Third and Fourth Kidney Transplant: Still a Reasonable Option

Introduction

At present, a second kidney transplant is considered an established therapeutic option for patients who have lost a previous graft. Second transplants show similar graft survival as first transplants. A debate exists about the benefit of submitting the patient to a third or fourth renal transplant, or to maintain dialysis.

Objective

We sought to analyze graft and patient survivals as well as associated variables and surgical complications of third and fourth transplantations.

Material and Methods

From July 1985 to December 2008, we performed 74 third and 8 fourth transplantations among 2763 cases. We prospectively collected the variables of age, gender, graft origin, hyperimmunization, time on dialysis, location, bench surgery, acute rejection episodes, graft survival, and operative complications.

Results

Third and fourth trasplantations were performed in 49 men and 33 women, with an overall mean age of 40.26 years who were on dialysis for an average of 126.89 months before transplantation. Mean graft survivals of their first and second grafts were 35.6 and 50.1 months, respectively. Acute or chronic rejection was reason for renal failure in 71% and 75% of cases, respectively. Patient survivals at 1 and 5 years were 92.7% and 90.6%, for third and both 85.7% for the fourth transplantation. The third and fourth transplantations showed 1- and 5-year graft survivals of 88% and 76.4% and 71.4% and 42.9%, respectively. Sixty-eight cases underwent cadaveric donor and 14 living donor (mean age, 42.1 years) transplantations. Nine patients were hyperimmunized.In 60 cases, we used the left kidney. Orthotopic kidney transplantation was performed in 15 cases; heterotopic transplant to the right iliac fossa in 40 and in the left iliac fossa in 17 cases. Arterial bench surgery was necessary in 6 cases and venous in 3. We performed 3 hepatorenal and 1 cardiorenal transplantation. The complications included 29 cases (35.4%) of postoperative acute tubular necrosis, 14 of acute rejection episodes (17.1%); 12 of perirenal hematoma (14.6%); 1 urinary fistula (1.2%); 4 lymphocele (4.9%); 2 ureteral stenosis (2.4%); variables arterial kink requiring surgery (1.2%), and 1 venous thrombosis with graft loss (1.2%). The 4 patients who died in the perioperative period succumbed to intravascular disseminated coagulation (n = 1) cardiac failure (n = 2), and septic shock (n = 1). Induction antibody therapy, hyperimmunized status, or operative complications were not independent prognostic factors for patient or graft survival.

Conclusions

Third or fourth renal transplantations constitute a valid therapeutic option with reasonable short- and long-term patient and graft survivals. Although orthotopic kidney transplantation was used in selected patients, we preferred an iliac fossa approach for most.     

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.     

Nontraditional sites for vascular anastomoses to enable kidney transplantation in patients with major systemic venous thromboses

Successful renal transplantation requires low‐pressure venous drainage to permit adequate outflow from the allograft. We report here a series of three patients in whom the inferior vena cava as well as bilateral iliac veins were thrombosed, making it necessary to explore less traditional vessels for venous drainage of the renal allograft. We utilized the splanchnic vasculature in two cases and the native left renal vein in another. The resulting atypical intra‐abdominal locations of these allografts also presented difficulties for arterial anastomoses and for urinary drainage. Arterial conduits were utilized in two cases to facilitate anastomosis to the common iliac artery or the aorta, and in the third case, the splenic artery was used for arterial inflow. A traditional ureterocystostomy was technically feasible for only one patient. In another, ureteroureterostomy to the native ureter was performed, and in the third case, the creation of an ileal conduit was necessary. All three patients had antibodies to human leukocyte antigens and two required desensitization. All three kidneys had immediate graft function and continued to function at 1 year post‐transplant. With a combination of planning, creativity, and persistence, patients with IVC thrombosis can enjoy the benefits of renal transplantation.     

儿童肾移植23例临床分析

目的　探讨儿童肾移植的临床特点及围手术期处理特点。方法　回顾性分析平均年龄(15 4± 1 0 )岁的 2 3例儿童肾移植患者的临床资料 ,统计术后移植肾功能变化、急性排斥及并发症发生率。结果　 2 3例手术过程顺利 ,均未出现外科并发症。 1例治疗非顺应致移植肾失去功能 ,2 2例术后平均 5 5d恢复肾功能。术后 6个月内科并发症包括高血压 13例 (5 7% )、肺部感染 4例 (17% )、骨髓抑制与药物性肝损害各 3例 (13% )。术后 1年内急性排斥反应 4例 (17% )。术后第 1年体重平均增加 2 3kg ,身高平均增高 1 0cm。 1年、3年人 /肾生存率分别为 10 0 % / 96 %、90 % / 80 %。结论　肾移植是治疗儿童终末期肾病的有效治疗措施。合适的术式、术后免疫抑制药物的合理应用、并发症的预防和及时治疗是提高人、肾存活率的关键。     

肝、肾联合移植12例报告

目的 对肝、肾联合移植的临床情况进行总结。方法 为12例肝、肾功能异常患者施行肝、肾联合移植，采用多器官联合切取术整块切取供者器官。8例行经典式肝移植，4例行背驮式肝移植，均未行体外静脉转流；肾移植为常规术式。术前进行抗CD25单克隆抗体和抗胸腺细胞球蛋白诱导治疗，术后应用他克莫司（FK506）、霉酚酸酯及泼尼松预防排斥反应。结果 12例手术均获成功，移植肝及肾功能恢复良好。术后的并发症有移植肝急性排斥反应、FK506中毒、消化道出血、腹腔出血、肺部感染、腹腔感染（各1例次），所有患者均未发生移植肾急性排斥反应。结论 肝、肾联合移植是治疗终末期肝病合并肾功能衰竭的理想选择。     

Orthotopic placement of a segmental pancreas graft for transplant: a case report

Garcia‐Roca R, Humar A, Sturdevant M, Kobayashi T, Dunn T, Kandaswamy R, Sutherland D. Orthotopic placement of a segmental pancreas graft for transplant: a case report.
Clin Transplant 2010: 24: 424–428. © 2009 John Wiley & Sons A/S. Abstract: Pancreas retransplantation has become more frequent and represents a technical challenge for surgeons. Knowledge of alternative surgical options could be useful in difficult cases. We present a case of brutal diabetes mellitus in a patient with severe vascular disease that underwent a third pancreas transplant. Difficulties in obtaining arterial inflow were solved utilizing the native splenic vessels, placing the graft in orthotopic position, and a combination of historical surgical techniques in pancreas transplantation; that is, segmental grafts and duct injection for exocrine management made transplantation successful.     

Successful renal transplantation with ipsilateral femoral arteriovenous grafts

BACKGROUND: The choice of location for revascularization of a renal allograft is frequently influenced by the presence of previous pelvic surgery or failed allografts that remain in situ. The presence of polytetrafluoroethylene (PTFE) loop grafts in the femoral vessels may potentially result in iliac venous hypertension, thereby compromising the function of a renal allograft placed nearby. The purpose of this study is to report the hemodynamic changes within the iliac veins as a result of PTFE femoral grafts and report the outcome of renal allografts placed ipsilateral to such grafts. METHODS: THREE patients with a failed renal allograft in the right iliac fossa and functioning left groin PTFE loop grafts underwent left iliac venography and hemodynamic measurements of the iliac venous system. All three patients underwent renal transplantation in the left iliac fossa without ligation or alteration of the loop graft. Standard clinical data were collected after transplantation. RESULTS: All three patients demonstrated widely patent external iliac and common iliac veins ipsilateral to the loop graft. Elevated pressures measured within the venous limb of the loop graft dissipated rapidly within the common femoral and external iliac veins. All three kidneys were well perfused, as documented by posttransplant technetium 99m-diethylenetriaminepentaacetic acid nuclear renography. All three patients have normal renal function past 7 months after transplant, and all three femoral loop grafts are still functioning. CONCLUSIONS: PTFE loop grafts to the femoral vessels are not associated with local venous hypertension in the ipsilateral external iliac veins. Revascularization of a renal allograft may be performed ipsilateral to a femoral loop graft provided other venous diseases, such as strictures, have been excluded.     

Peripheral vascular disease and renal transplant artery stenosis: a reappraisal of transplant renovascular disease

BACKGROUND: Renal transplant artery stenosis (RTAS) continues to be a problematic, but potentially correctable, cause of post-transplant hypertension and graft dysfunction. Older transplant recipients, prone to peripheral vascular disease (PVD), may have pseudoRTAS with PVD involving their iliac system. METHODS: We retrospectively analyzed 819 patients who underwent kidney transplantation between 1993 and 1997 to determine the contribution of pseudoRTAS to renal transplant renovascular disease. Univariate analyses were performed for donor and recipient variables, including age, weight, gender, race, renal disease, cholesterol and creatinine values, human leukocyte antigen (HLA) matching, cytomegalovirus (CMV) infection, and immunosuppressive medications. Significant variables were then analyzed by a Cox proportional hazards model. RESULTS: Ninety-two patients (11.2%) underwent renal transplant arteriogram (Agram) or magnetic resonance angiography (MRA) for suspected RTAS. RTAS or pseudoRTAS, defined as one or more hemodynamically significant lesions in the transplant artery or iliac system, was evident in 44 patients (5.4%). Variables significantly associated with RTAS by univariate analysis were weight at the time of transplant (p = 0.0258), male gender (p = 0.034), discharge serum creatinine > 2 mg/dL (p = 0.0041), and donor age (p = 0.0062). Variables significantly associated with pseudoRTAS by univariate analysis were weight at the time of transplant (p = 0.0285), recipient age (p = 0.0049), insulin-dependent diabetes mellitus (IDDM; p = 0.0042), panel reactive antibody (PRA) at transplant (p = 0.018), and body mass index (p = 0.04). Weight at transplant and donor age remained significantly associated with an increased risk for RTAS in a multivariate stepwise Cox proportional hazards model. IDDM, transplant PRA, weight at transplant, and donor age were significantly associated with an increased risk for pseudoRTAS in a multivariate stepwise Cox proportional hazards model. Importantly, both RTAS and pseudoRTAS were associated with poorer graft survival (p < 0.007 for each). CONCLUSIONS: Renal transplant renovascular disease encompasses pre-existing PVD acting as pseudoRTAS, as well as classical RTAS. Efforts to identify and correct renal transplant renovascular disease of either nature are important, given its negative impact on graft survival.     

Kidney Retransplantation in the Ipsilateral Iliac Fossa: A Surgical Challenge

The aim of this study is to review the surgical outcome of kidney retransplantation in the ipsilateral iliac fossa in comparison to first kidney transplants. The database was screened for retransplantations between 1995 and 2013. Each study patient was matched with 3 patients with a first kidney transplantation. Just for graft and patient survival analyses, we added an extra control group including all patients receiving a second transplantation in the contralateral iliac fossa. We identified 99 patients who received a retransplantation in the ipsilateral iliac fossa. There was significantly more blood loss and longer operative time in the retransplantation group. The rate of vascular complications and graft nephrectomies within 1 year was significantly higher in the study group. The graft survival rates at 1 year and 3, 5, and 10 years were 76%, 67%, 61%, and 47% in the study group versus 94%, 88%, 77%, and 67% (p < 0.001) in the first control group versus 91%, 86%, 78%, and 57% (p = 0.008) in the second control group. Patient survival did not differ significantly between the groups. Kidney retransplantation in ipsilateral iliac fossa is surgically challenging and associated with more vascular complications and graft loss within the first year after transplantation. Whenever feasible, the second renal transplant (first retransplant) should be performed contralateral to the prior failed one.     

A Novel Technique for Auxiliary Partial Liver Transplantation With Reno-Portal Anastomosis and Avoidance of the Hepatoduodenal Ligament

Auxiliary liver transplantation (ALT) is a treatment for acute liver failure when regeneration of the native liver is possible or for metabolic disorders. In selected cases ALT and orthotopic liver transplantation (OLT) have similar survival when ALT is performed in the orthotopic position (auxiliary partial orthotopic liver transplantation, APOLT). Drawback of ALT with portal vein to portal vein anastomosis is the frequent occurrence of thrombosis, compromising both graft and native liver, and the necessity of a significant resection. To avoid division of portal flow we performed ALT with an end-to-end anastomosis between the graft portal vein and the left renal vein of the recipient (reno-portal ALT, REPALT). The hepatic artery was anastomosed to the aorta using an iliac arterial graft conduit. The bile duct was anastomosed to the stomach. In the two cases presented here excellent immediate graft function occurred with rapid regeneration of the graft and without early vascular complications.     

Late cardiac reoperation after cardiac transplantation

BACKGROUND: The intermediate and long-term results of cardiac transplantation continue to improve. Subsequent cardiac procedures may be required to extend patient survival and protect graft function. METHODS: The medical records of all adult and pediatric cardiac transplant recipients who underwent a subsequent cardiac procedure at our institution were reviewed. RESULTS: Three hundred sixty patients have undergone primary orthotopic transplantation in our institution. Seventeen patients (12 adults, 5 children) underwent a subsequent procedure requiring cardiopulmonary bypass including cardiac retransplantation (10), coronary artery bypass grafting (3), ascending aortic replacement (2), tricuspid valve repair (1), and myotomy and myomectomy (1 patient). Mean interval from time of transplantation to second procedure was 8.3 years. There was one perioperative death. Two patients, both retransplants, died late postoperatively at 22 and 84 months, respectively. Overall mean follow-up in the late survivors is 26.6 months. All survivors are currently asymptomatic and doing well. CONCLUSIONS: A variety of subsequent cardiac procedures, in addition to retransplantation, can be performed safely in carefully selected cardiac transplant recipients. The intermediate term results are gratifying in terms of survival and freedom from symptoms.     

移植肾动脉瘤五例报告

目的 探讨移植肾动脉瘤(RAA)的病因、诊断及治疗. 方法 1998年8月至2004年12月共行同种异体肾移植手术1251例,发生RAA 5例(0.4%).5例均为男性,平均年龄43岁,移植肾血管吻合方式均为移植肾动脉一髂内动脉端端吻合.患者主要临床表现为进行性肾功能减退,突发少尿或无尿,顽固性高血压及肾区疼痛,均经彩色多普勒超声、数字减影血管造影检查确诊为动脉瘤,动脉瘤大小1.8 cm×2.0 cm×2.0 cm～4.0 cm×4.0 cm×5.0 cm. 结果 移植肾动脉吻合口动脉瘤2例,1例发现动脉瘤后1个月内移植肾功能丧失,行移植肾切除术,术后规律透析治疗,随访1年后行二次肾移植;1例移植肾失功后1周内行对侧髂窝二次肾移植手术,保留原移植肾,术后随访2年肾功能正常.RAA合并近端移植肾动脉狭窄2例,1例行吻合口球囊扩张并放置支架后,以弹簧螺圈栓塞动脉瘤,术后随访1年肾功能稳定;1例行移植肾切除、二次.肾移植术,术后随访3年肾功能正常.吻合口髂内动脉侧粥样硬化斑块导致髂内动脉狭窄、移植肾动脉侧动脉瘤1例,行移植肾切除术,术后2 d因脑干栓塞死亡. 结论 移植肾动脉-髂内动脉端端吻合易诱发血管并发症,RAA治疗应谨慎采用开放手术切除,可选择近期行二次肾移植和血管内介入治疗.     

Cardiac transplant vasculopathy treated by percutaneous coronary intervention

AIM: Cardiac transplant vasculopathy is a limit to long-term survival in heart transplantation (H-Tx) recipients. PTCA results in our H-Tx population were retrospectively analyzed. METHODS: From November 1985 to May 2004, 767 patients underwent heart transplantation. All patients received immunosuppressive therapy with cyclosporine or tacrolimus, azathioprine, steroids and mycophenolate mofetil. Lymphocyte was administrated by 3-7 days course of either rabbit antithymocyte globulins or anti-lymphocyte globulins or by a 14 days course of OKT3. Coronary angiograms were performed every year and more frequently if graft vasculopathy was already diagnosed or suspected. RESULTS: Fifty-two coronary artery lesions were treated during 42 percutaneous transluminal cardioangioplasty (PTCA)/stent procedures in 36 patients. Mean time since heart transplantation to PTCA was 80 +/- 27 months. Indication to PTCA was asymptomatic angiographic graft vasculopathy in 34 patients (94%) and acute myocardial infarction in 2 patients (6%). PTCA was performed on left anterior descending artery in 34 cases (65.4%), on circumflex artery in 10 cases (19.2%), on right coronary artery in 8 cases (15.4%). There were no procedure related deaths. None of the patients required emergency bypass surgery. Two patients had transient acute renal failure. Patient follow-up showed 10 deaths after 1 +/- 54 months from PTCA. Six died for progression of graft vasculopathy, three for cancer and one for gastrointestinal bleeding. Two patients underwent heart retransplantation after 20 and 107 months from the first procedure. Mean follow-up of the remaining patients is 78.3 +/- 50.3 months. CONCLUSION: PTCA may represent a reasonable treatment for graft vasculopathy in selected heart transplant recipients.     

Selective, concurrent bilateral nephrectomies at renal transplantation for autosomal dominant polycystic kidney disease

PURPOSE: An algorithm was developed for performing bilateral nephrectomies for specific indications before or at renal transplantation in patients with autosomal dominant polycystic kidney disease. Outcomes for the living donor arm of the algorithm are reported. MATERIALS AND METHODS: Patients with autosomal dominant polycystic kidney disease and end stage renal disease were evaluated for transplantation. Patients with recurrent pyelonephritis, hemorrhage, pain, early satiety or kidneys that extended into the true pelvis underwent bilateral nephrectomies. Bilateral nephrectomies with concurrent renal transplantation were performed if a living renal donor was identified. If no living donor was identified, pre-transplantation bilateral nephrectomies were done and the patients were listed for cadaveric donor renal transplantation. The living renal donor arm of the algorithm was evaluated by comparing certain parameters for 15 and 17 patients with autosomal dominant polycystic kidney disease who underwent pre-transplantation and concurrent bilateral nephrectomies, respectively, including patient and graft survival, delayed graft function, graft function, length of stay for each surgery, transfusions and complications. RESULTS: No deaths, graft failures or delayed graft function occurred. In the delayed renal transplant group median time from nephrectomy to living donor transplantation was 124 days. Serum creatinine at discharge home and 1 year after transplantation for the pre-transplantation nephrectomy cohort was 2.0 and 1.3 mg/dl, respectively. Seven of the 17 patients with concurrent nephrectomy underwent transplantation before starting renal replacement therapy. A longer mean total hospital stay in the pre-transplantation nephrectomy cohort was the only statistically significance outcome variable. CONCLUSIONS: Selective bilateral nephrectomies at living donor renal transplantation results in decreased total length of stay without compromising patient or graft outcomes and it allows preemptive renal transplantation. Concurrent nephrectomy is safe and it further validates the algorithm for selective, concurrent bilateral nephrectomies for patients with autosomal dominant polycystic kidney disease who undergo living donor renal transplantation.     

Single graft loss in dual renal transplant recipients: impact of graft placement on recipient outcomes

We aimed to assess the impact of graft placement in dual renal transplantation on the risk for single graft loss and to report recipient outcomes. Between 2004 and 2007, 55 dual renal transplants were performed at our institution. Allografts were placed bilaterally (one in each iliac fossa) in 42 patients and unilaterally (both in the same iliac fossa) in 14 patients. Nine recipients (16.4%) underwent explantation of a single graft as a consequence of vascular thrombosis designated as the SINGLE group, whereas 46 had two functional allografts (DUAL group). There was a higher rate of graft loss in case of unilateral placement (n = 5/14) compared with bilateral placement (n = 4/41) (35.7% vs. 9.8%, P = 0.035). One‐year glomerular filtration rate was significantly lower in the SINGLE group (29.4 ml/min/1.73 m² vs. 49.4 ml/min/1.73 m² in the DUAL group, P < 0.05). Significantly, none of the nine recipients of the SINGLE group returned to dialysis with a mean follow‐up of 34.1 months. Graft survival at 1 year was 100% and 97.9% in SINGLE and DUAL groups, respectively. Unilateral placement of both allografts is associated with an increased risk of single graft loss and therefore lower renal function at 1 year. However, this strategy is safe in selected indications.     

Arterial conduits for hepatic artery revascularisation in adult liver transplantation

Arterial complications after orthotopic liver transplantation (OLT), including hepatic artery thrombosis (HAT), are important causes of early graft failure. The use of an arterial conduit is an accepted alternative to the utilisation of native recipient hepatic artery for specific indications. This study aims to determine the efficacy of arterial conduits and the outcome in OLT. We retrospectively reviewed 1,575 cadaveric adult OLTs and identified those in which an arterial conduit was used for hepatic revascularisation. Data on the primary disease, indication for using arterial conduit, type of vascular graft, operative technique and outcome were obtained. Thirty-six (2.3%) patients underwent OLT in which arterial conduits were used for hepatic artery (HA) revascularisation. Six of these were performed on the primary transplant, while the rest (n=30) were performed in patients undergoing re-transplantation, including six who had developed hepatic artery aneurysms. The incidence of arterial conduits was 0.4% (6/1,426 cases) in all primary OLTs and 20.1% (30/149 cases) in all re-transplants. Twenty-nine procedures utilised iliac artery grafts from the same donor as the liver, six used iliac artery grafts from a different donor, and a single patient underwent a polytetrafluoroethylene (PTFE) graft. Two techniques were used: infra-renal aorto-hepatic artery conduit and interposition between the donor and recipient native HAs, or branches of the HAs. The 30-day mortality rate for operations using an arterial conduit was 30.6%. Three conduits thrombosed at 9, 25 and 155 months, respectively, but one liver graft survived without re-transplantation. The arterial conduits had 1- and 5-year patency rates of 88.5% and 80.8%. The 1- and 5-year patient survival rates were 66.7% and 44%. We can thus conclude that an arterial conduit is a viable alternative option for hepatic revascularisation in both primary and re-transplantation. Despite a lower patency rate than that of native HA in the primary OLT group, the outcomes of arterial conduit patency and patient survival rates are both acceptable at 1 and 5 years, especially in the much larger re-OLT group.     

肝动脉-腹主动脉架桥重建移植肝肝动脉74例报告

目的探讨原位肝移植术中采用肝动脉-腹主动脉架桥重建移植肝肝动脉的疗效。方法回顾分析2003年10月至2009年8月在中山大学附属第三医院肝移植中心行肝动脉-腹主动脉架桥重建移植肝肝动脉的74例患者的临床资料。全部患者采用供肝动脉通过供者髂动脉间置架桥与受者腹主动脉(肾动脉下方腹主动脉)行端侧吻合。总结手术治疗方法和术后并发症发生情况。所有患者均签署知情同意书,符合医学伦理学规定。结果 74例采用肝动脉-腹主动脉架桥重建肝动脉的患者中,68例治愈,6例术后早期死亡,治愈率为92%。术后急性排斥反应的发生率为18%(13/74),胆道并发症发生率为11%(8/74),肝动脉并发症发生率为14%(10/74),其中5例为架桥动脉血栓形成,5例为肝动脉(含架桥动脉)狭窄,行动脉支架置入溶栓术或动脉支架置入术,除1例上述治疗无效后行再次肝移植外,其余9例血管恢复通畅。结论肝移植术中若无法行供、受者肝动脉端端吻合术重建肝动脉,间置髂动脉的肝动脉-腹主动脉架桥术是一种安全可靠的肝动脉重建方法。     

再次肾移植对尿毒症患者性功能的影响

目的:探讨再次肾移植对尿毒症患者性功能的影响。方法:对接受2次肾移植和同期双肾移植的30例患者术后的性功能状态进行问卷调查及阴茎血流多普勒超声检查。2次移植选用髂外动脉与供肾动脉吻合者9例(A组);一侧选用髂内动脉另一侧选用髂外动脉吻合者11例(B组);均选用髂内动脉与供肾动脉吻合者10例(C组),其中包括同期行双肾移植的1例患者。结果:术后半年恢复正常性生活者,A组8例;B组7例;C组5例。C组患者的阴茎海绵体动脉收缩期最大血流速度明显低于A及B组。结论:2次肾移植均选用髂内动脉与供肾动脉吻合,对患者的性生活有影响;但通过侧支循环代偿一段时间后,一部分患者仍可有满意的性生活。     

Orthotopic Kidney Transplantation in an Elderly Patient With Various Severe Comorbid Conditions: A Case Report

In recent years, the frequency of high-risk kidney transplantations has increased. We report a case in which a 72-year-old man with various severe comorbidities (prostate cancer, diabetes mellitus, complete atrioventricular block, coronary artery stenosis, severe stenosis of the popliteal arteries, and severe calcification of the iliac arteries) who received an orthotopic kidney transplantation. To prevent the occurrence of acute limb ischemia due to the steal phenomenon (caused by the kidney graft), we decided that a heterotopic kidney transplantation involving the iliac arteries was not an appropriate option. Therefore, as an alternative, left native nephrectomy was performed followed by an orthotopic kidney transplantation to the native renal artery and renal vein through a left subcostal incision. Postoperative ureteral stenosis occurred, and so stent exchange was required every 6 months. Despite the ureteral complication, the patient's serum creatinine level was 1.5 mg/dL at 2 years after the procedure.     

Surgical aspects in the third and fourth kidney retransplant

Introduction and objectives: A quarter of patients waiting for kidney transplantation are patients with previous graft failure. Outcome of first and second renal transplant make these the gold standard for end renal stage disease, but this is not so clear in the case of third and further renal transplant, especially at the time of organ shortage. We revise our experience in patients with three or more kidney transplants focusing on surgical aspects and graft outcomeMaterial and methods1364 renal transplants have been carried out in our centre since 1975 until December 2003. We have retrospectively revised the 34 patients with three renal transplants and the 5 with four. We analyse the surgical technique, surgical complications and graft outcomeResultsMean age was 42 years (21-65). Average mismatches between donor and recipient was 3.2. All kidneys, but one case of living donor, were harvested from cadaver donors, mostly in multiple organ-procurement. Average time from the last renal transplantwas 5 years (3 days-17 years) and from the last transplant carried out in the iliac fossa reused until the new transplant was 9 years (3 days-17.5 years). All implants were performed through an iterative lumboliliac incision (25 on the right side, 11 on the left one and in 3 cases where side was not registered). Mean average duration of the procedure was 166 minutes (100-300). Nephrectomy of previous graft at the moment of the implant was carried out in 13 patients (33%). Vascular anastomosis was made on the common iliac vessels (50%) or on the external ones (50%) in end to side way. Ureteroneocystostomy was performed in an extravesical way except in 1 patient with cutaneous diversion. Vascular complications were 4 haemorrages (1 patient died), 3 venous and 2 arterial thrombosis. We had an abscess secondary to intestinal fistulae. Other surgical complications were 4 lymphoceles, three of them needed surgical treatment, and one perirenal haematoma treated in a conservative way. No urological complications were seen. In total 6 grafts (15%) were lost due to surgical complications. Graft actuarial survival rate at 1 year was 65%, 40% at 5 and 28% at 10 yearsConclusionsThree and four renal transplant survival rates are shorter than first and second ones. Iterative access through lumboiliac incision is associated with a higher vascular complication rate, probably in these patients a transperitoneal access would be better. Multicentric studies with higher numbers of patients are needed to define more clearly which patients would benefit from multiple kidney retransplants