Related Renal Donors Research Articles

Role of Arterial Phase Imaging In Assessing Venous Anatomy and Venous Anomalies in Multi-Detector Row CT Angiography of Living Related Renal Donors

Objective: To determine the role of arterial phase imaging in assessing venous anatomy and venous anomalies in multi-detector row CT angiography of living related renal donors Methodology: This retrospective study was conducted in the Radiology Department of Pakistan Kidney and Liver Institute and Research Center, Lahore (PKLI & RC). After institutional review board approval, we evaluated MDCT images of 56 consecutive renal donors. Two consultant radiologists independently assessed the renal venous anatomy on the arterial and venous phase images. The sensitivity of detection of accessory renal veins, gonadal veins and lumbar veins was determined. Interobserver agreement was assessed using Cohen’s kappa. Results: Both radiologists characterized renal venous anatomy variants correctly on arterial and venous phases. Circumaortic left renal vein (n=4) and retro aortic left renal vein (n=4). The sensitivity of detection of the accessory renal veins, right gonadal and left lumbar veins on arterial phase images was 97% each whereas that for left gonadal vein was 100%. Cohen’s kappa showed a substantial inter-observer agreement (kappa coefficient: 0.9; p<0.005). Conclusion: The renal venous anatomy, including the detection of anatomic variations, can be assessed on arterial phase MDCT images alone in renal donors, excluding the venous phase from the protocol in renal donor evaluation.

Abstract 2644: Relative T regulatory cell populations are indicative of HCC in patients with underlying liver disease

Abstract Hepatocellular carcinoma continues to be an increasing burden to patients and the health care system despite recent advances in treatment of viral hepatitis. Since the vast majority of cancers develop in patients with underlying liver disease, we would expect that efforts to cull out the patients at highest risk for cancer emergence would be possible, yet we have struggled to do so. The difficulty lies in the complex microenvironment of the diseased liver that leads to striking aberrancies, many of which are related to inflammation and can overlap with biomarkers felt to be related to cancer. Our goal with lymphocyte profiling is to stratify patients with underlying liver disease into those with and without cancer. Improved surveillance modalities for patients at highest risk of developing HCC are required. Moreover, there is an increasing push to include immunology in cancer detection and treatment. To address these issues, we performed lymphocyte profiling in patients with underlying liver disease with and without HCC and living related renal donors (LRD) by selective cell marker staining and flow cytometry, in order to determine if lymphocytes, which are key to cancer immunology, are modulated concordant with HCC. Specifically, whole blood was stained in order to quantitate T helper (Th), T cytotoxic (Tctx), B cells, natural killer (NK), and T regulatory cells (Treg) by flow cytometry. Th, Tctx and B cells were significantly reduced and NK cells were significantly increased in patients with underlying liver disease. These changes were independent of HCC diagnosis. In contrast, Treg cell levels were dependent on HCC diagnosis. In patients with underlying liver disease without HCC, Treg levels, when compared to LRD (30±6cells/mm3), were significantly reduced (15±3), whereas in patients with underlying liver disease and HCC, Treg levels were increased when compared to patients without HCC and unchanged when compared to LRD (28±6). To correct for the observed lower T-cell levels associated with underlying liver disease, lymphocyte populations were expressed as a ratio when compared to total T-cell numbers. This conversion identified proportional Treg cells population as a marker of HCC. In patients without HCC the Treg/T cell ratio was unchanged when compared to living related donors (0.02±0.002, 0.02±0.002, P=0.3). In contrast, Treg/Tcell ratio was significantly increased in patients with HCC (0.08±0.02, P=0.001). Consequently, given that the primary function of Treg cells is to inhibit T cytotoxic cells, a proportional increase in Treg cells would be associated with immunologic escape for HCC cells. Therefore, surveillance of lymphocyte populations, in particular T cells and Treg, would evaluate changes in immunologic capacity and increased Treg/Tcell ratio would be indicative of an increased risk for HCC in patients with underlying liver disease. Citation Format: Nicholas J. Skill, Mary A. Maluccio. Relative T regulatory cell populations are indicative of HCC in patients with underlying liver disease [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 2644.

Endourological management of live donors with urolithiasis at the time of donor nephrectomy: a single center experience.

Live related renal donors with urolithiasis are made suitable for renal transplantation in two-stage procedure in most of the centers: first making the donor kidney stone free surgically or by ESWL and then proceeding to renal transplantation. To reduce the cost and morbidity of two surgical procedures in donors, we did a pilot study of removing subcentimeter renal calculi in live donors, after explanting the kidney, during bench surgery. We included all prospective renal donors with subcentimeter (4-10 mm) calculi in one kidney in our study (n = 14). All these patients underwent standard donor evaluation and metabolic work up. After the donor nephrectomy, bench retrograde intra-renal surgery (RIRS) with or without pyelotomy was done for stone clearance followed by renal transplantation. Stone clearance was achieved in 13 out of 14 donors. Donors and recipients were followed for 6-24 months. No stone recurrence or graft dysfunction was seen in the follow-up period. We concluded that bench RIRS is an excellent modality in the management of small renal calculi in prospective renal donors who are not having metabolically active disease. This reduced the cost and morbidity to the donor and minimized waiting time for transplant.

Retroperitoneal Laparoscopic Live Donor Nephrectomy: A Cost-effective Approach

To establish a modified cost-effective and safe approach of retroperitoneal laparoscopic live donor nephrectomy (RPLLDN). Between December 2003 and December 2008, total of 109 living related renal donors underwent consecutive three-port RPLLDNs. The initial retroperitoneal space was created by insertion of a rubber catheter attached to a saline-filled midfinger of a glove. The renal hilum and ureter were circumferentially mobilized. The tributaries of renal vessels were divided by harmonic scalpel without any clips. In laparoscopy, the ureter was sheared with scissors. A longitudinal 6-8 cm skin incision was enlarged form the primary trocar distally to retrieve the graft. The main renal vessels were controlled, using 2 Hem-o-lok clips placed at each proximal ends. The graft was retrieved manually through the skin incision. All the 109 RPLLDNs were carried out successfully. The mean operation time and mean warm ischemic time was 129.7 +/- 42.6 and 3.6 +/- 1.2 minutes, respectively. The mean blood loss was 73.6 +/- 53.7 mL. No blood transfusion or open conversion was required. No major complication occurred in the donors, and only 5% of the donors suffered from minor complications. A total of 3% and 4% of the recipients developed major and minor complications, respectively, and 12.8% of the donors required analgesics. The mean level of postoperative serum creatinine of the donors was 1.31 +/- 0.22 mg/dL and the mean level of postoperative serum creatinine of the recipients at the first month was 1.59 +/- 0.91 mg/dL. The modified approach of RPLLDN could be a cost-effective and safe alternative for developing countries.

Multidetector row CT angiography of living related renal donors: Is there a need for venous phase imaging?

Objective To prospectively evaluate whether renal venous anatomy can be detected from arterial phase images of multidetector row CT (MDCT) of renal donors. Material and methods Institutional review board approved our study protocol with waiver of consent. Forty-eight consecutive renal donors (age range, 21–56 years; M:F, 20:28) referred for MDCT evaluation were included. Two sub-specialty radiologists performed an independent and separate evaluation of renal venous anatomy in arterial and venous phase images. Opacification of renal venous structures was scored on a five-point scale (1-not seen; 3-minimal opacification; 5-excellent opacification). Arterial and venous phase opacification scores were compared by Wilcoxon signed rank test. Results Both readers detected all renal venous anomalies in arterial as well as venous phase images. Each reader detected accessory right renal veins ( n = 14), retroaortic left renal vein ( n = 2), circumaortic left renal vein ( n = 1), and left renal hilar arteriovenous malformation ( n = 1) in arterial phase images. Retroaortic left renal venous branch was difficult to differentiate from lumbar vein (reader-1, n = 1; reader-2, n = 2) in both arterial and venous phase images. Sensitivity of detection of renal veins, left adrenal, gonadal and lumbar veins in arterial phase images was 100, 83–88, 100, and 85–90%, respectively. As expected, venous phase images showed significantly greater opacification of renal veins, left gonadal, adrenal and lumbar veins ( p < .05). However, this did not substantially limit the evaluation of renal venous anatomy in arterial phase images. Both readers had substantial interobserver agreement (kappa coefficient, 0.7; p < 0.05). Conclusions Arterial phase MDCT images alone can be used to detect renal venous anomalies, and to identify small left renal venous branches namely, the left gonadal, adrenal and lumbar veins in renal donors. Venous phase MDCT acquisition is not necessary for evaluation of renal venous anatomy in renal donors.

MDCT of renal and mesenteric vessels.

Computed tomography angiography (CTA) with multiple detector-row CT (MDCT) has evolved into an established technique for non-invasive imaging of renal and mesenteric vessels. With adequate selection of acquisition parameters (thin collimation) high spatial-resolution volumetric data sets for subsequent 2D and 3D reformation can be acquired. Contrast medium (CM) injection parameters need to be adjusted to the acquisition speed of the scanners. Whereas fast acquisitions allow a reduction of total CM volume in the setting of CTA, this is not the case when CTA is combined with a second-phase abdominal MDCT acquisition for parenchymal (e.g., hepatic) imaging. Renal CTA is an accurate and reliable test for visualizing vascular anatomy and renal artery stenosis, and therefore a viable alternative to MRA in the assessment of patients with renovascular hypertension and in potential living related renal donors. CTA, combined with abdominal/parenchymal MDCT is a first-line diagnostic test in patients with suspected abdominal vascular emergencies, such as acute mesenteric ischemia, and an excellent tool to assess a wide variety of vascular abnormalities of the abdominal viscera.

Screening a living kidney donor for polycystic kidney disease using heavily T2-weighted MRI

Autosomal dominant polycystic kidney disease (ADPKD) accounts for approximately 8% of those awaiting renal transplantation. Living related kidney donors for these patients require screening for ADPKD, most commonly by ultrasonography. Ultrasound has a negative predictive value (NPV) of 100% in patients aged older than 30 years, but only 96% for donors aged 20 to 30 years. This case shows that heavily T2-weighted magnetic resonance imaging (HT2MRI) may be a more sensitive screening method for ADPKD in younger kidney donors. Despite a normal screening ultrasound result, a kidney donor with a family history of ADPKD was found to have renal cysts intraoperatively, and the transplantation was canceled. Afterward, the donor was imaged with HT2MRI. In addition, the mathematical relationship between sensitivity, specificity, and NPV for ADPKD screening tests was derived. After the canceled transplantation, a second ultrasound still could not identify renal cysts. However, HT2MRI showed multiple small (~3-mm) cysts in both kidneys and a 2.5-cm cyst on the right kidney. Mathematical analysis showed that the NPV of a screening test for ADPKD was most closely related to sensitivity and that only tests with 100% sensitivity would have a 100% NPV. We conclude that ultrasound is not a sufficiently sensitive screening test for ADPKD in younger living related renal donors. HT2MRI has improved sensitivity and may be the best screening test for ADPKD in this population.

Screening a living kidney donor for polycystic kidney disease using heavily T2-weighted MRI

Autosomal dominant polycystic kidney disease (ADPKD) accounts for approximately 8% of those awaiting renal transplantation. Living related kidney donors for these patients require screening for ADPKD, most commonly by ultrasonography. Ultrasound has a negative predictive value (NPV) of 100% in patients aged older than 30 years, but only 96% for donors aged 20 to 30 years. This case shows that heavily T2-weighted magnetic resonance imaging (HT2MRI) may be a more sensitive screening method for ADPKD in younger kidney donors. Despite a normal screening ultrasound result, a kidney donor with a family history of ADPKD was found to have renal cysts intraoperatively, and the transplantation was canceled. Afterward, the donor was imaged with HT2MRI. In addition, the mathematical relationship between sensitivity, specificity, and NPV for ADPKD screening tests was derived. After the canceled transplantation, a second ultrasound still could not identify renal cysts. However, HT2MRI showed multiple small (~3-mm) cysts in both kidneys and a 2.5-cm cyst on the right kidney. Mathematical analysis showed that the NPV of a screening test for ADPKD was most closely related to sensitivity and that only tests with 100% sensitivity would have a 100% NPV. We conclude that ultrasound is not a sufficiently sensitive screening test for ADPKD in younger living related renal donors. HT2MRI has improved sensitivity and may be the best screening test for ADPKD in this population.

BREATHHOLD GADOLINIUM ENHANCED MR-ANGIOGRAPHY INLIVING (UN)RELATED RENAL DONORS: A NEW TECHNIQUE WITH ARTERIAL PITFALLS

566 Purpose: Gadolinium enhanced MR-angiography has become an important imaging procedure for the assessment of the suitability of renal organs for donation. The purpose of this study is to compare the diagnostic accuracy of gadolinium enhanced MRA with DSA in living (un)related renal donors. Material and Methods: 13 potential renal donors underwent MRA and intra-arterial DSA within a 3 days interval. Gadolinium enhanced MRA was performed on a 1.5T scanner with a phased array bodycoil. A 17 sec. 3D Flash fatsuppressing pulse sequence (TR/TE 3.8/1.3, 30°, FOV of 350mm, 256 matrix, slab thickness of 96mm) with a slice interpolation technique was repeated 4 times. DSA consisted of an aortogram and, if the aortogram was inconclusive, selective renal artery injections. Qualitative and quantitative comparison of the arterial and venous supply, the parenchymal phase and excretory system was made. Results:arterial: In the series of 26 kidneys 5 identical accessory arteries were depicted on both MRA and DSA. However, both techniques failed in one case of an accessory artery. Four early branching renal arteries (< 1.5 cm from the origin) were seen on MRA and DSA, one early branching artery on DSA was considered a double renal artery on MRA. One severe stenosis (>50%) on MRA was not confirmed on DSA, a mild stenosis (<50%) on MRA happened to be a severe long segment of unilateral fibromuscular dysplasia. No assessment of renal arteries distally from the renal hilum was possible on MRA, DSA showed these arteries in all selective renal studies (18). Venous: MRA identified more renal veins than DSA (30 versus 21). Parenchyma: Both MRA and DSA showed complete parenchymal perfusion in all cases. Excretory system: 6 out of 30 pyelocalyceal systems were inadequately depicted to analyze on MR, on DSA all were considered normal. In one donor the ureteral system was unclear on DSA, in three donors on MRA. A small bladder tumor was only seen on MR. Conclusion: Although MRA is superior in visualizing the venous system and of equal value in analyzing the number of renal arteries, there are problems with the accurate depiction of the arterial integrity and the pyelocalyceal system. This may lead to an unwanted acceptance or rejection of a potential renal donor. Until the spatial resolution in MRA is improved, all possible arterial "abnormalities" on MRA should be proved or disproved by a DSA.

Role of CT angiography in the preoperative evaluation for laparoscopic nephrectomy.

Laparoscopic nephrectomy (LN) was recently introduced as a minimally invasive alternative to open nephrectomy in living related renal donation. Because of the limited field of view available with laparoscopic techniques, the role of preoperative radiologic evaluation in LN has expanded to include anatomic definition of the renal arteries, collecting system, renal parenchyma, and renal venous anatomy. Computed tomographic (CT) angiography has proved to be a minimally invasive alternative to conventional angiography in the preoperative evaluation of living related renal donors. CT angiography has been shown to have an accuracy comparable to that of conventional angiography in predicting renal arterial anatomy. In addition, CT angiography provides comprehensive definition of the renal vascular anatomy including the location, size, and length of the renal, adrenal, gonadal, and lumbar veins. Dual-phase spiral CT combined with three-dimensional CT angiography constitute a single, minimally invasive procedure that can provide a complete preoperative evaluation of potential living related renal donors prior to LN. Comprehensive anatomic depiction of the renal arterial and venous supplies aids in surgical planning and helps avoid potential complications.

Selection Criteria for the Evaluation of Living Related Renal Donors

The documented long-term health of the living related renal donor is a tribute to careful preoperative selection and surgical technique. At our medical center 187 prospective donors were evaluated during a 6-year period and 91 underwent donor nephrectomy. Hypertension, renal artery anomalies and donor indecision were the most common reasons for donor rejection. Recipient health and/or death, or a positive crossmatch after pre-transplant donor specific transfusion were other post-arteriogram reasons not to proceed with transplantation. Women were more likely to undergo nephrectomy than men, and older or heavier donors were more likely to be rejected.Using the transcostal, extrapleural surgical approach for nephrectomy there were no deaths or major complications, and the mean postoperative length of stay was 6.4 days. The average postoperative increase in serum creatinine was 0.33mg./dl. with an average creatinine at discharge of the patient from the hospital of 1.2mg./dl. The latter creatinine values varied concordantly with donor age.Only 56% of fully evaluated donors (91 of 159) actually underwent donor nephrectomy. The minimal morbidity sustained by these patients re-emphasizes the importance of careful donor selection. (J. Urol., 144: 845–848, 1990)

Renal angiography in potential living related renal donors in Iraq

Between July 1983 and March 1986, 160 potential living related renal donors underwent renal angiography. One hundred and twenty-eight have (Group 1) and 32 have not (Group 2) become renal donors. The addition of selective renal angiography did not alter the pre-operative arterial prediction made on flush aortography in 102 of 109 renal donors who had both investigations. At surgery, nine of the 13 unexpected arterial findings were in patients who had both forms of angiography. Complications of angiography in 16 patients (11%) included failed groin puncture (two), groin haematoma (eight), haematocoele (one) and loin pain (five). Three patients had renal artery damage detected at surgery, one of which resulted in graft loss. The arterial anatomy demonstrated was similar in 22 of the 23 patients in Group 2 who had flush and selective angiography. One patient (3%) developed a small groin haematoma. Forty-six patients (29%) had multiple renal arteries demonstrated angiographically. This paper highlights the incidence of renal artery damage following selective renal angiography and suggests that flush aortography provides adequate pre-operative information.

Digital subtraction angiography for renal donor evaluation

A consecutive series of 52 living related renal donors were evaluated preoperatively by angiography. The preoperative angiographic interpretation was compared with the anatomy found at donor nephrectomy. Standard selective renal arteriography was found to be 100 per cent accurate in defining single (25) or multiple (1) renal arteries. Digital subtraction angiography (DSA) alone performed with an intra-arterial injection of contrast material was found to be 82 per cent accurate in determining the number of renal arteries. In five kidneys with multiple renal arteries, only two had the correct number of vessels identified. The errors are inherent in the DSA technology. DSA at the present time is not accurate enough to replace the standard arteriogram in the evaluation of the donor nephrectomy patient.

Optimal technique of renal arteriography in living renal transplant donors.

Sixty consecutive living related renal donors were evaluated retrospectively with regard to the adequacy of their preoperative angiograms. Comparison of the original radiologic reports and the surgical findings revealed no errors in the prediction of the number and length of renal arteries of the transplanted kidneys. The optimal arteriographic technique is defined in the context of the information required by the surgeon: it is concluded that selective renal arteriography, although often advocated, is seldom necessary if the standard anteroposterior view of the abdominal aortic injection is supplemented by oblique and occasionally other views in selected cases.

Incidence of Anatomical Variants in Renal Vasculature in the Presence of Normal Renal Function

This report defines the incidence of variations in the renal vascular pedicle in a group of patients with normal renal function as determined by standard laboratory criteria. The study group consisted of 166 patients undergoing renal arteriography as potential renal allograft donors. Ninety-seven patients were male and 69 were female. Ages ranged from 18-54 years, median age being 37 years. All patients underwent preliminary screening tests including blood chemistries, creatinine clearance, urinalysis, culture and excretory urography. If these studies were normal, renal arteriography was performed utilizing flush aortogram and, in 20% of cases, selective renal arteriography. The most common anomaly was the presence of multiple renal arteries supplying the same kidney, occurring in 32% of cases. Prehilar segmental branching was the second most common variation, occurring in 17% of patients. Other variations included fetal lobulation (4%), significant stenosis at origin of the renal artery (2%), fibromuscular dysplasia (2%), microaneurysms (0.5%), true aneurysms (1%) and dromedary hump (0.5%). Less than one-half of the patients demonstrated the simplest vascular pedicle, namely, single artery and vein bilaterally. The incidence of anatomical variations in the renal vascular pedicle is greater than attributed to normal subjects in previous reports. Anomalies determine the choice of kidney in renal allografting and may disqualify a potential donor, even in the face of ostensibly normal renal function. Routine arteriography should be considered a standard prerequisite in the evaluation of potential living related renal donors.

Live donor nephrectomy

Donor nephrectomy was performed on 39 living related renal donors. The preoperative evaluation, surgical technique, and postoperative follow-up are presented. Major or minor complications developed in 23 per cent of the patients and included acute myocardial infarction, brachial plexus injury, acute glomerulonephritis, ileus, pneumonia, and urinary tract infection. All complications had resolved by six months postoperatively.