Renal retransplantation after kidney and pancreas transplantation using the renal vessels of the failed allograft: pitfalls and pearls

Medical and Surgical Management of the Failed Pancreas Transplant

Despite the continued improvements in pancreas transplant outcomes in recent decades, a subset of recipients experience graft failure and can experience substantial morbidity and mortality. Here, we summarize what is known about the failed pancreas allograft and what factors are important for consideration of retransplantation. The current definition of pancreas allograft failure and its challenges for the transplant community are explored. The impacts of a failed pancreas allograft are presented, including patient survival and resultant morbidities. The signs, symptoms, and medical and surgical management of a failed pancreas allograft are described, whereas the options and consequences of immunosuppression withdrawal are reviewed. Medical and surgical factors necessary for successful retransplant candidacy are detailed with emphasis on how well-selected patients may achieve excellent retransplant outcomes. To achieve substantial medical mitigation and even pancreas retransplantation, patients with a failed pancreas allograft warrant special attention to their residual renal, cardiovascular, and pulmonary function. Future studies of the failed pancreas allograft will require improved reporting of graft failure from transplant centers and continued investigation from experienced centers.

How to Deal With Kidney Retransplantation-Second, Third, Fourth, and Beyond

Kidney transplantation is the best health option for patients with end-stage kidney disease. Ideally, a kidney transplant would last for the lifetime of each recipient. However, depending on the age of the recipient and details of the kidney transplant, there may be a need for a second, third, fourth, or even more kidney transplants. In this overview, the outcome of multiple kidney transplants for an individual is presented. Key issues include surgical approach and immunologic concerns. Included in the surgical approach is an analysis of transplant nephrectomy, with indications, timing, and immunologic impact. Allograft thrombosis, whether related to donor or recipient factors merits investigation to prevent it from happening again. Other posttransplant events such as rejection, viral illness (polyomavirus hominis type I), recurrent disease (focal segmental glomerulosclerosis), and posttransplant lymphoproliferative disease may lead to the need for retransplantation. The pediatric recipient is especially likely to need a subsequent kidney transplant. Finally, noncompliance/nonadherence can affect both adults and children. Innovative approaches may reduce the need for retransplantation in the future.

Beyond the Limits: How to Avoid a Surgical Nightmare in the Third and Subsequent Renal Transplantation Procedures

PURPOSE OF REVIEW

Approximately, 25% of the patients with ESRD will enter the waiting list for kidney transplantation. Among these patients, almost 15% will require a retransplantation surgery. This review aims to summarize the most recent information on different controversial issues regarding retransplantation, to provide the reader with a clear and updated view on the topic.

RECENT FINDINGS

Despite current evidence is mainly based on retrospective, small, single-center experiences, it seems clear that retransplantation remains a surgical and immunological challenge, for which the perioperative management still remains crucial to avoid mishaps. Different surgical approaches have been tested, but the general consensus advocates for the heterotopic extraperitoneal in first instance. Although higher immunological risk and complication rates are reported invariably in the available series, the benefits in terms of overall survival are superior to those obtained under dialysis, thus still representing the most recommended option for this group of patients.

Surgical Safety and Efficacy of Third Kidney Transplantation in the Ipsilateral Iliac Fossa

BACKGROUND Kidney re-transplantation is a relevant option for patients who are returning to dialysis after graft failure. However, evidence is lacking to what extend a third kidney transplantation in the ipsilateral iliac fossa is safe and effective. The aim of this study was to investigate the outcomes of third kidney transplantations in the ipsilateral iliac fossa compared to first and second ipsilateral fossa kidney transplantations. MATERIAL AND METHODS There were 2074 kidneys transplanted at the Erasmus MC Rotterdam and at the University Medical Centre Groningen. Donor, recipient, and surgical data were collected. The cohort was divided into 3 groups: recipients of a first graft (I KTx; n=1744), recipients of a second graft (II KTx; n=44), and recipients of a third graft (III KTx; n=7). RESULTS Recipients from the II KTx group had a significantly higher rate of primary non-function (PNF) compared to recipients in the I KTx group and recipients in the III KTx group (4.5% versus 0.7% and 0% respectively; P=0.006). The 1-year graft survival did not differ between groups: 96% for I KTx, 91% for II KTx, and 85% for III KTx (P=0.214). The 5-year graft survival did differ significantly between groups: 89% for I KTx, 82% for II KTx, and 68% for III KTx (P=0.029). There were no differences regards hospital stay and rate of complications between groups. CONCLUSIONS Third kidney transplantation in the ipsilateral iliac fossa is feasible and viable. Short-term results are comparable to the first and the second kidney transplantation, however, long-term results are inferior but acceptable compared to dialysis.

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.