肝、小肠整块联合移植模型.方法 用Wistar大鼠行同种异体肝、小肠整块联合移植.肝肠联合移植整块切取移植物时,保留门静脉完整性,利用供体腹段下腔静脉在门静脉侧壁上建立一侧袖,并安置套管.然后按kamada二套管法行原位肝移植,动脉重建通过供体腹主动脉与受体腹主动脉行端侧吻合以建立肠系膜上动脉及肝固有动脉血供.回肠末端在右下腹造瘘.结果 手术成功率为86%,动物平均存活时间大于30 d.病理组织学检查发现移植肝和小肠结构正常.结论 用门脉建立袖套式血管吻合技术施行大鼠肝、小肠整块联合移植模型是可行的.     

TRANSPLANTING HORSESHOE KIDNEYS: A WORLDWIDE SURVEY

PURPOSE: Horseshoe kidney is the most common anatomical renal variation. It represents a fusion anomaly, usually of the lower poles. Horseshoe kidneys can be transplanted en bloc or after division of the renal isthmus. We constructed a decision cascade for horseshoe kidney transplantation. MATERIALS AND METHODS: A worldwide survey of transplantation clinics and foundations was performed to discover cases of horseshoe kidney transplantation. In each case data were collected on horseshoe kidney anatomy and post-transplantation results. The number of renal arteries and veins was correlated with primary nonfunction due to technical failure. RESULTS: From 1975 to 2000, 23 horseshoe kidneys were transplanted en bloc, while 57 were split and transplanted into 97 recipients. Primary nonfunction was observed in 4.3% and 13.4% of en bloc and divided transplanted kidneys, respectively. Postoperatively a urinary fistula formed after renal isthmus division in 2 cases. An increased number of renal vessels was not associated with an increased risk of primary nonfunction. CONCLUSIONS: Horseshoe kidney anatomy should be closely inspected after explantation. The decision to split a horseshoe kidney should be based on urinary collecting system anatomy in the renal isthmus and on the number as well as the position of the renal vessels. Horseshoe kidneys can and should always be considered for transplantation.     

A novel technique for en bloc kidney transplantation from infant donors with extremely low body weight by using the distal abdominal aorta as an outflow tract

Pediatric kidney donors remain underutilized due to the high risk of postoperative thrombosis. To address this problem, we developed a novel en bloc kidney transplantation technique using donor thoracic aorta and the distal abdominal aorta as inflow and outflow tracts, respectively. Briefly, eight kidneys from deceased infant donors under five months old and with low body weight (1.9‐4.9 kg) were transplanted en bloc into four pediatric and four adult patients. The donor's common iliac artery or external iliac artery was anastomosed to the recipient's distal external iliac artery or inferior epigastric artery, respectively, as an outflow tract. Recipients received basiliximab or antithymocyte globulin as induction therapy followed by tacrolimus, mycophenolate mofetil, and prednisone but without prophylactic anticoagulation. Delayed graft function was observed in one patient but was reversed at 90 days posttransplant. Two patients had urine leakage, which was cured by conservative treatment. Two recipients developed lung infections that eventually cleared. No patients experienced posttransplant vascular thrombosis. After 1‐1.5 years of follow‐up, all patients are well and have normal serum creatinine levels. In conclusion, this novel en bloc kidney transplantation technique using a modified arterial inflow and outflow tract can prevent vascular thrombosis and provide adequate graft function.     

改良膀胱壁瓣输尿管成形术治疗婴幼儿供肾肾移植术后输尿管坏死的临床分析

目的探讨采用改良膀胱壁瓣输尿管成形术（改良Boari术）治疗婴幼儿供肾肾移植术后输尿管长段坏死的疗效。方法回顾性分析济南军区总医院泌尿外科2012年1月至2014年4月施行婴幼儿供肾肾移植术后发生移植肾输尿管长段坏死的3例受者临床资料。第1例为婴儿供者双肾整块移植。第2例和第3例为同一名幼儿供者双侧供肾分别移植给2例成人受者。3例受者分别于术后21,23,26d出现移植肾区肿胀、疼痛,切口渗液或阴囊水肿,以及血清肌酐升高;行移植肾彩色多普勒超声示。肾周积液增多;1例受者行CT尿路造影示造影剂大量外漏、单侧肾积水、输尿管扩张。手术探查切除坏死的输尿管后行改良Boari术,将移植肾输尿管残端插入自体膀胱管状瓣内1-2cm,不作吻合,仅行黏膜和浆肌层缝合加固。术后酌情选用抗生素控制尿路感染,定期行肾功能检测和移植肾彩色多普勒超声检查,术后6个月复查CT尿路造影。结果3例患者均成功进行改良Boari术,手术时间分别为85,90,115min,术中无明显出血,术后切口愈合良好。3例患者分别在术后12,13,16周顺利拔除双J管,血清肌酐均下降至正常范围。截至2014年3月,术后随访6-18个月,复查移植。肾彩色多普勒超声和CT尿路造影均未发现移植肾积水、肾周积液、尿漏或尿液返流等异常。结论改良膀胱壁瓣输尿管成形术是治疗婴幼儿供肾肾移植术后输尿管长段坏死的有效方法。     

Horseshoe kidney transplantation: an overview

The horseshoe kidney is the most common anatomical renal variation. It represents a fusion anomaly, mainly at the lower poles, occurring between the 4th and 6th week of gestation. Horseshoe kidneys display a great variation in origin, number and size of the vasculature. Transplantation of these deviant kidneys can be done en bloc or they can be split into two halves and transplanted into two recipients, depending on the number of vessels and the anatomy of the urinary collecting system. A literature review reveals 31 case histories, published between 1975 and 1998. Of these 21 were transplanted into 38 recipients after division and ten were implanted en bloc. Nineteen grafts (41%) showed immediate function and 21 grafts (46%) showed delayed function. Thrombosis and acute rejection, leading to non-function was seen in six grafts (13%). The overall success rate was 87%) with a mean follow-up of 22 months. The results of horseshoe kidney transplantation are good. provided that attention is paid to certain technical details. Because of donor scarcity, horseshoe kidneys should be used for transplantation.     

Successful Surgical Treatment of Renal Cell Carcinoma in a Transplanted Kidney from a Cadaveric Donor: Report of a Case

Posttransplant renal cell carcinoma (RCC) usually arises in the native kidneys of renal transplant recipients rather than in the transplanted kidney. This report describes a case of RCC that developed in the transplanted cadaveric kidney in a 37-year-old male recipient 9 months after transplantation. An en bloc radical transplant nephrectomy was performed, and he has subsequently remained stable on hemodialysis for 3 years without any sign of recurrence. Received: March 27, 2000 / Accepted: September 26, 2000     

Horseshoe kidney transplantation within the eurotransplant region: a case control study.

BACKGROUND: The horseshoe kidney is the most common anatomic renal variation, with an incidence of 1 in 600 to 800. It represents a fusion anomaly, usually of the lower poles. Horseshoe kidneys can be transplanted en bloc or after division of the renal isthmus. However, the great variation in origin, number, and size of renal arteries and veins leads to some reluctance to use horseshoe kidneys for transplantation. The aim of this study is to assess the results of horseshoe kidney transplantation. METHODS: All data concerning horseshoe kidney transplantations within the Eurotransplant region were collected and were divided into en bloc and split transplantations. A matched control group was defined, and the three groups were analyzed with respect to the occurrence of primary nonfunction, graft survival, patient survival, and finally posttransplant serum creatinine values. RESULTS: From 1983 to 2000, 8 horseshoe kidneys were transplanted en bloc and 26 were split and transplanted into 47 recipients. The results of these transplantations were compared with 110 transplantations in the control group. No significant differences among the three groups could be found, either in the short- or long-term posttransplant results. CONCLUSIONS: The results of horseshoe kidney transplantation, either en bloc or split, are equal to the posttransplant results of kidneys with a normal anatomy. Bearing in mind the shortage of donors, horseshoe kidneys should certainly be used for transplantation.     

Long-term clinical outcome of paediatric kidneys transplanted to adults.

BACKGROUND: We have earlier shown an increase in the size and excellent graft function of paediatric kidneys transplanted to adults up to 1 year following transplantation. This study was performed to assess the long-term outcome of these transplants. METHODS: From a primary cohort of 19 adults, receiving a first kidney transplant from a paediatric donor <10 years of age, 16 patients were available for a complete long-term follow-up, 5-9 years post-transplant. Of these, eight patients were transplanted with a donor of <5 years. All medical files and registry data of the cohort, from the time of transplantation to the follow-up time point, were recalled and events were registered. The patients' general condition, body weight, blood and urine tests, blood pressure (BP), use of antihypertensive agents and GFR were recorded. To explore the temporal increment in the size of paediatric donor kidneys transplanted to adults, the maximal cranio-caudal length of the kidneys from the time of transplantation to follow-up was established by ultrasound. Volumes (length x width x thickness x pi/6) of en bloc kidneys versus single paediatric kidneys and adult-to-adult transplants were compared. RESULTS: Long-term (7 years, median) patient and graft survival was 95% and 89%, respectively. Mean serum creatinine was 85 micromol/l (range, 32-131). The mean estimated GFR was 84 ml/min/1.73 m(2). The mean BP was 134/79 mmHg (range, 120-185/70-90). The number of antihypertensive agents used was not statistically different from the number used at 1 year post-transplant. None of the patients had significant proteinuria as a sign of hyperfiltration injury of the graft. There were no statistically significant increases in the maximal cranio-caudal length of the transplanted kidney(s) from 1 year post-transplant to follow-up; however, the en bloc kidneys tended to be larger than single paediatric grafts (240 ml and 204 ml) and adult-to-adult grafts (170 ml). CONCLUSION: Paediatric kidneys transplanted to adults should be considered as excellent for transplantation on a long-term basis.     

Kidney transplantation with two donor ureters in patient with previous ileogastric conduit

The purpose of our publication is to focus upon the technical aspects of a rare combination of kidney transplant with two donor ureters in a patient with neurogenic bladder and previous reconstruction of a continent ileogastric conduit.