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Saudi Journal of Kidney Diseases and Transplantation
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Table of Contents   
ORIGINAL ARTICLE  
Year : 2012  |  Volume : 23  |  Issue : 2  |  Page : 246-250
Renal transplantation in allografts with multiple versus single renal arteries


1 Department of Urology, Hasheminejad Hospital, Iran University of Medical Science, Tehran, Iran
2 Department of Internal Medicine, Shahid Beheshti University of Medical Science, Tehran, Iran
3 Department of Urology, Isfahan University of Medical Sciences, Isfahan, Iran

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Date of Web Publication28-Feb-2012
 

   Abstract 

Allograft with multiple renal arteries (MRA) is considered to have an increased post-transplantation risk due to vascular and urologic complications. The aim of this study is to inves­tigate the outcome of living donor kidney transplantation using allograft with a single artery and recipients of allografts with multiple arteries. Seven hundred and eighteen consecutive adult kidney transplants done between 1998 and 2007, with living unrelated kidney donors, were enrolled in this retrospective analysis. Data from the group with MRA (n = 60) were compared with those from the group with single renal artery (SRA) (n = 658). Delayed graft function (DGF) was more frequent in recipients' allografts with more than 2 arteries when compared with SRA recipients (Odds Ratio: 1.2; 95% CI:1.08-1.9, P = 0.02), but there was no difference between SRA and allograft with two arteries. The incidence of acute rejection (AR) was not statistically greater in recipients with MRA. Renal artery stenosis (RAS) occurred more frequently in patients with MRA (8.3% vs. 5.9% and P = 0.02), but other vascular complications such as renal artery thrombosis and hematoma revealed no differences (P > 0.05). Urologic complications such as UVJ obstruction, urinary leakage and ureteropelvic obstruction were not statistically different between the groups. The actuarial 1-year allograft survival rate was comparable in both groups (93.6% vs 96.8%, P = 0.22). Allografts with more than two arteries were associated with increased DGF and RAS, but no surgical or urological complications were detected in our series. Our findings demonstrate that renal allograft transplantation with multiple arteries could be performed with reasonable complications and acceptable outcomes.

How to cite this article:
Kamali K, Abbasi MA, Ani A, Zargar MA, Shahrokh H. Renal transplantation in allografts with multiple versus single renal arteries. Saudi J Kidney Dis Transpl 2012;23:246-50

How to cite this URL:
Kamali K, Abbasi MA, Ani A, Zargar MA, Shahrokh H. Renal transplantation in allografts with multiple versus single renal arteries. Saudi J Kidney Dis Transpl [serial online] 2012 [cited 2014 Oct 25];23:246-50. Available from: http://www.sjkdt.org/text.asp?2012/23/2/246/93145

   Introduction Top


Although some studies have suggested that new and less invasive techniques have signi­ficantly contributed to an increase in live kid­ney donations in the recent years, [1],[2],[3] anatomical variations of the graft are still a challenging problem. Among these variations, multiple renal arteries (MRA) is considered the most common. Autopsy studies have reported pre­valence rates of MRA as 18-30%, with 15% being bilateral. [4] This becomes important espe cially in the developing countries, where living donor nephrectomy contributes to the major part of the graft pool. [5] It is suspected that pro­longed ischemia time, increased incidence of acute tubular necrosis and acute rejection epi­sodes are the drawbacks of transplanting a kidney with MRA. Prolonged hospitalization and poor graft function are also considered as the drawbacks. [4] Renal transplantations with multiple arteries are reported as having a major index of vascular and urologic complications. [6] The aim of this study is to investigate the outcome of living donor kidney transplantation using allografts with a single artery and with multiple arteries.


   Patients and Methods Top


During July 1998 and April 2007, 718 con­secutive kidney transplant recipients were en­rolled in this retrospective cohort study. The patients received their kidney allografts from living unrelated kidney donors. Recipients with multiple organ transplantation, history of prior renal transplantation, age <15 years, hyper- or hypothyroidism, body mass index (BMI) >35 (kg/m [2] ) and liver cirrhosis were excluded from this study. The study was approved by the ethics committee of the medical center and informed consent was obtained from all the participants.

In order to exclude artery stenosis directly related to the surgical procedure, transplant renal artery stenosis (TRAS) occurring only three months after transplantation were consi­dered. TRAS was suspected in patients with new-onset or refractory hypertension, oliguria and renal allograft dysfunction (increase in serum creatinine greater than 20% compared with baseline). The diagnosis was based on abnormal Doppler findings, peak systolic velo­cities of <105 cm/s or increase above 50% in peak systolic and a narrowing of greater than 50% of the luminal diameter.

Surgical procedure

End-to-end arterial anastomosis was performed between renal transplanted artery and the in­ternal iliac artery. The renal vein was anastomosed to the external iliac vein with an end-to-side anastomosis. The ureters were anasto­mosed using the anterior Lich technique and ureteric stenting was carried out in all reci­pients. As a routine, stents were removed after two weeks.

All of them received pulse Methylpredni solone therapy (1000 mg) for three days from the day of transplantation. All patients re­ceived Prednisolone, 1 mg/kg, after the methylprednisolone pulse course was over. The prenisolone dose was tapered to 5 mg/day in six months after transplantation in all recipients. Acute rejection was diagnosed when there were clinical signs of rejection including fever (>38%), decreased urine secretion, hyperten­sion and pain over an enlarged kidney graft and progressive elevation of serum creatinine (Cr) (>20% of baseline Cr), which responded to anti-rejection therapy. The following data were recorded: recipients and donors' age, BMI, cause of renal disease, warm ischemia time, immunosuppressive regimen, incidence of acute rejection and delayed graft function (DGF), which was defined as the need for hemodialysis during the first seven days after transplantation, urologic and vascular, graft and patients' survival.


   Statistical Analysis Top


Quantitative results were expressed as mean values ± SD. Statistical analysis was performed with SPSS version 15.0 (SPSS, Chicago, IL, USA). Chi-square test was used for categorical variables and independent Student's t-tests or ANOVA tests for continuous variables. Kaplan-Meier analysis was performed for survival ana­lysis of recipients and renal grafts. Signifi­cance was defined as P < 0.05.


   Results Top


Among 718 patients (442 male and 276 female) who underwent transplantation, 658 recipients with single renal artery (SRA) and 60 recipients with MRA (49 with two arteries and 11 with >2 arteries) were investigated. Descriptive statistical data of the donors and recipients are demonstrated in [Table 1]. The reci­pients were followed-up for a mean of 15.3 ± 2.7 months (range: 11-18 months). There was only one recipient with four-artery allograft, and this patient developed acute rejection (AR). Overall, AR and DGF were detected in 3.4% (25/718) and 7.6% (55/718) of the pa­tients, respectively. Urologic complications occurred in 14% of the recipients. DGF was more common in patients receiving allografts containing three or four arteries when compared with allografts with two arteries (18.8% vs 10.2%, respectively, P = 0.03). DGF was more frequent in those who received allografts with MRA when compared with SRA recipients (Odds Ratio:1.2; 95% CI:1.08-1.9, P = 0.02), but there was no difference between allografts with SRA and those with two arteries. The incidence of AR was not statis­tically greater in recipients with MRA [Table 2]. Although RAS occurred more frequently in patients with MRA (8.3% vs 5.9% and P = 0.02), other vascular complications such as renal artery thrombosis and hematoma revealed no significant differences (P > 0.05). As shown in [Table 3], urologic complications such as UVJ obstruction, urinary leakage and uretero-pelvic obstruction were not statistically different between the groups. At the end of 1-year follow-up, no deaths have been observed in any of the recipients. Graft survival rate in patients with MRA and SRA were 93.6% and 96.8%, respectively, which was not statisti­cally significant (P = 0.22).
Table 1. Baseline characteristics of the patients (n = 718).

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Table 2. Graft function in patients with single renal artery and multiple renal artery.

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Table 3. Vascular and urologic complications following transplantation in single and multiple renal
arteries.


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   Discussion Top


MRA is considered a common anatomical variation of the kidneys, with the incidence range varying in different studies. Aydin et al [7] reported it to be up to 30%. In our study, the incidence of MRA was 8.3%, which was higher than that reported by Gawish et al [8] but lower than in other studies, which reported it as 15% [9] and 16%. [10] Allograft transplantation with MRA was always considered more risky and was usually avoided because of the pos­sibility of higher post-transplant complications. [11] The reports suggest that incidence of post-transplantation surgical complications among MRA recipients are comparable with that in the SRA group.

In this study, we analyzed MRA recipients in two subgroups, one having two arteries and the other, more than two arteries. MRA recipients were more prone to develop RAS while DGF was detected more frequently in patients re­ceiving allografts with more than two arteries, and there were no significant differences in patients receiving allografts with less than two arteries. Kadotani et al [11] reported a higher but not significant DGF incidence in MRA allografts. Osman et al [12] reported that grafts with MRA were associated with a higher risk for hemorrhagic complications, which was con­trary to our findings that wound bleeding or hematoma showed no significant difference. As mentioned, MRA have been associated with a higher rate of RAS, which was similar to previous studies that revealed the asso­ciation of MRA with vascular complications, including arterial thrombosis and RAS. [13],[14]

Our findings demonstrated no differences in urologic and vascular complications (with the exception of RAS) and 1-year patient and graft survival between the SRA and the MRA groups, as has been reported by other investigators. [6],[13] At the end of 1-year follow-up, no deaths have been observed in recipients. The graft survival rates in patients with MRA and SRA were 93.6% and 96.8%, respectively (P = 0.22).

Allografts with more than two arteries were associated with an increased number of DGF and RAS, but no surgical or urological compli­cations were detected in our series. Overall, our findings demonstrate that renal allograft transplantation with multiple arteries could be performed with reasonable complications and acceptable outcomes.

 
   References Top

1.Ratner LE, Montgomery RA, Maley WR, et al. Laparoscopic live donor nephrectomy: The recipient. Transplantation 2000;69:2319-23.  Back to cited text no. 1
[PUBMED]  [FULLTEXT]  
2.Schweitzer EJ, Wilson J, Jacobs S, et al. Increased rates of donation with laparoscopic donor nephrectomy. Ann Surg 2000(232):392-400.  Back to cited text no. 2
[PUBMED]  [FULLTEXT]  
3.Cecka JM. The UNOS Scientific Renal Trans­plant Registry. In: Cecka JM, Terasaki PI, eds. Clinical Transplants 1999. Los Angeles, Calif: University of California; 1999:1-21  Back to cited text no. 3
    
4.Roza AM, Perloff LJ, Naji A, et al. Living related donors with multiple renal arteries-a twenty year experience. Transplantation 1989; 47(2):397-9.  Back to cited text no. 4
    
5.Desai MR, Ganpule AP, Gupta R, Thimmegowda M. Outcome of renal transplantation with multiple versus single renal arteries after laparoscopic live donor nephrectomy: A com­parative study. Urology 2007;69(5): 824-7.  Back to cited text no. 5
    
6.Mazzucchi E, Souza A, Nahas WC, et al. Surgical complications after renal transplan­tation in grafts with multiple arteries. Int Braz J Urol 2005;31(2):125-30.  Back to cited text no. 6
    
7.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. 7
[PUBMED]  [FULLTEXT]  
8.Gawish AE, Donia F, Samhan M, Halim MA, Al-Mousawi M. Outcome of renal allografts with multiple arteries. Transplant Proc 2007; 39(4):1116-7.  Back to cited text no. 8
    
9.Oh HK, Hawasli A, Cousins G. Management of renal allografts with multiple renal arteries resulting from laparoscopic living donor nephrectomy. Clin Transplant 2003;17(4):353-7.  Back to cited text no. 9
    
10.Benedetti E, Troppmann C, Gillingham K, et al. Short- and long-term outcomes of kidney transplants with multiple renal arteries. Ann Surg 1995;221:406.  Back to cited text no. 10
[PUBMED]  [FULLTEXT]  
11.Kadotani Y, Okamoto M, Akioka K, et al. Management and outcome of living kidney grafts with multiple arteries. Surg Today 2005; 35:459.  Back to cited text no. 11
[PUBMED]  [FULLTEXT]  
12.Osman Y, Shokeir A, Ali-el-din B, et al. Vas­cular complications after live donor transplan­tation: study of risk factors and effects in graft and patient survival. J Urol 2003;169:859.  Back to cited text no. 12
    
13.Guerra EE, Didone EG. Renal transplant with multiple arteries. Transplant Proc 1992;24:1868.  Back to cited text no. 13
    
14.Hsu TH, Su LM, Ratner LE, Trock BJ, Kavoussi LR. Impact of renal artery multiplicity on out­comes of renal donors and recipients in laparoscopic donor nephrectomy. Urology 2003; 61:323-7.  Back to cited text no. 14
[PUBMED]  [FULLTEXT]  

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Correspondence Address:
Koosha Kamali
Department of Urology, Hasheminejad Hospital, Vanak Sq., Tehran
Iran
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PMID: 22382214

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    Tables

  [Table 1], [Table 2], [Table 3]

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    Abstract
   Introduction
   Patients and Methods
   Statistical Analysis
   Results
   Discussion
    References
    Article Tables
 

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