En Bloc Kidney Transplantation Research Articles

Perioperative Anesthetic Management and Outcome of a Cadaveric Pediatric En-bloc Kidney Transplantation: A Case Report

Kidney transplantation stands as the favored approach to treat end-stage renal disease in children, offering enhanced survival, improved quality of life, and better neuropsychological development compared to dialysis. Transplanting kidneys en bloc remains a complex procedure, diverging from the conventional single kidney transplantation in several aspects, requiring precise skill and expertise to achieve favorable outcomes. In this paper, we report a successful en-bloc kidney transplantation from a 16-month-old pediatric cadaveric donor to a 5-year-old recipient, the youngest individual to undergo an en-bloc kidney transplant in the country, and the contribution of meticulous anesthetic management to this success story.

En bloc Kidney Transplant – A Surgical Illustration and Clinical Experience from a Tertiary Care Hospital in South India

There is a global shortage of transplantable organs, especially in a resource-limited country like India. Deceased pediatric donors provide an excellent opportunity to expand the donor pool. Herein, we report a rare case of multi-organ harvesting from a 3-year-old brain-dead donor, where both the kidneys were transplanted en bloc to an adult male recipient and the liver to a 4-year-old male child. This case report provides the surgical steps and our experience.

En bloc kidney transplantation of an infant to an adolescent girl - one-year follow-up

Introduction. En bloc kidney transplantation (EBKT) overcomes the problems of insufficient nephron mass of the solitary kidney of the youngest donors and the creation of a vascular anastomosis with small blood vessels. Although there are positive experiences with EBKT in adult patients, there is little data in pediatric recipients. Case outline. The kidney donor was a six-month-old male infant (7 kg), and the recipient was a 16-year-old adolescent girl (58.7 kg). The estimated glomerular filtration rate increased during the one-year follow-up after EBKT and reached 88.8 ml/min/1.73m2, which was accompanied by an increase in the dimensions of the medial and lateral kidneys. Normalization of proteinuria and tubular functions occurred 6 and 12 months after transplantation, respectively. Conclusion. EBKT in an adolescent girl was performed without vascular complications, with satisfactory kidney function and physiological values of proteinuria after a one-year follow-up. EBKT of infants could increase the number of cadaveric donors but also enable better function and survival of the graft, given that the growth and functional maturation of the infant's kidneys continue postnatally in the body of the graft recipient.

Outcomes of Different Donor and Recipient Vessel and Ureteral Anastomoses in En Bloc Kidney Transplant From Pediatric Deceased Donors: A Retrospective Cohort.

This study aimed to investigate the possible role of different donor and recipient vessel and ureteral anastomoses on survival and functional outcomes in en bloc kidney transplants. This retrospective cohort included 99 en bloc kidney transplants performed from December 2005 to March 2022. Recipients were grouped based on donor's vessel (distal [n = 84] or proximal [n = 15] abdominal aorta), recipient's vessel (abdominal aorta [n = 3], external [n = 21], internal [n = 50], or common [n = 25] iliac artery), and ureteral anastomosis (separate [n = 32] or common [n = 67]). Patient and graft survival, complication rates, and estimated glomerular filtration rate trends were compared between groups. Pediatric brain dead donors had a mean age and weight of 37 ± 22 months and 14 ± 4 kg, respectively. Donor and recipient vessel and ureteral anastomoses did not affect overall survival (P = .306, .296, and .225), graft survival (P = .720, .172, and .124), and vascular (P = .347, .689, and .264) and urinary (P = .587, .172, and .385) complication rates. Lymphoceles requiring intervention were significantly more prevalent in the recipient external iliac artery group (P = .008) but were independent of donor vessel and ureteral anastomosis (P = .587 and 1.00). Estimated glomerular filtration rate trend was independentofdonor(P=.921) andrecipient vessel(P=.878 and .536). We found that different arterial and ureteral anastomoses appear to have comparable outcomes in en bloc kidney transplant with the exception of recipient external iliac artery, which may be slightly inferior because of the relatively higher rate of lymphoceles requiring intervention.

Use of Kidneys from Anencephalic Donors to Offset Organ Shortage

Background: It is well recognized that patient survival and quality of life are superior with renal transplantation than with dialysis. Organ availability is far outweighed by the large number of wait-listed patients. Additional stratagems are sought to expand the donor pool, and kidneys from anencephalic infants can be considered a source of organs, until now unexplored. We plan to assess the feasibility of using the kidneys from anencephalic infants for transplantation. Material and Methods: Information about anencephaly, the characteristics of the infant kidneys, the ethical, social and medico-legal aspects raised by the use of these kidneys, their procurement and their transplantation are reviewed. Conclusions: En bloc kidney transplants from infants can provide long-term normal renal function after an accelerated catch up growth. They are not subjected to hyperfiltration since they have a full complement of nephrons. They can be transplanted using the techniques currently available.

En Bloc Kidney Transplantation: A Retrospective Study of an 18-year Experience in a Single Institution

BackgroundRenal transplantation is facing a shortage of grafts. En bloc kidney transplantation (EBKT) from pediatric donors could increase the number of available grafts. ObjectiveTo describe the surgical technique as well as the long-term functional and morphological results of EBKT. Design, setting, and participantsWe performed a retrospective study of all the EBKT procedures performed in Lyon between 2002 and 2020. Electronic medical records were checked with an analysis of demographics, and peri- and postoperative results. Outcome measurements and statistical analysisA descriptive analysis of donor and recipient characteristics, perioperative data, complications, and renal function was performed. Results and limitationsBetween 2002 and 2020, 21 EBKT procedures were performed. Donors had a mean weight of 8.6 kg and a mean age of 12 mo, with a mean cold ischemia time of 11 h and 30 min. Receivers had a mean age of 30 yr and a body mass index of 20. The mean follow-up time was 62 mo, with patient survival of 100% and graft survival of 95%. There were 13 reinterventions comprising one early unilateral transplantectomy for thrombosis. Renal function was excellent, and the morphological findings described an important growth in size in the first 2 yr before attaining the adult size. This study’s limitations include its retrospective nature and a small number of participants. ConclusionsThe present study reports excellent results with EBKT and supports the pursuit and spread of this technique. Patient summaryIn this report, we describe the technique and results of en bloc kidney transplantation. We found that results are excellent for renal function and patient survival. We conclude that en bloc kidney transplantation should be considered to increase the number of grafts.

232.3: Longitudinal Analysis of Donor-derived Cell-Free DNA (Dd-cfDNA) in En-bloc Kidney Transplantation

Introduction: The longitudinal dd-cfDNA patterns in en-bloc kidney transplant recipients have not been studied. It is unknown how the initial smaller mass of thetwo pediatric organs impacts dd-cfDNA early post-transplant or if the dd-cfDNA rises over time as the organs enlarge. We analyzed dd-cfDNA scores over thefirst 12 months in recipients of pediatric en-bloc kidneys enrolled in the Kidney allograft Outcomes AlloSure Registry (KOAR, NCT03326076). Methods: 16 recipients of pediatric en-bloc kidneys with donors aged ≤7 years old were identified and compared with 931 single, non en-bloc deceased donorrecipients. Patients with rejection were excluded. Results: Of the 16 en-bloc recipients, 56.2% were male with median donor age of 1.4 years and median cold ischemia time (CIT) of 20 hours. None of the en-bloc transplants had delayed graft function. Aside from KDPI, donor age, and recipient age, no other differences were observed between groups (Table 1). Higher median dd-cfDNA values were seen in the en-bloc cohort compared to not en-bloc at month 1 (M1, 1.4% vs 0.4%) and month 2 (0.58% vs 0.23%) aftertransplant (p<0.001) (Figure 1a). Median dd-cfDNA values were comparable for month 3 (0.21% vs 0.16%, p = 0.07) and all subsequent time points (Figure 1a, 1b). Among 8 patients with M1 dd-cfDNA results, there was no significant association between M1 dd-cfDNA and either CIT (r=0.33, p=0.419) or KDPI (r=0.23,p=0.589) (Figure 2). Conclusion: Our results demonstrate higher early post-transplant dd-cfDNA values among en-bloc kidney compared to single kidney recipients however, nodifference or upward trend is observed beyond month 2 and out to 12 months.

Pull-Through Ureteroneocystostomy for Very Small En Bloc Kidney Transplants from Donors Weighing ≤ 5 kg

Background: Urologic complications are the most dreaded complications of renal transplantation, particularly when pediatric en bloc kidneys (EBKs) are used. Current techniques of ureteroneocystostomy (UNC) are not applicable to the very small ureters of very small en bloc kidneys. We reviewed our experience with the pull-through ureteroneocystostomy in kidney transplantation from donors under or equal to 5 kg weight. Material and Methods: The technique was used in 32 EBKs. Complications and 4-year graft survival are discussed. Results: One single graft thrombosed and required nephrectomy. The remaining kidneys provided good renal function. Hematuria was transient in five patients and did not require fulguration. No leakage was experienced. Delayed graft function occurred in 16% of cases. No primary nonfunction was noted. During the follow-up period, hydronephrosis and/or pyelonephritis were not observed. The 4-year graft survival was 95% with serum creatinine levels averaging 0.9 mg/dl. Conclusions: The procedure proved to be safe and reproducible. It can be applied to the ureteral re-implantation of very small EBKs.

Case Report: Mini-endoscopic combined intrarenal surgery in an en-bloc kidney transplant

BackgroundOverall incidence of stones in kidney transplant recipients is 1%. En-bloc kidney transplant is a rare anatomical condition in which kidney stones treatment can be extremely difficult to treat. As far as we know, no cases of staghorn calculi in en-bloc kidney transplant have been published so far.Case presentationA 27-year-old woman presented to the Emergency Department because of asthenia, adynamia and weight loss associated with lower urinary tract symptoms and subfebrile temperature. Ten years before, she had undergone an en-bloc kidney transplant because of end-stage renal disease secondary to perinatal asphyxia syndrome. One kidney was implanted capo-volta in the right iliac fossa and the other one in the right flank. NCCT scan showed incomplete staghorn calculi in the iliac fossa transplanted kidney. Besides, severe dilation of the native and the right flank transplanted kidney, due to two ureteral stones of 6 and 7 mm impacted in the uretero-ureteral anastomosis, was found. After hospital admission and under ceftriaxone prophylaxis, an attempt to perform primary RIRS following our COVID protocol was carried out. Nevertheless, we ended up placing a JJ stent because once the guidewire passed through the ureteral stones, purulent material came out from the ureteral orifice. She stayed 9 days in-hospital for management of postobstructive polyuria and was discharged with oral antibiotics. Three weeks afterward, we removed the stent and performed flexible ureteroscopy and holmium laser lithotripsy of the ureteral stones. In the same procedure, we performed Mini-ECIRS (21 French) previous ultrasound-guided upper pole puncture. Postoperative NCCT scan showed neither residual fragments nor operative complications.ConclusionThis is the first clinical case reporting Mini-ECIRS in a patient with an en-bloc kidney transplant. This endourological approach seems to be a feasible, safe and effective approach to treat stones in this anatomically challenging condition.

Donor-Recipient BSA Matching Is Prognostically Significant in Solitary and En Bloc Kidney Transplantation From Pediatric Circulatory Death Donors.

Background.As the rate of early postoperative complications decline after transplant with pediatric donation after circulatory death (DCD) kidneys, attention has shifted to the long-term consequences of donor–recipient (D-R) size disparity given the pernicious systemic effects of inadequate functional nephron mass.Methods.We conducted a retrospective cohort study using Organ Procurement and Transplantation Network data for all adult (aged ≥18 y) recipients of pediatric (aged 0–17 y) DCD kidneys in the United States from January 1, 2004 to March 10, 2020.Results.DCD pediatric allografts transplanted between D-R pairs with a body surface area (BSA) ratio of 0.10–0.70 carried an increased risk of all-cause graft failure (relative risk [RR], 1.36; 95% confidence interval [CI], 1.10–1.69) and patient death (RR, 1.32; 95% CI, 1.01–1.73) when compared with pairings with a ratio of >0.91. Conversely, similar graft and patient survivals were demonstrated among the >0.70–0.91 and >0.91 cohorts. Furthermore, we found no difference in death-censored graft survival between all groups. Survival analysis revealed improved 10-y patient survival in recipients of en bloc allografts (P = 0.02) compared with recipients of single kidneys with D-R BSA ratios of 0.10–0.70. A similar survival advantage was demonstrated in recipients of solitary allografts with D-R BSA ratios >0.70 compared with the 0.10–0.70 cohort (P = 0.02).Conclusions.Inferior patient survival is likely associated with systemic sequelae of insufficient renal functional capacity in size-disparate DCD kidney recipients, which can be overcome by appropriate BSA matching or en bloc transplantation. We therefore suggest that in DCD kidney transplantation, D-R BSA ratios of 0.10–0.70 serve as criteria for en bloc allocation or alternative recipient selection to optimize the D-R BSA ratio to >0.70.

Successful single kidney transplantation from pediatric donors less than or equal to 10 kg to adult recipient: a retrospective cohort study.

BackgroundKidneys from very small pediatric donors (≤10 kg) are underutilized. Compared to en bloc kidney transplantation (EBKT), single kidney transplantation (SKT) can maximize donor resources. However, it remains unknown whether it’s appropriate to perform SKTs from donors weighing ≤10 kg.MethodsA total of 35 adult recipients undergoing kidney transplantation from donors weighing ≤10 kg at our center from December 2014 to December 2019 were included and grouped into SKT group (n=20) and EBKT group (n=15). Transplant outcomes were retrospectively analyzed and compared between 2 groups.ResultsThe 1-year and 3-year death-censored graft survival in SKT group was 95%, it is not significantly higher than that in EBKT group (80%, log-rank test, P=0.38). Significant improvement in estimated glomerular filtration rate (eGFR) was noted in both groups, despite eGFR at 1 year was lower in the SKT group (P<0.01). Proteinuria was common in both groups but subsided gradually during the follow-up time. Complication rates were similar between 2 groups with no vascular thrombosis in the SKT group.ConclusionsIn conclusion, SKTs from donors weighing ≤10 kg to adult recipients achieves comparable outcomes with EBKTs, which provides evidence to support performing SKTs from donors weighing ≤10 kg in certain donor and recipient scenarios.

En-Bloc Kidney Transplant Using an Aortic Extension from a Paediatric Multi-Visceral Donor to a Paediatric Recipient

Aim: To analyze the results of surgical treatment of cicatricial post-traumatic deformities of the breasts. Methods: There has been presented treatment experience of 149 patients with cosmetic and post-traumatic changes of the breasts in the clinical base of the Department of Surgery, Endoscopy and Reconstructive Surgery of DNMU. The number of the patients treated for post-traumatic cicatricial deformity was 34 patients (22.8%) aged 7 to 62 years. There were 27 injured of them (79.4%) with the consequences of burns, 2 (5.9%) after the complications of cosmetic surgeries, 5 patients (14.7%) were operated on for the consequences of cancer treatment and three of them (8,8%) were hospitalized for radiation ulcers. The patients underwent 54 surgical interventions: Free autodermoplasty 13 (24.1%); local flaps grafting 14 (25.9%); combined plastic surgery and endoprosthetics 13 (24.1%); expander dermatotension 5 (9.3%); plastic surgery with complex composite flaps 9 (16.7%). Results: The article gives a historical overview of breast reconstructive operations and the classification of their post-traumatic injuries. Depending on the anatomy of cicatricial damage to the chest wall and the breast an algorithm for reconstructive mammoplasty is generalized. When performing surgical interventions in patients with the consequences of any type of the injury the main task was to eliminate scar-modified skin, correct the elevation of the breast, functional disorders such as contractures and make normal development of breast tissue possible. In any case, the operation is aimed at releasing the breasts from scars and creating the conditions for their normal development in adolescents, as well as restoring the shape, size and the appearance of already formed breasts in case of the patients’ late appointment with a doctor. When eliminating breast deformities in women of mature age it is often rational to separate the nipple-areolar complex from cicatricial tissue and transpose it to its usual location. Conclusion: Good cosmetic results, stable restoration of the shape, position and the skin of the breasts deformed by scars were obtained during all surveys. Reconstructive operations contribute to a significant regression of psychological and social disorders in patients with cicatricial deformities after a burn injury, and therefore they improve their overall rehabilitation result. If it’s possible surgical treatment of cicatricial deformities of the anterior surface of the chest wall should be started before breast development in adolescent girls and they should be followed-up.

Donor Age and Ischemia Time Are Independent Factors Affecting Graft Survival after En Bloc Kidney Transplantation from Donors Less than Three Years of Age

This study aimed to investigate the outcomes of transplantation from donors aged less than three years in a single-center consecutive series. A total of 52 en bloc kidney graft transplantations were performed. In 22 cases, organs were procured from donors aged less than one year (group 1). In 30 cases, the age of donors varied from one to three years (group 2). After transplantation, renal function and graft and patient survival were evaluated retrospectively. No significant difference was observed between the groups regarding recipient age, time on dialysis, ischemia time, human leukocyte antigen matching, the time needed to reach serum creatinine levels of ≤2 mg/mL, and patient survival. Eight grafts were lost during the first six months after grafting in group 1, whereas only two grafts were lost in group 2. Immature glomeruli were observed in three preimplantation biopsy samples. Graft survival was significantly longer in group 2 (hazard ratio, 0.5 [95% CI, 0.28–0.91]; p = 0.025). In a multivariate analysis, donor age (p = 0.01) and ischemia time (p = 0.02) were independent factors affecting graft survival. En bloc kidney transplantation from donors aged less than one year was associated with high early graft loss and poor long-term survival rates. Further investigations are needed to confirm the possible relationship to the histological glomerular maturity.

A Multicenter Clinical Study of Single-Kidney Transplantation vs En Bloc Transplantation with Kidneys from Deceased Pediatric Donors

BackgroundThere are still disputes regarding the choice of surgical approach to harvest organs from pediatric donors for organ recipients. The primary goal of this multicenter, retrospective analysis was to compare outcomes between single-kidney transplantation (SKT) and en bloc kidney transplantation (EBKT). MethodsData from donors and recipients aged 4 to 18 months from 3 transplant centers over 5 year were collected to compare postoperative complications and recoveries of renal function between SKT and EBKT and to determine whether there is a difference in the 1-year patient and kidney survival rate between the 2 groups. ResultsBetween the SKT and EBKT groups, the incidence of delayed graft function was significantly higher in the SKT group than in the EBKT group (44.1% vs 17.3%, P = .03), and there were no significant differences in other complications (47.0% vs 59.0%, P = .36). Moreover, no significant differences were observed for the overall patient survival rate (P = .08) or the overall graft survival rate (P = .71). ConclusionsThe short-term effects of SKT make it worthy of consideration. For infants aged 4 to 18 months, SKT can provide good results, alleviating the current tense situation in kidney donation.

En bloc kidney transplant from pediatric donor to an adult

The use of pediatric kidney donors is not a common practice. Transplant physicians and surgeons are concerned with technical issues as well as inadequate nephrons mass. We reported a case of en bloc kidney transplant from a pediatric donor to serve as a teaching case. The donor is a 3-year-old infant who died as a result of influenza. Due to the age and size discrepancy with an adult, it was decided to transplant the kidneys en bloc into an adult with successful outcome. En bloc technique renders the kidneys transplantable which would have been otherwise discarded and theoretically protect against hyperfiltration injury. Small pediatric donors are excellent resources and should be considered for donation whenever option is available.

En-bloc kidney transplant from an 11-month-old pediatric donor to an adult recipient: Case report and review of literature

The huge disparity between the number of end-stage renal disease patients awaiting renal transplant and the available donor organs can be overcome by increasing the utilization of donor organs from deceased donors. The use of kidneys from a deceased pediatric donor is technically challenging because of the smaller size of the donor organ, leading to a higher incidence of graft thrombosis apart from concerns of low nephron load resulting in early graft failure. We present a case of en-bloc kidney transplant from an 11-month-old to a 38-year-old female recipient. The cold ischemia was 250 min and operative time was 300 min. The 1st day urine output was 6.7 l with serum creatinine dropped to 0.9% mg on postoperative day 3.

Unusual Bilateral Renal Parenchymal Urine Leak After Pediatric En Bloc Kidney Transplantation: First Case Study Report.

Kidney transplantation is usually the best course of treatment for patients with end-stage renal disease. En bloc kidney transplantation (EBKT) is a surgical treatment option that increases available donor organs with excellent graft survival for patients with end-stage renal disease. Herein, we report a case of an unusual bilateral renal parenchymal urine leak after EBKT leading to removal of both moieties of the EBKT. This unfortunate complication after EBKT, to our knowledge, is the only reported of its kind. We explore the possible causes of the bilateral parenchymal urine leaks and suggest preventive strategies to avoid urological complications after EBKT.

Long-term outcomes of en-bloc renal transplantation from paediatric donors into adult recipients

IntroductionTransplant units are exploring strategies to increase the availability of donor kidneys. The use of en-bloc kidney transplantation (EBKT) from paediatric donors represents one potential solution. We present our long-term experience with paediatric EBKT among adult recipients. MethodsTwenty-three paediatric to adult EBKTs were performed by the Irish National Kidney Transplant Service between 1990 and 2016. The primary outcome variable was long-term en-bloc allograft survival rate. Secondary outcome variables were incidence of allograft thrombosis, incidence of delayed graft function, overall patient survival and serum creatinine at most recent follow-up. Outcomes were compared to single kidney transplant recipients from the same time period. ResultsMean donor age was 1.8 ± 0.97 years (range: 7 months to 3 years). Recipient age was 46 ± 12 years. Mean follow-up was 133 ± 64 months (range: 36–264). Overall graft survival was 100%, 91% and 80% after 1, 5 and 10 years respectively, compared to 92%, 79% and 61% in single kidney transplant recipients (p = 0.04). There were 5 cases of allograft failure, 3 due to death from unrelated causes. Median time to graft failure was 108 months (range: 36–172). Mean serum creatinine was 72.6 ± 21.6 μmol/l after the follow-up period. There were no cases of graft thrombosis or delayed graft function. Overall survival was 96.4%, 88.0%, 76.23% and 50.5% at 1, 5, 10 and 20 years respectively. ConclusionEn-bloc paediatric kidney transplantation is associated with excellent long-term allograft and patient survival and is a feasible strategy for increasing the transplant donor pool in carefully selected recipients.

Graft survival of en bloc versus single kidney transplantation from small pediatric donors: a meta-analysis with trial sequential analysis

Background: Although renal transplantation from small pediatric donors can relieve the pressure of the shortage of organs, the graft survival differs among different studies. We conducted this meta-analysis to evaluate the prognosis of patients receiving en bloc versus single allograft from small pediatric donors. Methods: A systematic search in PubMed, Embase, and web of science was performed to identify relevant studies. Individual hazard ratios (HRs) and corresponding 95% confidence intervals (CIs) were combined to calculate the prognostic value. A cumulative meta-analysis based on publication year was also conducted. Trial sequential analysis (TSA) was performed to estimate the quantity of the evidence. Results: Seven studies consisting of 4,284 cases were included, and risk estimates from six of these studies were finally pooled for quantitative analysis. We found that compared with single kidney transplantation from small pediatric donors, en bloc kidney transplant suggested a better graft outcome of recipients (HR=0.57, 95% CI: 0.49–0.67). The findings in the current study were based on sufficient evidence by TSA. Furthermore, no evidence of publication bias in the meta-analysis was noted. Conclusions: En bloc kidney transplantation from small pediatric donors was significantly associated with a superior graft survival when compared with single kidney transplant.

Pediatric Deceased En Bloc Kidney Transplantation: A Case Report

[b]BACKGROUND[/b] After the lifting of legal and religious bans, deceased donor transplantations in Iran have increased. However, the prevalence and incidence of end-stage renal disease have also has increased in Iran in recent years, so there is a need for a donated organ mandate seeking new techniques and protocols like pediatric en bloc kidney transplantation. We report a case of en bloc kidney transplant from a pediatric deceased donor to an adult and long-term follow-up of similar case that we reported before. [b]CASE REPORT[/b] The deceased pediatric donor was a 30-month-old, 15-kg boy who died because of head trauma after falling. The recipient was a 21-year-old, 45-kg woman with end-stage renal failure secondary to glomerulonephritis, who was on hemodialysis. [b]CONCLUSIONS[/b] In our limited experiences, pediatric en bloc kidney transplant is feasible and has acceptable short- and long-term outcomes.