The management of kidney transplants damaged during their removal from the donor

Transplanting a left or right donor kidney into the left or right iliac fossa: importance of laterality and site of venous anastomosis

Data on the impact of donor-to-recipient laterality on kidney transplantation are lacking. This study evaluated the impact of donor-to-iliac fossa laterality and the site of venous anastomosis on operating time and surgical outcome. This retrospective single-center study analyzed 1262 deceased donor adult kidney transplants into pristine iliac fossa. Multivariable linear and logistic regression analyses were used to identify variables with an impact on operating time and surgical complications. Operating time was shorter by 11 min in median for transplantations into the right iliac fossa compared to the left iliac fossa (p < 0.001). Operating time in left-to-right donor-to-recipient combination was shorter by 17 min in median if venous anastomoses were performed on the caval vein or common iliac vein as compared to anastomoses to the external iliac vein (p < 0.001). Overall, the shortest operating times (median 112.5 min) were achieved in left-to-right donor-to-recipient combinations with venous anastomosis to the caval or common iliac vein, without an increase in surgical complications. Kidney transplantation into the right iliac fossa with anastomosis to the caval vein or the common iliac vein saves operating time and reduces thrombotic complications. Acceptance of a left donor kidney is likely to further reduce operating time.

Risk Balancing of Cold Ischemic Time against Night Shift Surgery Possibly Reduces Rates of Reoperation and Perioperative Graft Loss

Background. This retrospective cohort study evaluates the advantages of risk balancing between prolonged cold ischemic time (CIT) and late night surgery. Methods. 1262 deceased donor kidney transplantations were analyzed. Multivariable regression was used to determine odds ratios (ORs) for reoperation, graft loss, delayed graft function (DGF), and discharge on dialysis. CIT was categorized according to a forward stepwise pattern ≤1h/>1h, ≤2h/>2h, ≤3h/>3h,…, ≤nh/>nh. ORs for DGF were plotted against CIT and a nonlinear regression function with best R² was identified. First and second derivative were then implemented into the curvature formula k(x) = f′′(x)/(1 + f′(x)²)^3/2 to determine the point of highest CIT-mediated risk acceleration. Results. Surgery between 3 AM and 6 AM is an independent risk factor for reoperation and graft loss, whereas prolonged CIT is only relevant for DGF. CIT-mediated risk for DGF follows an exponential pattern f(x) = A · (1 + k · e^{(I · x)}) with a cut-off for the highest risk increment at 23.5 hours. Conclusions. The risk of surgery at 3 AM–6 AM outweighs prolonged CIT when confined within 23.5 hours as determined by a new mathematical approach to calculate turning points of nonlinear time related risks. CIT is only relevant for the endpoint of DGF but had no impact on discharge on dialysis, reoperation, or graft loss.

Surgical Stapler for Right Renal Vein Elongation Using the Inferior Vena Cava in Kidney Transplant

Elongation of the right renal vein with the inferior vena cava (caval patch) using a vascular stapler offers a safe means of extending the deceased-donor right renal vein, while minimizing the ischemic time of the kidney during preparatory dissection. The aortic patch of the right renal artery also can be preserved, which minimize the danger of arterial stenosis, kinking, and dissection.

Fax Extension of the Right Renal Vein With a Remodeled Receptor Saphenous Vein in a Living-Donor Kidney Transplant: A Case Report

The right kidney may be chosen for donor safety as the donor kidney in a living renal transplant. However, the short length of the right renal vein may increase technical difficulties and affect the implanted graft. We report a method that uses the remodeled receptor saphenous vein to reconstruct and extend the transplanted renal vein.

Right renal vein elongation with the inferior vena cava for cadaveric kidney transplants: an old neglected surgical approach

INTRODUCTION

Short right renal vein is a frequent and well-known technical inconvenience that is commonly observed during transplantation of the right kidney. We present our experience with the elongation of short cadaveric right renal veins using the contiguous vena cava during cadaveric renal transplants.

METHODS

We performed 34 kidney transplantations with a short right renal vein requiring elongation using the inferior vena cava, to make the venous anastomosis technically feasible. The elongated right renal vein was anastomosed end to side to the external iliac vein in 24 patients, to the common iliac vein in 8 patients and to the inferior vena cava in 2 patients. The right renal artery with an aortic patch was implanted end to side in 33 patients, and end to end without aortic patch to the internal iliac artery in one patient.

RESULTS

In all cases, the vascular anastomoses were easily performed in the recipient and no thrombosis was observed.

CONCLUSION

Elongation of a short right renal vein with the inferior vena cava is a feasible mean to overcome technical problems that may compromise the results of cadaveric renal transplantation.

Microvascular reconstructive "bench" surgery for donor kidneys before transplantation: techniques and results

Forty kidneys (10 from live donors) with either multiple renal arteries or damaged vasculature were reconstructed accurately ex vivo with microsurgical techniques before transplantation. The end product in all cases was a kidney requiring a single arterial and venous in situ anastomosis. The warm ischemia time was minimized by this adjunctive "bench" microsurgery. There was no surgical complication relating to the vascular reconstruction. The potential technical and hemodynamic benefits of this surgical approach to kidneys with multiple vessels are discussed. In addition, some kidneys with damaged vasculature can be salvaged for transplantation with microvascular reconstruction.

Use of vena cava to obtain additional length for the right renal vein during transplantation of cadaveric kidneys

During cadaveric organ harvesting removal of the right renal vein and a segment of the vena cava may facilitate venous anastomosis of the right kidney. The technique to obtain adequate length of the right renal vein using the vena cava is simple, physiological and effective. A segment of the inferior vena cava should be harvested with the right but not necessarily with the left kidney. The use of a long segment of vena cava makes the renal transplantation much easier and does not interfere with multiorgan procurement. The method is most useful when the right renal vein is extremely short or when the recipient has a large abdomen and a deep pelvis.

Microvascular surgery in experimental and clinical kidney transplantation

An improved microsurgical technique for orthotopic rat kidney transplantation is described in detail. (1) End-to-end anastomosis of renal arteries with 7-8 interrupted 10-0 sutures. (2) End-to-end anastomosis of renal veins with 2 continuous semicircular 10-0 sutures. (3) Non-splinted end-to-end ureteric anastomosis with 4 interrupted full-thickness 11-0 sutures. (4) Simultaneous bilateral nephrectomy. Seventy transplantations were analysed. No failure due to complications of the vascular anastomoses occurred. The ureteric anastomoses were complicated by stenosis in only 5 animals (7%). The operation times for vascular anastomoses were 20 (15-24) minutes and for complete transplantation 50 (45-60) minutes. This technique seems to be less time consuming than other methods. Our method has produced a success rate of 93% with well standardized and reproducible organ quality. Preliminary clinical experiences with extracorporeal microvascular reconstruction in 4 cases of injured small polar kidney allograft arteries support the continued application in appropriate situations to increase the number of suitable donor kidneys.

Arterial anastomoses in renal transplantation

A consecutive series of 260 renal transplants was analysed to find the outcome of different arterial anastomoses. In 177 cases the renal vessel was anastomosed to the end of the internal iliac artery; 15 per cent developed vascular complications. Thirty-eight of these patients subsequently underwent allograft nephrectomy; none died from haemorrhage. In 83 patients the renal vessel was anastomosed end to side to the iliac artery, and vascular complications occurred in 14 per cent. Thirty-two patients subsequently underwent allograft nephrectomy; 8 were associated with severe haemorrhage and 5 of these were fatal.

Successful allotransplantation of a kidney removed because of ureteral damage in an unrelated living donor

The use of a kidney removed because of ureteral damage in an unrelated donor has produced a well functioning renal allograft in the transplant recipient. The kidney demonstrated calicectasis and hydronephrosis on an excretory urogram before removal of the ureteral cutaneous fistula. An excretory urogram performed 8 months after the renal allotransplantation of this kidney shows prompt function of a delicate collecting system without any residual calicectasis. This case emphasizes the need for us to explore the possible use of free kidneys removed from living unrelated donors for non-neoplastic diseases of the ureter.