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Cover page of the Journal of Health Sciences


 
 Table of Contents  
REVIEW ARTICLE
Year : 2019  |  Volume : 12  |  Issue : 3  |  Page : 211-214

Multiple renal arteries in kidney transplantation


1 Department of Urology, JN Medical College, KLE Academy of Higher Education and Research (Deemed-to-be-University), JNMC Campus; KLES Dr. Prabhakar Kore Hospital and Medical Research Centre, KLES Kidney Foundation, Belagavi, Karnataka, India
2 Department of Urology, JN Medical College, KLE Academy of Higher Education and Research (Deemed-to-be-University), JNMC Campus, Belagavi, Karnataka, India
3 Department of Urology, KLES Dr. Prabhakar Kore Hospital and Medical Research Centre, KLES Kidney Foundation, Belagavi, Karnataka, India

Date of Web Publication15-Oct-2019

Correspondence Address:
Dr. Rajendra B Nerli
Department of Urology, JN Medical College, KLE Academy of Higher Education and Research (Deemed-to-be-University), JNMC Campus, Belagavi - 590 010, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/kleuhsj.kleuhsj_318_18

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  Abstract 


Kidney transplantation has become the preferred renal replacement therapy for patients suffering from end-stage renal disease. Today, the results of kidney transplantation have improved enormously due to advances in organ harvesting, organ preservation, surgical techniques, and last but not least immunosuppressive regimens. Renal transplantation is more cost-effective than hemodialysis and provides better quality of life. The success story of transplantation has led to significant demand for organs, which is not met by the current supply of donors be it living or deceased. Besides augmentation of the number of living kidney donation, the lack of organs is partially compensated by extended donor criteria including multiple renal arteries. This article reviews the techniques and pitfalls of arterial reconstruction during renal transplantation.

Keywords: Arterial reconstruction, kidney transplantation, multiple renal arteries, sequential anastomosis, surgical technique


How to cite this article:
Nerli RB, Shankar K, Ghagane SC, Dixit NS. Multiple renal arteries in kidney transplantation. Indian J Health Sci Biomed Res 2019;12:211-4

How to cite this URL:
Nerli RB, Shankar K, Ghagane SC, Dixit NS. Multiple renal arteries in kidney transplantation. Indian J Health Sci Biomed Res [serial online] 2019 [cited 2019 Nov 19];12:211-4. Available from: http://www.ijournalhs.org/text.asp?2019/12/3/211/269201




  Introduction Top


Kidney transplantation remains the standard of care in patients with end-stage renal disease as it leads to improved survival and quality of life.[1] In India, there is a continuing shortage of donors leading to a growing pressure to find suitable donor organs. Different strategies have been used so as to resolve donor shortage issues by extending existing donor criteria and establishing living donor programs.[2],[3] Minimally invasive techniques, such as laparoscopic live donor nephrectomy, have made it more attractive to potential donors to donate a kidney.[4] In the Netherlands, >50% of kidneys are procured by laparoscopic living donor nephrectomy.[5]

Kidneys with multiple renal arteries (MRAs) when used as a graft appear to be a potential risk factor that could impair the outcome of kidney transplantations [Figure 1]. The incidence of MRA grafts is about 17%–35% as per autopsy studies, depending on the donor ethnic origin.[6] Kidneys with MRAs are likely to have a higher incidence of vascular complications, delayed graft function (DGF), and increased warm ischemia time (WIT).[5]
Figure 1: Renal angiogram showing bilateral accessory renal arteries

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  Cadaveric Donors Top


The age of potential cadaveric donors has been increasing during the last years. Dissection of abdominal cadaveric organs for transplantation is usually performed after cold perfusion. Single cannulation of the aorta is done after ligation of the common iliac arteries as well as the proximal aorta above the coeliac trunk. Perfusion itself is then carried out with increased pressure for around 15 min. After perfusion in hypothermia, the abdominal organs should be removed rapidly.[7] During harvesting of the kidneys, all renal arteries should be preserved and explanted with a common aortic patch. Special attention must be paid to polar arteries which often originate afar from the main renal artery. If a common patch is not possible to preserve all the renal arteries, then individual patches for each artery are to be harvested.


  Live Donors Top


The advantages of living donation include cold ischemia time, optimal selection, and timing. Different explantation techniques have been described such as open lumbar donor nephrectomy and laparoscopic donor nephrectomy.[8] It is obvious that for technical reasons, no aortic patch can be harvested in living donor nephrectomy. Attention must be paid to expose and harvest all the arteries and an adequate length of the explanted vessels. Cannulation of every single artery must be done and perfused ex situ immediately.


  Implantation Techniques and Sites of a Living Donor Transplant Top


Standard renal transplantation is performed to the right iliac fossa. The heterotopic approach allows easy access to the iliac vessels without opening the peritoneal cavity and without the need to remove the recipient's kidney. Moreover, the proximity to the urinary bladder reduces the required length of the ureter and impairs the risk of distal necrosis. The heterotopic kidney transplantation enables different arterial anastomosis techniques. All techniques require gentle dissection of the recipient's vessels with respect to the lymphatic vessels to avoid lymphoceles. All anastomoses are performed using running suture technique. Every anastomosis should be preferably performed in an area free of arteriosclerotic lesions. End-to-side anastomosis of the renal artery is possible to the common iliac artery as well as the external iliac artery and also to the distal abdominal aorta, for example, in pediatric patients. End-to-end anastomosis is commonly performed to the internal iliac artery.[7],[9],[10]


  Implantation in Case of Multiple Renal Arteries Top


The use of grafts with MRAs poses a challenge to a transplant surgeon. MRAs are unilaterally found in 25% and bilaterally in 10% of the population.[11] The presence of MRAs has been considered a relative contraindication because of the presumed incidence of vascular and urologic complications. However, recent multiple studies have shown that despite technical difficulties, grafts with multiple arteries present similar indexes of surgical complications and outcome as compared to grafts with single artery.[12],[13] Sequential anastomosis of renal arteries is suggested. Whenever possible, sequential end-to-side anastomoses can be performed. Common and external iliac arteries may be used for up to three or even more anastomoses. Despite slightly increased incidence of postoperative lymphoceles, sequential anastomosis is a safe procedure with excellent short- and long-term results.[13]


  Complications in Grafts With Multiple Arteries Top


Renal transplantation is liable to complications due to technical problems and peculiarities inherent to patients with chronic renal failure. Difficulties arise from anatomical anomalies such as multiple arteries and ureters, pediatric donors, and horseshoe kidneys.[11] The out-of-body vascular reconstruction (bench technique) aims at generating a unique arterial ostium to facilitate the vascular anastomosis and to decrease the incidence of complications.[14],[15] Instead, in situ reconstruction of multiple artery grafts can be used, like anastomosis between the inferior epigastric artery and the small caliber polar arteries.[15],[16]

Mazzucchi et al.[16] compared the surgical complications and short-term outcome of renal transplants with multiple arteries and single artery grafts. The data of 64 renal transplants with multiple arteries performed between January 1995 and December 1999 were compared to the ones of 292 transplants with single renal artery (SRA). The incidence of surgical complications in grafts with multiple arteries and SRA was, respectively: vascular – 3.1% and 3.1%; urological – 6.3% and 2.7%; and other surgical complications – 15.6% and 10.6%. The incidence of lymphoceles was 3.1% in grafts with a single artery and 12.5% in grafts with more than one artery (P < 0.0015). The incidence of DGF in grafts with multiple arteries and with an SRA was, respectively, 35.1 and 29.1% (P < 0.295). Mean serum creatinine at the 30th postoperative day was 2.46 and 1.81 in grafts with multiple and with one artery, respectively (P < 0.271). The authors concluded that transplantation using grafts with single and multiple arteries present similar indexes of surgical complications and short-term outcome; lymphoceles were more frequent among grafts with multiple arteries.


  Outcome of Kidney Transplants With Multiple Renal Arteries Top


Although graft and patient survival has significantly improved because of standardization in surgical technique and immunosuppressive therapy, grafts with anatomic variants are still challenging problems to the surgeon. Aydin et al.[17],[18] reviewed the records of 225 adult kidney transplants done consecutively at their institution. Twenty-nine patients (12.8%) had grafts with MRAs. In 17 cases, reconstruction was done as conjoined anastomosis between two arteries of equal size, and in six cases, reconstruction was done as end-to-side anastomosis of smaller arteries to larger arteries. Multiple anastomoses were performed in six cases. In one patient, postoperative bleeding occurred. Mean systolic blood pressures, creatinine levels at the 1st year and the last follow-up, and complication rates were all in acceptable ranges. There was no significant difference in graft and patient survival between MRA and SRA allografts.

Zorgdrager et al.[5] did a systematic review of a total of 23 studies, comprising a total of 18,289 patients who were eligible to be included in the meta-analysis. Patients who received a MRA graft showed significantly higher complication rates (13.8% vs. 11.0%, odds ratio [OR] 1.393, P < 0.0001), showed significantly more DGF (10.3% vs. 8.2%, OR 1.333, P < 0.022), and had an associated significantly lower 1-year graft survival (93.2% vs. 94.5%, OR 0.819, P < 0.034) when compared to SRA grafts. Both the creatinine level and the WIT were significantly higher in patients with MRA grafts but showed high heterogeneity (I2 98% for WIT and I2 70% for creatinine level). Although MRA grafts were associated with more complications compared to SRA grafts, long-term outcomes were similar for 5-year graft survival (81.4% vs. 81.6%) and 1- and 5-year patient survival (95.4% and 89.6% in MRA group vs. 95.4% and 87.0% in SRA group, respectively).

Saidi et al.[19] compared the outcome of living donor kidney transplantation using allografts with a single artery with that observed in recipients of allografts with multiple arteries. Three hundred and nineteen allografts (91.1%) had a single artery (Group 1) and 31 (8.9%) had multiple arteries (Group 2), including two arteries in 21 grafts (67.8%), three arteries in 6 (19.3%), and four arteries in 4 grafts (12.9%). The overall surgical complication rate in Groups 1 and 2 was comparable (9.6% vs. 9.7%; vascular, 2.8% vs. 3.2%; urological, 1.6% vs. 3.2%; symptomatic lymphocele, 2.8% vs. 3.2%; and wound infections, 2.8% vs. 3.2%). The actuarial 1- and 5-year allograft survival rates were comparable in both groups (98.4% and 91.5% in Group 1 and 96.8% and 87.1% in Group 2). A significant increase in the use of allografts with multiple arteries had been observed in recent years: 7.8% (n = 10) in grafts that were procured by open technique (n = 127), 4.1% (n = 5) during their initial experience with laparoscopic nephrectomy (n = 123), and 16% (n = 16) in the most recent 100 cases (P < 0.01).


  Conclusions Top


Multiplicity of renal arteries in kidney transplantation does not adversely affect allograft survival compared with the SRA group. Multiplicity of the renal arteries is not associated with a higher rate of complications than in the single artery.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Tonelli M, Wiebe N, Knoll G, Bello A, Browne S, Jadhav D, et al. Systematic review: Kidney transplantation compared with dialysis in clinically relevant outcomes. Am J Transplant 2011;11:2093-109.  Back to cited text no. 1
    
2.
Dixit N, Nerli R, Ghagane S, Hiremath M, Guntaka A. The role of public relation in-charge in kidney transplantation: the cognitions, emotions, ethical, and religious issues in a multicultural society like India. Int J Nephrology and Kidney Failure 2015;2:1-7.  Back to cited text no. 2
    
3.
Pascual J, Zamora J, Pirsch JD. A systematic review of kidney transplantation from expanded criteria donors. Am J Kidney Dis 2008;52:553-86.  Back to cited text no. 3
    
4.
Yuan H, Liu L, Zheng S, Yang L, Pu C, Wei Q, et al. The safety and efficacy of laparoscopic donor nephrectomy for renal transplantation: An updated meta-analysis. Transplant Proc 2013;45:65-76.  Back to cited text no. 4
    
5.
Zorgdrager M, Krikke C, Hofker SH, Leuvenink HG, Pol RA. Multiple renal arteries in kidney transplantation: A systematic review and meta-analysis. Ann Transplant 2016;21:469-78.  Back to cited text no. 5
    
6.
Dasgupta P, Challacombe B, Compton F, Khan S. A systematic review of hand-assisted laparoscopic live donor nephrectomy. Int J Clin Pract 2004;58:474-8.  Back to cited text no. 6
    
7.
Khamanarong K, Prachaney P, Utraravichien A, Tong-Un T, Sripaoraya K. Anatomy of renal arterial supply. Clin Anat 2004;17:334-6.  Back to cited text no. 7
    
8.
Beckmann JH, Jackobs S, Klempnauer J. Arterial reconstruction in kidney transplantation. Transplant Med 2008;20:7-12.  Back to cited text no. 8
    
9.
Velidedeoglu E, Williams N, Brayman KL, Desai NM, Campos L, Palanjian M, et al. Comparison of open, laparoscopic, and hand-assisted approaches to live-donor nephrectomy. Transplantation 2002;74:169-72.  Back to cited text no. 9
    
10.
Benoit G. Surgical technics of kidney transplantation. Prog Urol 1996;6:594-604.  Back to cited text no. 10
    
11.
Magdum PV, Nerli RB, Patil SM, Ghagane SC, Karuppasamy S, Musale A. Early post-transplant ureterovesical junction obstruction managed by an endourological procedure: A case report. J Egypt Soc Nephrol Transplant 2016;16:106.  Back to cited text no. 11
  [Full text]  
12.
Sampaio FJ, Passos MA. Renal arteries: Anatomic study for surgical and radiological practice. Surg Radiol Anat 1992;14:113-7.  Back to cited text no. 12
    
13.
Makiyama K, Tanabe K, Ishida H, Tokumoto T, Shimmura H, Omoto K, et al. Successful renovascular reconstruction for renal allografts with multiple renal arteries. Transplantation 2003;75:828-32.  Back to cited text no. 13
    
14.
Neipp M, Becker T, Jackobs S. Kidney Transplant after living donation: Results of organs mit anatomical variations. 14th Annual Meeting of the Germans Transplant Society. Rostock, Germany: Transplantation Med Supplement; 2005. p. 23.  Back to cited text no. 14
    
15.
Novick AC, Magnusson M, Braun WE. Multiple-artery renal transplantation: Emphasis on extracorporeal methods of donor arterial reconstruction. J Urol 1979;122:731-5.  Back to cited text no. 15
    
16.
Nghiem DD. Donor aortoplasty for transplantation of kidneys with multiple arteries. J Urol 1994;152:2055-6.  Back to cited text no. 16
    
17.
Mazzucchi E, Souza AA, Nahas WC, Antonopoulos IM, Piovesan AC, Arap S, et al. Surgical complications after renal transplantation in grafts with multiple arteries. Int Braz J Urol 2005;31:125-30.  Back to cited text no. 17
    
18.
Aydin C, Berber I, Altaca G, Yigit B, Titiz I. The outcome of kidney transplants with multiple renal arteries. BMC Surg 2004;4:4.  Back to cited text no. 18
    
19.
Saidi R, Kawai T, Kennealey P, Tsouflas G, Elias N, Hertl M, et al. Living donor kidney transplantation with multiple arteries: Recent increase in modern era of laparoscopic donor nephrectomy. Arch Surg 2009;144:472-5.  Back to cited text no. 19
    


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