Successful Kidney Transplantation Using a Deceased Donor Graft With Fibromuscular Dysplasia

All over the world there is serious concern about the shortage of organs available for transplantation. In an effort to address this, transplantation with grafts, which was previously considered a contraindication, are now performed. In some cases, this practice has contributed to increasing the organ pool. Fibromuscular dysplasia (FMD) is the second-most-common cause of renovascular hypertension and is observed in 2%–6.6% of potential live kidney donors. Kidney with FMD is generally considered to be a contraindication for renal transplantation because renal artery stenosis may progress after transplantation and cause graft loss. Here, we report on a successful case of kidney transplantation using a graft with FMD of a deceased donor who had multiple aneurysms in the renal artery.     

Renal Transplantation for Fibromuscular Dysplasia

This is the first report that presents renal transplantation after bilateral nephrectomy as the final treatment for severe renovascular hypertension due to fibromuscular dysplasia (FMD). We describe the history of a 1‐year‐old girl who suffered from renovascular hypertension due to FMD. Imaging revealed multiple bilateral stenoses of the renal artery extending into the distal branches. The hypertension proved unresponsive to pharmacologic treatment and the intrarenal peripherally located stenoses rendered a conventional approach such as transluminal or surgical angioplasty not feasible. At the age of 5 years, a unilateral nephrectomy of the most affected kidney was performed, but she remained hypertensive and developed progressive cardiomyopathy and retinopathy. At the age of 6 years the remaining kidney was removed, followed by a living related renal transplantation with a kidney donated by her mother. Posttransplantation, she developed mild hypertension due to a postanastomotic stenosis, which was easily controlled with antihypertensives. Now 8 years after transplantation, she has experienced no further blood pressure related problems. Although there is a risk of recurrence of FMD after performing a living related transplantation, our report suggests that this procedure is relatively safe, provided appropriate preoperative evaluation and follow up is performed.     

Rapid Progression of Native Renal Artery Fibromuscular Dysplasia Following Kidney Donation

Fibromuscular dysplasia is the second commonest anatomical abnormality apart from multiple renal arteries in the potential live donors. Pretransplant evaluation of the donors may include an angiography to evaluate the renal arteries, and failure to recognize renal arterial stenosis, particularly fibromuscular dysplasia, by noninvasive methods may eventually lead to hypertension and ischemic renal failure. We report a case of fibromuscular dysplasia that was undetected by computed tomographic angiography prior to donation. One year after kidney donation, it rapidly progressed to severe symptomatic stenosis with hypertension and acute renal failure. Following renal artery angioplasty, her blood pressure normalized over a period of 2 weeks without any need for antihypertensive medications and the serum creatinine returned to her baseline. The acceptability of renal donors with fibromuscular dysplasia depends on the age, race and the availability of the other suitable donors. Mild fibromuscular dysplasia in a normotensive potential renal donor cannot be considered a benign condition. Such donors need regular follow-up postdonation for timely detection and treatment.     

Increasing the supply of kidneys for transplantation

Kidney transplantation confers a survival advantage for patients with end-stage renal disease (ESRD) when compared to dialysis and improves the quality of life in a cost-effective manner. Currently there are more than 60,000 patients on the U.S. waiting list for kidney transplantation. In 2004, 16,879 kidney transplants, including 880 simultaneous kidney and pancreas transplants, were performed in this country. Recent strategies for increasing the supply of kidneys hold promise, such as systematic programs designed to improve consent rates for deceased donor organ procurement. Efforts to increase donation after cardiac death (DCD) have been highly successful and now account for more than 5% of all deceased organ donors. Transplantation of kidneys from DCD donors yields 1-year graft and patient survival rates equivalent to kidneys from brain-dead donors. Expanded criteria donor (ECD) kidneys from donors > or = 60 years of age (or donors age 50-59 years with certain comorbidities) confer a survival benefit for end-stage renal disease (ESRD) patients compared to remaining on dialysis on the waiting list. The number of live donor kidney transplants, both from biologically related and unrelated donors, is increasing. Paired live donor kidney transplants provide yet another transplantation opportunity for ESRD patients with willing but incompatible (by ABO or direct antibody) living donors.     

Management of renal hypertension in children with Takayasu's arteritis using renal autografting or allograft transplantation in selected circumstances and total lymphoid irradiation.

In a decade from 1980, 11 children aged 3 to 11 years presented with Takayasu's arteritis (TA). All were severely hypertensive. Operative correction was offered to 10 of 11 children presenting with renovascular hypertension (RVH) including cardiac failure alone in 1 and both renal and cardiac failure in 8, a result of TA involving renal arteries by stenosis or occlusion. Nine patients had renal autotransplantation to an heterotopic site in the pelvis. Seven of 12 kidneys were salvaged by autotransplant with relief of RVH. Renal artery stenosis was successfully corrected by this procedure in 5 patients. Autotransplantation failed in 4 patients, 1 of whom subsequently had a successful allograft transplant. One patient was treated primarily by cadaver allograft transplantation. One patient whose autotransplant failed had a functioning contralateral kidney and is well with controlled RVH. One patient died prior to any treatment. Patient survival improved with the use of total lymphoid irradiation in the most recent 7 patients.     

Association of donor hypertension and recipient renal function in living donor kidney transplantation: A single‐center retrospective study

Transplant centers now accept living donors with well‐controlled hypertension. Little is known whether hypertension in living donors affects recipient's kidney function. We aimed to examine potential differences in kidneys from hypertensive donors compared to normotensive donors with respect to renal function over 36 months and histologic findings at transplantation (T0) and 12 months after transplantation (T1). Retrospective single‐center analysis of 174 living donor‐recipient pairs (age > 18; transplantation date 1/2008‐3/2016). Hypertension in donors was defined as being on antihypertensive medication. All biopsies were assessed by the same blinded, experienced renal pathologist. Biopsies were scored for glomerulosclerosis, IFTA, and arteriosclerosis. Regression models were used to examine the relationship of donor hypertension with renal function and histologic changes. Hypertensive donors were significantly older than normotensive donors. Chronic changes such as tubular atrophy and atherosclerosis were more evident in kidneys from hypertensive donors at T0 as well as T1. Donor hypertension was independently associated with histologic changes at T0 and T1 but not with renal function over the follow period. Despite more pronounced histologic changes in kidneys from hypertensive living donors, these grafts exhibited a similar functional outcome. However, they subsequently might be at a greater risk and warrant thorough follow‐up care.     

Kidney transplantation from living related donors with multiple vessels. A problem revisited

Thirty-one renal transplantations were performed using kidneys from living donors with known bilateral double renal arteries. In twenty-one patients both vessels were anastomosed but in ten patients a tiny polar vessel was sacrificed resulting in a small infarct in the grafted kidney. Results of transplantation in these patients were compared with those in recipients of related and cadaver kidneys matched for time of transplant, sex, and age of recipient. There is an increased incidence of acute tubular necrosis in recipients of transplants from living donors with double renal arteries. By several weeks after transplantation, however, renal function is identical to that in recipients of related donor organs with single arteries. Hypertension that is more common in patients with double renal arterial anastomoses is relatively easy to control with increased antihypertensive medications. Two patients had loss of the kidney transplants because of stenosis of one or both renal arterial anastomoses. Despite these losses, the results of renal transplantation from living related donors with double renal arteries are almost as successful as those from a related donor with single renal arteries.In contrast, recipients of kidneys with polar infarcts appear to undergo more episodes of rejection, infection, or both, than do recipients of related transplants with single renal arteries. In one patient with a polar infarct, delayed total ureteral necrosis developed.Living related donors with bilateral double renal arteries should be accepted as donors in preference to cadaver donors if both vessels can easily be anastomosed. If, however, a polar vessel must be sacrificed, it is suggested that a cadaver donor be utilized in preference to a related donor.     

Early diagnosis and management of renovascular hypertension

Renovascular hypertension is more common in hypertensive children than in hypertensive adults, and renal artery stenosis is second only to coarctation of the thoracic aorta as a cause of surgically correctable hypertension. Three infants presented with uncontrollable hypertension secondary to renal artery thrombosis due to umbilical artery catheterization for respiratory distress in the neonatal period. They all responded to nephrectomy. A fourth infant had stenosis of a polar vessel secondary to umbilical artery catheterization and was cured by partial nephrectomy. Two infants with renal artery stenosis secondary to fibromuscular dysplasia benefited from revascularization and, at last follow-up, were normotensive and off all blood pressure medication. Ultrasonography, isotope scanning, angiography and selective renal vein renin assays should be used to identify patients with surgically correctable lesions. The use of fine suture material and microvascular surgical techniques, including ex vivo revascularization and autotransplantation, can salvage renal parenchyma and relieve hypertension. Infants with less than 10 percent renal function on the involved side should have a nephrectomy. The infant with an umbilical arterial catheterization line needs blood pressure monitoring and aggressive evaluation and treatment of persistent hypertension.     

Renal artery stenosis in pediatric transplant recipients

From 1967 through 1985, 400 cadaveric transplants were performed at Children Hospital of Los Angeles. Of these 400, 31 were later identified as having renal artery stenosis. No live related graft developed RAS. Of the 31 grafts, 11 were from donors less than 2 years of age. The major feature suggesting stenosis was hypertension: either persistent or a sudden exacerbation often associated with hypertensive encephalopathy. In individuals with hypertension without obvious cause, renal angiography should be promptly conducted under controlled conditions to avoid complications. The stenotic lesion involved 13 end-to-end and 19 end-to-side arterial anastomoses. Surgery for revascularization of RAS was performed in 21 of 31 with success or improvement in 14, no change in 2, and graft loss in 5. Percutaneous transluminal angioplasty was performed in 4. Two were unsuccessful, 1 was successful and 1 graft was lost. The 7 remaining patients were treated medically.     

ACE inhibition scintigraphy in the management of hypertension in children

Angiotensin converting enzyme (ACE) inhibition scintirenography was performed to help establish the diagnosis and plan treatment of renovascular hypertension (RVH) in 57 hypertensive pediatric patients, 33 infants and 24 children older than 1 year. In 16 of 33 hypertensive infants, ACE inhibition scintirenography established the diagnosis of RVH from renal ischemia (due to aortic or renal arterial thrombi). Two scintigraphic criteria were used for the diagnosis of RVH: criterion I, ischemic and damaged kidney (a non-functioning kidney on or off ACE inhibition) and criterion II, ischemic but not damaged kidney (ACE inhibition induced deterioration of function of the kidney). When criterion I was present and the contralateral kidney was normal, ACE inhibitors could be used for treatment of hypertension without deterioration of renal function; kidneys satisfying criterion I eventually involuted or manifested growth arrest and frequently caused persistent RVH, even after resolution of the thrombus, requiring nephrectomy. When criterion II was present bilaterally, or it was associated with criterion I contralaterally, the use of antihypertensive drugs other than ACE inhibitors was necessary in order to prevent renal insufficiency or failure from ACE inhibitors. However, kidneys with criterion II showed normal growth and, following retraction or dissolution of the aortic thrombus, hypertension resolved. In 2 of 24 hypertensive children older than 1 year, the test was diagnostic of branch renal artery stenosis; RVH was cured by selective angioplasty. ACE inhibition scintirenography is useful in the evaluation and planning of treatment in children with hypertension and may predict the outcome of therapy and ultimate renal function. Received: 7 May 1997 / Revised: 3 September 1998 / Accepted: 3 September 1998     

Simultaneous bilateral renal artery reconstruction and intraoperative renal protection. A case report

A 22-year-old Japanese man with bilateral renal artery stenosis associated with hypertension underwent successful surgery of simultaneous bilateral renal artery reconstruction under conditions of intraoperative renal perfusion with St. Thomas Hospital solution which is used for cardioplegia in open heart surgery. Circulation in the left kidney was interrupted for 58 minutes and that of the right kidney for 35 minutes. The patient fully recovered with no serious impairment of renal function. In addition to these stenotic lesions of the renal artery, there were medial necrosis of the aorta and fibromuscular dysplasia of the superior mesenteric artery. Administration of SQ14,225, an angiotensin I converting enzyme inhibitor, was effective in controlling hypertension during the preoperative period.     

KIDNEY TRANSPLANTATION: THE USE OF LIVING DONORS WITH RENAL ARTERY LESIONS

Purpose

A shortage of organs for transplantation has forced surgeons to optimize the use of marginal organs, such as kidneys with arterial disease. We present a retrospective study of the outcome of donors with renal artery disease and recipients of kidneys from living related and unrelated donors.

Materials and Methods

Kidneys with vascular abnormalities from healthy living donors were grafted into 11 recipients. These kidney transplants comprised 1.8% of those performed at our institution. The vascular abnormalities were aneurysms in 3 cases, atherosclerotic lesions in 4 and fibromuscular dysplasia in 4. After nephrectomy all abnormalities were corrected under hypothermic conditions during bench surgery except in 3 cases of ostial atherosclerotic plaque, which was left in the donors. The renal artery was anastomosed to the external iliac artery in 5 cases and to the internal iliac artery in 6. The ureter was reimplanted using an extravesical technique.

Results

All patients had immediate diuresis and no delayed post-transplant graft dysfunction was observed. One patient died of an unrelated cause and 3 had post-transplant graft function loss due to acute vasculopathy in 1, post-diarrhea with acute arterial thrombosis in 1 and recurrence of the hemolytic-uremic syndrome in 1. All remaining patients are well with median serum creatinine of 1.4 mg./dl. (normal 0.4 to 1.4). All donors are well and normotensive with normal renal function.

Conclusions

The use of kidneys with arterial disease from living donors with unilateral disease is safe. Complete informed consent regarding the risks and benefits by donor and recipient is mandatory.     

Post-Transplant Renal Artery Stenosis: Impact of Therapy on Long-Term Kidney Function and Blood Pressure Control

Purpose

We assessed the long-term outcome of different treatment methods for transplant renal artery stenosis.

Materials and Methods

Outcome data for 23 patients with transplant renal artery stenosis treated during a 16-year period were reviewed and analyzed.

Results

There was a higher incidence of renal artery stenosis in cadaveric donor kidneys compared to living donor kidneys (2 percent versus 0.3 percent, p less than 2), and in cadaveric kidneys from pediatric donors less than 5 years old compared to those from adults (13.2 percent versus 1.3 percent, p less than 0.01). Six patients underwent primary medical treatment for renal artery stenosis, with a successful outcome in 4 (mean followup plus or minus standard error 57 plus/minus 22 months) and failure in 2. Of the patients 16 were treated with percutaneous transluminal angioplasty, including 12 who were cured or improved with respect to hypertension (followup 44.7 plus/minus 7.6 months). Five patients underwent surgical revascularization for renal artery stenosis with postoperative improvement of hypertension (followup 18.8 plus/minus 11.6 months). Overall, 21 of 23 patients (91 percent) were treated successfully for transplant renal artery stenosis with cure or improvement of associated hypertension. Posttreatment renal function was stable or improved in 18 patients, while renal function deteriorated due to parenchymal disease in 3.

Conclusions

Most patients with transplant renal artery stenosis can be treated successfully. Percutaneous transluminal angioplasty is the initial interventive treatment of choice for high grade renal artery stenosis. Surgical revascularization is indicated if percutaneous transluminal angioplasty cannot be done or is unsuccessful.     

Pre-existing arteriosclerotic intimal thickening in living-donor kidneys reflects allograft function

Background: Donor shortage is a serious problem worldwide and it is now debated whether kidneys from marginal donors are suitable for renal transplantation. Recent studies have shown that the findings of preimplantation kidney biopsy are useful to evaluate vasculopathy in the donated kidney, and may predict transplant outcomes in deceased- donor kidney transplantation. However, few studies have focused on the pathological findings of preimplantation biopsy in living-donor kidney transplantation. Therefore, we investigated whether arteriosclerotic vasculopathy in living-donor kidneys at the time of transplantation predicts the recipient's kidney function (allograft function) later in life. Methods: We retrospectively analyzed 75 consecutive adult living-donor kidney transplants performed at Kagawa University Hospital. Renal arteriosclerotic vasculopathy was defined according to the presence of fibrous intimal thickening in the interlobular artery. Results: Forty-one kidneys exhibited mild arteriosclerotic vasculopathy on preimplantation kidney biopsies. The decreases in estimated glomerular filtration rate after donation were similar in donors with or without renal arteriosclerotic vasculopathy. Pre-existing arteriosclerotic vasculopathy did not affect graft survival rate, patient survival rate or the incidence of complications. Recipients of kidneys with arteriosclerotic vasculopathy had lower allograft function at 1 and 3 years after transplantation than the recipients of arteriosclerosis-free kidneys with or without donor hypertension. In multivariate analysis, fibrous intimal thickening on preimplantation biopsy was predictive of reduced allograft function at 1 year after transplantation. Conclusions: The present study demonstrated that mild arteriosclerotic vasculopathy in the donated kidney is an important pathological factor that reflects future impaired function of renal allografts from marginal donors.     

Change in live donor characteristics over the last 25 years: A single centre experience

Aim: While deceased donor kidney transplantation rates have remained stagnant, live donor kidney transplantation (LDKT) rates have increased significantly over the last decade, and are now a major component of renal transplantation programmes worldwide. Additionally, there has been an increased utilization of more marginal donors, including donors who are obese, older and subjects with well-controlled hypertension. Method: A retrospective audit of all live donors at the Princess Alexandra Hospital Renal Transplantation unit was performed from 24 August 1982 to 29 May 2007 to assess any change in donor characteristics over time. Results: There were 373 live donor operations. Over the last 25 years there has been a significant increase in the number of donors who are either older or obese. Furthermore, there is a greater proportion of spousal and emotionally related LDKT. Conclusion: It is imperative that donors, in particular marginal donors, are followed up long-term to determine their risk of kidney and cardiovascular disease and initiation of appropriate treatment if required.     

Captopril-induced acute renal failure in a kidney transplant recipient

A living related kidney transplant recipient with normal renal function and severe hypertension secondary to renal artery stenosis, was treated with captopril and developed reversible renal failure requiring temporary hemodialysis. This complication of captopril, an angiotensin converting enzyme inhibitor, has been reported previously in hypertensive patients with renal artery stenosis with and without a kidney transplant. It is recommended that this drug be used with caution in this setting.     

亲属活体肾移植供肾多支动脉变异的血管重建

目的多支动脉供肾是亲属活体供肾移植手术的难点，探讨多支动脉供肾手术中的血管重建方法。方法2006年4月-2008年3月，实施亲属活体肾移植77例，其中单支动脉型供肾组63例，多支动脉型供肾组14例。14例多支动脉型供肾，左肾9例，右肾5例，其中2支动脉变异者11例，3支动脉变异者3例。所有供、受者手术前常规行淋巴细胞毒交叉试验、人类白细胞抗原配型等检查。供者取肾手术采取经12肋腰部切口取肾，对多支动脉型右侧供肾，采取在腔静脉后方游离肾动脉。受者植肾手术采取经典的下腹部大L型切口将移植肾置于髂窝内。多支动脉型供肾组移植肾动脉采取分别与髂内动脉和／或髂外动脉吻合。结果多支动脉型供肾组14例供肾者术中均未输血，术后7～9d出院，无任何并发症。随访3个月～1年，肾功能、血压及尿常规完全正常。术后受者均无急性肾小管坏死、肾血管栓塞、肾动脉狭窄、尿瘘、输尿管坏死等并发症，彩色超声检查示移植肾血供均良好。与单支动脉供肾组比较，多支动脉型供肾组受者吻合血管开放后开始泌尿时间、术后第1周的平均血肌酐、平均动脉压、住院时间差异均无统计学意义（P〉0．05）。结论正确处理活体供肾多支动脉是活体肾移植安全的保证。     

Autorenal transplantation in the treatment of renovascular hypertension

Autorenal transplantation was performed on 32 renal units including three bilateral transplants, in 29 renovascular hypertensive patients. Aortoarteritis in 18, fibromuscular dysplasia in six, and atherosclerosis in five were the causative renal arterial lesions. Young patients with severe or uncontrolled hypertension but with functioning kidneys were selected for this procedure. Follow-up varied from one to seven years. Twenty-two patients were cured of hypertension, four showed improvement and in three the transplanted kidneys failed to function due to vascular thrombosis postoperatively. There was no death in the series.     

Doppler ultrasonography before and 6 to 12 months after kidney transplantation

INTRODUCTION: Ultrasound examination of the kidney is relatively inexpensive and provides a way to assess renal location, contour, and size. Doppler ultrasonography is a noninvasive tool for screening renal artery stenosis. It not only provides kidney morphology data, but also describes hemodynamic changes associated with renal artery stenosis, such as increased peak systolic velocity and decreased resistance index (RI). The aim of this study was to compare the Doppler ultrasonographic changes between the donor's kidney before transplantation and the recipient's kidney at 6 to 12 months after transplantation. METHODS: We compared the results of Doppler ultrasonography in 20 kidney donors and recipients before and 6 to 12 months after transplantation. For this purpose the size, cortical thickness, echogenicity, anastomosis, mean pulsatility index (MPI), and RI of the kidney were recorded in potential donors before transplantation and in recipients at 6 to 12 months after transplantation for statistical analysis. RESULTS: There was more than a 10-mm increase in transplanted kidney length 6 to 12 months after transplantation in 75% of recipients. There was also more than a 10-mm increase in the width of the transplanted kidney in 80% of recipients. There was no significant change in cortical thickness between the donor and the recipient of the kidney. MPI and RI increased slightly after transplantation. There was more than 50% anastomotic stenosis in only 10% of transplanted kidneys. CONCLUSION: There was significant enlargement of the kidney size with a nonsignificant increase in MPI and RI of the transplanted kidney. Anastomotic stenosis was also less significant in our study.