Transplantation of Dual Adult Kidneys Into a Recipient With Minimal Abdominal Vascular Access

Abstract

Dual kidney transplantation has become increasingly utilized as a means of decreasing the organ shortage and optimizing outcomes of marginal kidneys (1). Among deceased-donor kidney transplant recipients at the University of Pittsburgh Medical Center, transplantation of dual kidneys transplants from adult donors has increased from 4% (7/04–6/05), to 11% (7/05–6/06), to 32% since 7/06. Our criteria to perform dual renal transplantation generally includes donor age ≥70 years, or younger donors with glomerulosclerosis ≥10%, and/or arterial luminal narrowing of 25% to 50%. Recipients of dual kidneys must have adequate space for the transplantation of two kidneys (either both kidneys in one iliac fossa or single bilateral kidneys), so that candidates are usually limited to those who have had one or no previous kidney transplants. We describe the transplantation of dual adult kidneys into a recipient with two previous kidney transplants (one on each side) and diffuse severe aortoiliac atherosclerosis. Two kidneys from a 68-year-old male donor who expired from a myocardial infarction were accepted as an open offer with permission to utilize as a two-for-one transplantation. The terminal creatinine and calculated CCr were 1.7 mg/dL and 70 mL/min, respectively. Kidney biopsy showed glomerulosclerosis in 14% (9/63) and 5% (3/59) of the glomeruli of each kidney, respectively, and minimal interstitial fibrosis, arteriosclerosis, and arteriolosclerosis. Pulsatile perfusion of the kidneys demonstrated terminal resistances of 30% and 32%. Three wait-listed candidates were >50 years of age. The first patient, a 55-year-old male with end-stage renal disease secondary to hypertension with two failed kidney transplants and historically high antibody levels (100% class I and II enzyme-linked immunosorbent assays), had a history of several previously positive crossmatches. He shared five human leukocyte antigen antigens with this donor. To optimize his chances of transplantation, he was included in the crossmatch and it was negative for both T and B cells. The recipient operation was performed through a midline incision with the intention of revascularizing the kidneys separately to the common iliac vessels; however, the patient had diffuse hard aortoiliac atherosclerotic disease. Attempts to isolate the distal left external iliac vessels were aborted, because the previous kidney transplant was too large to allow room for exposure. The right iliac fossa was more optimal as the previous kidney transplant was atrophic. With retraction of the ilioinguinal ligament, 4 cm segments of recipient external iliac artery and vein were isolated and were healthy enough to allow anastomosis of a segment of donor common iliac artery (Y-graft) and vein (from a different donor with a compatible blood type), respectively. The right kidney renal artery and vein were anastomosed to the internal iliac artery of the Y-graft end-to-end and the middle portion of the common iliac vein graft end-to-side. The left kidney was next revascularized by end-to-end anastomoses to the external iliac artery and vein grafts, respectively (Fig. 1. The ureters were anastomosed to the bladder using separate extravesical ureteroneocystostomies over 6F 12 cm double-J stents. The cold ischemia was 21 hr. The renal allografts functioned immediately; the creatinine is currently 1.7 at 2 months follow-up.FIGURE 1.: Iliac vessel Y-graft to dual kidney allografts.The technique described illustrates a method to transplant dual adult kidneys in recipients with suboptimal vascular access for transplantation. Liise K. Kayler Ron Shapiro Department of Surgery University of Pittsburgh Medical Center Pittsburgh, Pennsylvania Ernesto Molmenti Department of Surgery University of Arizona Tucson, Arizona