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Saudi Journal of Kidney Diseases and Transplantation
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Table of Contents   
LETTER TO THE EDITOR  
Year : 2011  |  Volume : 22  |  Issue : 1  |  Page : 139-141
DMSA SPECT scan of dual transplanted pediatric kidneys in an adult recipient


1 Department of Transplant Surgery, Royal Free Hospital, Pond Street, London, United Kingdom
2 Department of Nephrology SHO, Royal Free Hospital, Pond Street, London, United Kingdom
3 Department of Urology, Royal Free Hospital, Pond Street, London, United Kingdom
4 Department of Nuclear Medicine, Royal Free Hospital, Pond Street, London, United Kingdom

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Date of Web Publication30-Dec-2010
 

How to cite this article:
Al Midani A, Parvathareddy S, Al-Akraa M, Buscombe J, Burns A. DMSA SPECT scan of dual transplanted pediatric kidneys in an adult recipient. Saudi J Kidney Dis Transpl 2011;22:139-41

How to cite this URL:
Al Midani A, Parvathareddy S, Al-Akraa M, Buscombe J, Burns A. DMSA SPECT scan of dual transplanted pediatric kidneys in an adult recipient. Saudi J Kidney Dis Transpl [serial online] 2011 [cited 2019 Jul 22];22:139-41. Available from: http://www.sjkdt.org/text.asp?2011/22/1/139/74389
To the Editor,

A 40-year-old patient, who developed chronic kidney disease (CKD) in childhood, secondary to posterior urethral valves, which necessitated renal replacement therapy from the age of 20, was called for his second renal transplant. Twenty years earlier, he had suffered a graft loss from post-transplant lymphoproliferative disorder (PTLD), one year after his first live related transplant.

The deceased donor was a 3-year-old child weighing less than 16 kg. The kidneys were har­vested en bloc, each measuring 7 cm in length. The HLA mismatch was 0-1-1 and the immu­nosuppressive regimen included induction with basiliximab and maintenance on tacrolimus, my­cophenolate mofetil and prednisolone. The reci­pient weighed 53 kg at the time of transplan­tation, with a height of 1.65 cm and body mass index (BMI) of 19.4.

The kidneys were transplanted en bloc into the right iliac fossa. The aorta and vena cava supe­rior to the renal vessels were (closed) sutured and other branches of the great vessels were carefully ligated. The vena cava was then anas­tomosed to external iliac vein and the aorta was anastomosed to the external iliac artery. The kidneys were carefully positioned to avoid any kinking of blood vessels and to avoid tension on either ureter. They were then implanted into the bladder separately (Lich Gregoire technique) and two double J stents were inserted. Anticoa­gulation therapy was used (200 units heparin per hour plus 75 mg of aspirin) in the postope­rative period to prevent thrombosis in the grafts as the risk is increased in pediatric kidneys.

The double J stents were subsequently re­moved at six weeks according to our unit pro­tocol. There was good immediate function and now, several months later, the grafts have main­tained excellent function with a recent crea­tinine of 56 μmol/L and a urine output of 2-3 L/day.

En bloc transplantation of pediatric kidneys into adults was first reported back in 1972 by Meakins et al. [1] Transplanting pediatric kidneys into adults remains controversial with vessel size, body mass and BP mismatch being blamed for poor short- and long-term outcomes in some early studies. [2],[3] In the UK, pediatric donors are first offered to suitable pediatric patients on the donor waiting list and if there are no acceptable recipients, the offer is then made to potential adult recipients. It is, however, widely held that pediatric kidneys should, if possible, be re­served for adult recipients with a relatively low BMI, i.e. 21.8 ± 2.9. [4]

Currently, kidneys from donors under the age of 5 years are retrieved only for use en bloc for adults. Not all centers accept these kidneys and they believe this is an unnecessary waste of a precious resource.

Double renal transplants (en bloc) on an aor­tic patch are technically easier and have resul­ted in better short- and long-term outcomes according to recent authors. [5],[6],[7]

These beautiful images and our patient's excellent renal function attest to the feasibility and significance of using such pairs of kidneys for adult transplantation.


   Science of the DMSA SPECT scan Top


The two kidneys could not be accurately assessed by a conventional Tc-99m MAG3 scan [Figure 1], as this was a planar image with one kidney overlapping the other. Therefore, a Tc­99m DMSA SPECT scan was performed 3 hours post administration of 150 MBq of Tc-99m DMSA. The acquisition was performed in 8 mi­nutes on a triple-headed gamma camera (Phillips Irix, Cleveland, OH, USA) into a 128 × 128 matrix.
Figure 1: 10– 15 minute frame of Tc-99m MAG3 renogram showing the two conjoint kidneys in a
planar view.


Click here to view


The images were reconstructed using six in­teractions and smoothed by a count-optimized Butterworth filter. The images were then dis­played on a series of slices to allow internal structures to be seen [Figure 2] and a surface rendered image to allow the relationship of the two transplanted kidneys to be assessed [Figure 3].
Figure 2: Coronal slice of a Tc-99m DMSA SPECT showing the internal structure that reveals good cortical thickness of the two kidneys.

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Figure 3. Posterior view of a three-dimensional surface rendered imaging surface image of the Tc- 99m DMSA SPECT showing the anatomical relationships of the two kidneys.

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The two transplanted kidneys are well visua­lized with good cortex throughout both the kid­neys, with no focal defects seen.

 
   References Top

1.Meakins JL, Smith EJ, Alexander JW. En-bloc transplantation of both kidneys from pediatric donors into adult patients. Surgery 1972;71:72-5.  Back to cited text no. 1
[PUBMED]    
2.Kremer GD, Slooff MJ, Tegzess AM et al. Transplantation of cadaveric paediatric donor kidneys into adult recipients. Proc Eur Dial Transplant Assoc 1981;18:469-74.  Back to cited text no. 2
    
3.Schneider JR, Sutherland DE, Simmons RL, et al. Long-term success with double pediatric cadaver donor renal transplants. Ann Surg 1983; 197(4):439-42.  Back to cited text no. 3
    
4.Csapo Z, Knight R, Podder H, et al. Long-term outcomes of single paediatric vs. ideal adult renal allograft transplants in adult recipients. Clin Transplant 2006;20(4):423-6.  Back to cited text no. 4
    
5.Keitel E, Fasolo LR, D'Avila AR, et al. Results of en-bloc renal transplants of pediatric deceased donors into adult recipients. Transplant Proc 2007;39(2):441-2.  Back to cited text no. 5
    
6.Ratner LE, Cigarroa FG, Bender JS, et al. Transplantation of single and paired pediatric kidneys into adult recipients. J Am Coll Surg 1997;185(5):437-45.  Back to cited text no. 6
    
7.Foss A, Line P, Brabrand K, et al. A prospective study on size and function of paediatric kidneys (<10 years) transplanted to adults. Nephrol Dial Transplant 2007;22:1738-42.  Back to cited text no. 7
    

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Correspondence Address:
Ammar Al Midani
Department of Transplant Surgery, Royal Free Hospital, Pond Street, London
United Kingdom
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PMID: 21196632

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  [Figure 1], [Figure 2], [Figure 3]



 

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