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Goodman J, Kulkarni S, Selvarajah V, Hilliard N, Russell N, Wilkinson IB. Renal Autotransplantation for Uncontrolled Hypertension in Nonatherosclerotic Renal Artery Stenosis-2 Case Reports and a Brief Review of the Literature. Hypertension 2024; 81:669-675. [PMID: 38507507 DOI: 10.1161/hypertensionaha.123.19878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2024]
Abstract
Fibromuscular dysplasia is the most common cause of renovascular hypertension in young adults under 40 years old. It is potentially amenable to renal artery angioplasty, which frequently normalizes blood pressure. However, limited options exist if angioplasty is not technically possible, or restenosis occurs. Here, we describe 2 patients who presented with hypertension secondary to renal artery stenosis. In the first case, a young adult with hypertension secondary to renal artery stenosis (fibromuscular dysplasia), developed restenosis 11 weeks after an initially successful renal artery angioplasty. In the second case, a patient with neurofibromatosis type 1 was diagnosed with hypertension secondary to renal artery stenosis. Angioplasty was not possible due to multiple branch occlusions. Both individuals went on to have successful renal autotransplantations, which ultimately cured their hypertension. In this article, we review the background, indications, and blood pressure outcomes in relation to renal autotransplantation in nonatherosclerotic renal artery stenosis.
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Affiliation(s)
- James Goodman
- Department of Clinical Pharmacology and Therapeutics (J.G., S.K., V.S., I.B.W.), Cambridge University Hospitals NHS Foundation Trust, United Kingdom
| | - Spoorthy Kulkarni
- Department of Clinical Pharmacology and Therapeutics (J.G., S.K., V.S., I.B.W.), Cambridge University Hospitals NHS Foundation Trust, United Kingdom
- Department of Medicine, Experimental Medicine and Immunotherapeutics, University of Cambridge, United Kingdom (S.K., I.B.W.)
| | - Viknesh Selvarajah
- Department of Clinical Pharmacology and Therapeutics (J.G., S.K., V.S., I.B.W.), Cambridge University Hospitals NHS Foundation Trust, United Kingdom
| | - Nicholas Hilliard
- Department of Radiology (N.H.), Cambridge University Hospitals NHS Foundation Trust, United Kingdom
| | - Neil Russell
- Department of Transplant Surgery (N.R.), Cambridge University Hospitals NHS Foundation Trust, United Kingdom
| | - Ian B Wilkinson
- Department of Clinical Pharmacology and Therapeutics (J.G., S.K., V.S., I.B.W.), Cambridge University Hospitals NHS Foundation Trust, United Kingdom
- Department of Medicine, Experimental Medicine and Immunotherapeutics, University of Cambridge, United Kingdom (S.K., I.B.W.)
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Han DS, Johnson JP, Schulster ML, Shah O. Indications for and results of renal autotransplantation. Curr Opin Nephrol Hypertens 2023; 32:183-192. [PMID: 36683544 DOI: 10.1097/mnh.0000000000000860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
PURPOSE OF REVIEW To understand the indications and outcomes of renal autotransplantation, and when to consider this unique procedure for patients. RECENT FINDINGS Renal autotransplantation confers acceptably low rates of graft failure and prevents need for long-term dialysis. Renal autotransplantation remains an important management strategy in very select patients for complex renovascular disease, ureteral stricture disease, ureteral trauma, upper urinary tract urothelial carcinoma, renal cell carcinoma, and Loin-Pain Hematuria Syndrome. With advancements in minimally invasive procedures, the application of renal autotransplantation for refractory stone disease is rare but exists. Robot-assisted laparoscopic renal autotransplantation demonstrates reproducible graft success and complication rates with improved perioperative outcomes (ex. hospital length of stay) - though comparative studies are lacking. Patients would benefit from a multidisciplinary approach from renal transplant surgeons, vascular surgeons, urologists, nephrologists, dieticians, pain management providers, social workers, and psychiatrists. SUMMARY In experienced hands, renal autotransplantation is a reasonable treatment approach for complex and refractory renal vascular disease, Loin-Pain Hematuria Syndrome, ureteral strictures and trauma, upper urinary tract malignancy, and stone disease in highly select patients.
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Affiliation(s)
- David S Han
- Columbia University Irving Medical Center, Department of Urology
| | - Jeffrey P Johnson
- Weill Cornell Medical College, Department of Urology, New York, New York, USA
| | | | - Ojas Shah
- Columbia University Irving Medical Center, Department of Urology
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Anesthetic Management and 30-Day Outcomes After Renal Autotransplantation. Ochsner J 2020; 20:267-271. [PMID: 33071658 PMCID: PMC7529139 DOI: 10.31486/toj.19.0086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background: Renal autotransplantation is a complex procedure performed for various indications such as treatment of renal vascular and urologic lesions and loin pain hematuria syndrome (LPHS). Because of the rarity of the procedure, few reports have been published, and little is known about anesthetic management and postoperative outcomes of patients with LPHS. The goal of this study was to review and describe all cases of renal autotransplantation performed at Cleveland Clinic during a specified period, focusing on anesthetic management and postoperative 30-day outcomes. Methods: We performed a retrospective review of the records of all patients who underwent renal autotransplantation from 2005 to 2014 at the Cleveland Clinic and collected demographic, anesthetic, surgical, and postoperative data. Results: A total of 64 patients underwent renal autotransplantation from 2005 to 2014. The most frequent indications were nephrolithiasis and LPHS. General endotracheal anesthesia with epidural for pain control was used in 47% of cases. Median duration of anesthesia was 528 minutes. Most patients were sent to a regular nursing floor postoperatively, but 28% of patients required intensive care unit admission. Two patients developed graft ischemia, and 1 patient developed graft failure requiring nephrectomy. No anesthetic-related complications and no mortality were associated with this procedure during the study. Conclusion: Renal autotransplantation is a safe option for patients with LPHS. Additional studies are needed to assess the effect of intraoperative anesthetic management on outcomes in this patient population.
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Gwon JG, Kim YH, Han DJ. Real Renal Function After Renal Autotransplantation Through the Analysis of Solitary Kidney Autotransplantation Cases. Transplant Proc 2017; 49:2055-2059. [PMID: 29149960 DOI: 10.1016/j.transproceed.2017.09.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Revised: 07/13/2017] [Accepted: 09/02/2017] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Previous studies of the safety of renal autotransplantation (RAT) have been limited by a lack of evidence. Because of the influence of the opposite kidney, it is difficult to evaluate actual renal function. This study evaluated the actual results of RAT by collecting only cases involving a solitary kidney. METHODS Between September 1, 1999, and November 30, 2015, 9 RAT procedures were performed in 9 patients with a solitary kidney. We retrospectively evaluated medical data collected prospectively. Renal function was evaluated using the creatinine level and the estimated glomerular filtration rate (eGFR). RESULTS The indications for RAT differed among the nin9e study patients. Five patients had complex renovascular problems, 2 were treated for partial nephrectomy, 1 was had a radically resected ureter due to ureteral cancer, 1 patient underwent RAT for the preservation of renal function during suprarenal-type abdominal aortic aneurysm repair. The mean cold ischemic time was 116.66 minutes (range, 21-256), and the mean follow-up duration was 54.2 months (range, 1 to 184). There were no significant decreases in eGFR until 12 months except 1 patient who underwent RAT with partial nephrectomy due to renal cell cancer. CONCLUSIONS We report stable renal function after RAT in patients with solitary kidney. Postoperative complications were rare. This is evidence for the safety of RAT.
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Affiliation(s)
- J G Gwon
- Department of Vascular Surgery, University of Hanyang College of Medicine Guri Hospital, Guri-si, Republic of Korea
| | - Y H Kim
- Department of General Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - D J Han
- Department of General Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea.
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Özyüksel A, Aktaş S, Çalıs E, Erol C, Sevmiş Ş. Ex Vivo Resection and Renal Autotransplantation for the Treatment of a Large Renal Vein Aneurysm Causing Recurrent Pulmonary Embolism and a Coexisting Vascular Malformation: A Case Report. Vasc Endovascular Surg 2016; 50:415-20. [PMID: 27334478 DOI: 10.1177/1538574416655893] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
A 36-year-old young woman with a medical history of recurrent pulmonary embolism and chronic pelvic pain was admitted to our hospital. Contrast-enhanced imaging techniques revealed a large left renal vein aneurysm with a coexisting vascular mass. The patient was operated on electively, and the left kidney was autotransplanted to the right ileac fossa following the ex vivo resection of the vascular mass and the left renal vein aneurysm. Herein, we report an unusual coexistence of a vascular mass and recurrent pulmonary embolism treated successfully with our surgical treatment strategy.
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Affiliation(s)
- Arda Özyüksel
- Department of Cardiovascular Surgery, Istanbul Medipol University, Istanbul, Turkey
| | - Sema Aktaş
- Department of General Surgery, Istanbul Medipol University, Istanbul, Turkey
| | - Elif Çalıs
- Department of Pathology, Istanbul Medipol University, Istanbul, Turkey
| | - Cengiz Erol
- Department of Radiology, Istanbul Medipol University, Istanbul, Turkey
| | - Şinasi Sevmiş
- Department of General Surgery, Istanbul Medipol University, Istanbul, Turkey
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Woods T, Jennings NB, Fernandez HT, Onaca N, Carlile BK, Levy MF, Gould DL, Ruiz R. Renal Autotransplantation in Lynch Syndrome: A Viable Option in a Patient With Contralateral Metachronous Ureteral Cancer. Am J Transplant 2015; 15:2507-10. [PMID: 25847116 DOI: 10.1111/ajt.13279] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Revised: 02/18/2015] [Accepted: 02/22/2015] [Indexed: 01/25/2023]
Abstract
The success of human kidney allotransplantation was realized over six decades ago. First described 50 years ago, renal autotransplantation has been utilized sparingly as a salvage procedure for patients at risk of losing renal function, either from a benign or malignant condition. While classically associated with colorectal malignancies, Lynch syndrome also carries a small yet significant risk for the development of ureteral carcinoma. For these patients who develop chronic kidney disease, allotransplantation may not be an option due to the lifelong risk of several malignancies. We report the first known case of renal autotransplantation in a patient with metachronous ureteral cancer due to Lynch syndrome.
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Affiliation(s)
- T Woods
- Annette C. and Harold C. Simmons Transplant Institute, Baylor All Saints Medical Center at Fort Worth, Fort Worth, TX
| | - N B Jennings
- Annette C. and Harold C. Simmons Transplant Institute, Baylor All Saints Medical Center at Fort Worth, Fort Worth, TX
| | - H T Fernandez
- Annette C. and Harold C. Simmons Transplant Institute, Baylor All Saints Medical Center at Fort Worth, Fort Worth, TX
| | - N Onaca
- Annette C. and Harold C. Simmons Transplant Institute, Baylor All Saints Medical Center at Fort Worth, Fort Worth, TX
| | - B K Carlile
- Annette C. and Harold C. Simmons Transplant Institute, Baylor All Saints Medical Center at Fort Worth, Fort Worth, TX
| | - M F Levy
- Annette C. and Harold C. Simmons Transplant Institute, Baylor All Saints Medical Center at Fort Worth, Fort Worth, TX
| | - D L Gould
- Annette C. and Harold C. Simmons Transplant Institute, Baylor All Saints Medical Center at Fort Worth, Fort Worth, TX
| | - R Ruiz
- Annette C. and Harold C. Simmons Transplant Institute, Baylor All Saints Medical Center at Fort Worth, Fort Worth, TX
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Cowan NG, Banerji JS, Johnston RB, Duty BD, Bakken B, Hedges JC, Kozlowski PM, Hefty TR, Barry JM. Renal Autotransplantation: 27-Year Experience at 2 Institutions. J Urol 2015; 194:1357-61. [PMID: 26055825 DOI: 10.1016/j.juro.2015.05.088] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/12/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE Renal autotransplantation is an infrequently performed procedure. It has been used to manage complex ureteral disease, vascular anomalies and chronic kidney pain. We reviewed our 27-year experience with this procedure. MATERIALS AND METHODS This is a retrospective, observational study of 51 consecutive patients who underwent renal autotransplantation, including 29 at Oregon Health and Science University between 1986 and 2013, and 22 at Virginia Mason Medical Center between 2007 and 2012. Demographics, indications, operative details and followup data were collected. Early (30 days or less) and late (greater than 30 days) complications were graded according to the Clavien-Dindo system. Factors associated with complications and pain recurrence were evaluated using a logistic regression model. RESULTS The 51 patients underwent a total of 54 renal autotransplants. Median followup was 21.5 months. The most common indications were loin pain hematuria syndrome/chronic kidney pain in 31.5% of cases, ureteral stricture in 20.4% and vascular anomalies in 18.5%. Autotransplantation of a solitary kidney was performed in 5 patients. Laparoscopic nephrectomy was performed in 23.5% of cases. Median operative time was 402 minutes and median length of stay was 6 days. No significant difference was found between preoperative and postoperative plasma creatinine (p = 0.74). Early, high grade complications (grade IIIa or greater) developed in 14.8% of patients and 12.9% experienced late complications of any grade. Two graft losses occurred. Longer cold ischemia time was associated with complications (p = 0.049). Of patients who underwent autotransplantation for chronic kidney pain 35% experienced recurrence and 2 underwent transplant nephrectomy. No predictors of pain recurrence were identified. CONCLUSIONS The most common indications for renal autotransplantation were loin pain hematuria syndrome/chronic kidney pain, ureteral stricture and vascular anomalies in descending order. Kidney function was preserved postoperatively and 2 graft losses occurred. At a median followup of 13 months pain resolved in 65% of patients who underwent the procedure. Complication rates compared favorably with those of other major urological operations and cold ischemia time was the only predictor of postoperative complications.
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Affiliation(s)
- Nick G Cowan
- Department of Urology, Oregon Health and Science University, Portland
| | - John S Banerji
- Section of Urology and Renal Transplantation, Virginia Mason Medical Center, Seattle, Washington
| | - Richard B Johnston
- Section of Urology and Renal Transplantation, Virginia Mason Medical Center, Seattle, Washington
| | - Brian D Duty
- Department of Urology, Oregon Health and Science University, Portland
| | - Bjørn Bakken
- Department of Urology, Oregon Health and Science University, Portland
| | - Jason C Hedges
- Department of Urology, Oregon Health and Science University, Portland.
| | - Paul M Kozlowski
- Section of Urology and Renal Transplantation, Virginia Mason Medical Center, Seattle, Washington
| | - Thomas R Hefty
- Section of Urology and Renal Transplantation, Virginia Mason Medical Center, Seattle, Washington
| | - John M Barry
- Department of Urology, Oregon Health and Science University, Portland
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9
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Use of a pulsatile perfusion pump for renal autotransplantation in a patient undergoing thoracoabdominal bypass for malignant hypertension secondary to Takayasu arteritis. Ann Vasc Surg 2014; 28:1793.e11-4. [PMID: 24698771 DOI: 10.1016/j.avsg.2014.03.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2013] [Revised: 03/19/2014] [Accepted: 03/22/2014] [Indexed: 11/23/2022]
Abstract
Aortorenal bypass is an effective and durable therapy for autoimmune-induced renovascular hypertension. However, when technical and patient factors preclude this option, renal autotransplantation can be a viable alternative. We present a 32-year-old woman who underwent aortobi-iliac bypass with left renal autotransplantation for malignant hypertension secondary to Takayasu arteritis. This is the first description of using machine preservation with a continuous pulsatile perfusion pump to maintain renal preservation before reimplantation. Our method proved safe to the patient and allowed for protection of the organ from prolonged warm ischemia and intraoperative hypoperfusion during a complex reconstruction.
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Song X, Liu Q, Zheng Y, Liu C, Liu D, Ji Z. Surgical treatment of renal artery compression by diaphragmatic crus. Ann Vasc Surg 2011; 26:276.e11-6. [PMID: 22050884 DOI: 10.1016/j.avsg.2011.08.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2010] [Revised: 06/14/2011] [Accepted: 08/07/2011] [Indexed: 10/15/2022]
Abstract
Symptomatic compression of the renal artery by the diaphragmatic crus is a rare disorder. To our knowledge, renal artery compression by the diaphragmatic crus complicated with poststenosis aneurysm has not been reported. We present the case of a 28-year-old man with refractory hypertension. Extrinsic compression of the bilateral renal arteries and celiac artery and the aneurysm were proven by surgical exploration. We successfully performed left renal artery revascularization and renal autotransplantation in situ. Normal perfusion of the two bypass graft vessels was proven by computed tomography angiography.
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Affiliation(s)
- Xiaojun Song
- Departments of Vascular Surgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
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Corbetta JP, Durán V, Burek C, Weller S, Sager C, Dingevan R, Lopez JC. Renal autotransplantation for the treatment of renovascular hypertension in the pediatric population. J Pediatr Urol 2011; 7:378-82. [PMID: 21527221 DOI: 10.1016/j.jpurol.2011.02.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE To evaluate the effectiveness of renal autotransplantation (RA) for the treatment of renovascular hypertension (RVH) in a selected group of children in whom medical care, a percutaneous transluminal angioplasty or vascular reconstruction failed or was technically impossible, in addition to the short-term and long-term morbidity. MATERIALS AND METHODS A retrospective case review of 13 pediatric patients with severe or complicated RVH who underwent RA between May 1993 and August 2008 was conducted. We defined blood pressure (BP) response as follows: Cured: normal BP values with no need of antihypertensive medication (AM); Improved: normal BP values with AM requirements; Failed: abnormal BP values despite treatment with AM. RESULTS 16 RA were performed in 7 female and 6 male patients. Bilateral RA were performed in 2 females and in 1 male. The average age at consultation for hypertension was 8.5 years (range 4-12 years) and the time of transplantation was 9.12 years (range 6-13 years). Etiological diagnoses were: Takayasu disease (n = 5); renal artery fibrodysplasia (n = 3); mid-aortic syndrome (n = 3) and neurofibromatosis type I (n = 2). Results after RA were: Cured: 61.5%; Improved: 38.5%. No patient presented therapeutic failure during follow up time (median = 53.4 months). Only 1 case presented a postoperative complication. CONCLUSIONS RA is a procedure with no mortality and low morbidity rates that renders very satisfactory therapeutic results in the pediatric population.
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Affiliation(s)
- Juan Pablo Corbetta
- Urology Department, Hospital de Pediatría Prof. Dr. Juan P. Garrahan, Buenos Aires, Argentina.
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