 Abstract | | |
Kidney donation from hypertensive donors is now an accepted norm in live related kidney transplantation. The use of hypertensive donors with renal artery stenosis due to atherosclerosis and fibromuscular dysplasia is still debated. The prime concern is about the deleterious effect of hypertension on the donor and the risk of recurrence of such lesions in the solitary kidney. Even as the response of atherosclerotic renal artery stenosis to revascularisation is unpredictable, there is an improvement in blood pressure following revascularisation of kidneys with fibro-muscular dysplasia. The first use of such kidney donors was reported in 1984 and, since then, there have been a few reports of successful use of kidneys from donors with renal artery stenosis. We report here two interesting cases of successful transplantation of kidneys from live related kidney donors with hypertension due to renal artery stenosis who became normotensive with good graft function in the recipient. We conclude that moderately hypertensive donors with renal artery stenosis are fit to donate.
How to cite this article:
Reddy VK, Guleria S, Bora GS. Donors with renal artery stenosis: Fit to donate. Saudi J Kidney Dis Transpl 2012;23:577-80 |
How to cite this URL:
Reddy VK, Guleria S, Bora GS. Donors with renal artery stenosis: Fit to donate. Saudi J Kidney Dis Transpl [serial online] 2012 [cited 2013 May 21];23:577-80. Available from: http://www.sjkdt.org/text.asp?2012/23/3/577/95817 |
| Introduction | |  |
In live related transplantation donor, safety is the prime concern. [1] The disparity between supply and demand for the donor organs has necessitated the acceptance of marginal donors in live related transplant programs, [2] including our own. While the success of the graft from such donors is important, the impact of nephrectomy on such a marginal donor cannot be ignored. Hypertension causes exclusion of up to 17% of potential live donors [3] even as moderately hypertensive donors have normal renal function and controlled blood pressure when on anti-hypertensive treatment following donation. [4] Atherosclerotic disease followed by fibromuscular dysplasia is the most common cause of renal artery stenosis in the donor population. Although there are reports of accepting such live related donors in the current literature, [1],[5]-[7] recommendations on the use of such donors are conflicting due to the fear of recurrence in the solitary kidney and hypertension in the donor. We describe two interesting cases of live related kidney donors with hypertension due to renal artery stenosis who became normotensive with good graft function in the recipient.
| Case Reports | | |
Case 1
A 53-year-old female donor was evaluated as a prospective kidney donor for her son who was diagnosed with end-stage renal disease. Routine workup showed that she was not diabetic, had a serum creatinine of 0.8 mg/dL and a blood pressure of 150/100 mmHg. Doppler ultrasonography of kidneys showed an essentially normal study. Computerized tomographic angiography showed bilateral single renal artery and renal vein with focal narrowing of left renal artery close to its origin. There was luminal irregularity of abdominal aorta suggestive of atherosclerotic change. Digital subtraction angiography was done to further evaluate the lesion, and it revealed tight stenosis in the proximal left main renal artery at the juxtaostial region, while the right main renal artery was normal [Figure 1]. There was a mild atherosclerotic irregularity of proximal abdominal aorta. Her urine protein was 0.2 g/24 h, which was at the upper end of the normal range, and urine creatinine was 1 g/24 h, which was normal. The global glomerular filtration rate as estimated by Diethylene triamine pentaacetic acid was 94 mL/min/1.73 m 2 of body surface area. The left kidney had a differential function of 45% and the right kidney had a differential function of 55% with Tc 99m Ethyl Cysteine Diuretic Renography. We decided to proceed with the kidney donation because she was the only compatible donor available for her son, and we also endeavoured to manage her hypertension by removing the kidney with the stenotic renal artery. A left open donor nephrectomy was performed and the renal artery was divided just distal to the stenosed segment. After the transplantation, there was diuresis in the immediate post-operative period. The recipient had an uneventful recovery and was discharged on a creatinine of 1.6 mg/dL on post-op day 7. She has now been on our follow-up for six years. The donor is normotensive on a single anti-hypertensive and the recipient is doing well, with a serum creatinine of 1.9 mg/dL. | Figure 1: Digital subtraction angiogram of the left kidney showing severe renal artery stenosis at the ostium.
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Case 2
A 65-year-old female was the only donor for her son who was on the transplant waiting list. She had a serum creatinine of 1.0 mg/dL and had a blood pressure of 160/110 mmHg at initial examination. Her blood pressure was controlled with two anti-hypertensives. There was no evidence of retinopathy or nephropathy as seen by a normal fundus examination and a normal urine protein examination. Angiography of the renal vessels revealed fibromuscular dysplasia of the left main renal artery [Figure 2]. The right renal artery was normal. She had a glomerular filtration rate of 88 mL/min/1.73 m 2 and a differential function of 48% in the left kidney and 52% in the right kidney. The decision was taken to accept her as a renal donor and she underwent a left open donor nephrectomy. Intra-operatively, the stenosed renal artery was identified and divided distal to the dysplastic area. Post-operatively, the donor did well and maintained normal blood pressure without any anti-hypertensive medications by four weeks. The recipient had a normal recovery and was followed-up with excellent renal function. Eleven years following the transplantation, the donor is normotensive and has a normal renal function, along with a healthy recipient. | Figure 2: Angiogram of the left kidney showing fibromuscular dysplasia of the main renal artery.
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| Discussion | | |
Atherosclerotic disease is the most common cause of renal artery stenosis, with a prevalence of 27% at necropsy. [8] It is usually due to an atherosclerotic plaque and calcification located at the renal arterial ostium. [9] Fibromuscular disease is the second most frequent cause of renal artery stenosis, and is more common in females aged less than 40 years, being usually localized to the middle and distal parts of the main renal artery. Although hypertension results from renal artery stenosis, its frequency is unknown. [10] However, unlike atherosclerotic renal artery stenosis, where the blood pressure response to revascularization is unclear, most patients with fibromuscular dysplasia become normotensive after revascularization. [10] Further, there is no correlation between the severity of the stenosis and renal function, except in cases where occlusion of the renal artery causes compromised renal function. [11] Computerized tomographic angiography and magnetic resonance angiography have largely replaced conventional angiography in the evaluation of donor renal vessels, and are useful in confirming or ruling out the diagnosis of renal artery stenosis. [10] However, fibromuscular dysplasia, which occurs in up to 4.4% of the donor population, is better diagnosed with conventional angiography. [12]
The use of kidneys from donors with such vascular anomalies who have a normal or higher blood pressure is controversial. The first published use of kidneys from donors with renal artery stenosis due to fibromuscular dysplasia was done by Nghiem et al [13] in 1984. Serrano et al [6] reported two cases of living related donors who had renal artery disease in the form of atheromatous renal artery stenosis in one of the cases and fibromuscular dysplasia in the other, with good graft function at follow-up of two years. Nahas et al [5] described a case series of marginal donors with vascular anomalies, where four donors had atherosclerotic narrowing of the proximal main renal artery and three donors had fibromuscular dysplasia. All the donors in this series had normal blood pressure. Among the grafts taken from donors with atherosclerotic disease, two were lost to other causes. The authors concluded that the presence of atherosclerotic lesions in the renal artery does not pose any problems in kidney donation, with a caveat that progression of atherosclerotic disease in the solitary kidney should be anticipated in high-risk donors, [5] notwithstanding the fact that the risk of radiological progression of atheromatous renal artery stenosis is about 50%. [8] Unfavorable results due to the use of grafts with fibromuscular dysplasia have been reported, wherein some form of revascularization was needed at a later time. [7],[14] In a study by Cragg et al, [15] the incidence of hypertension among donors with renal artery fibromuscular dysplasia who underwent donor nephrectomy was 26.3%, and the same in prospective donors who did not undergo donor nephrectomy was 26.6%. This was clearly higher than the incidence of hypertension in age-matched cohorts, which was 6%. Although our experience with donor kidneys with renal artery stenosis is limited, the two cases described speak in favor of safely using such kidneys without risk to the donor and the recipient. The second donor had fibromuscular dysplasia and responded well to the nephrectomy, as evident by the 11-year follow-up. We conclude that in the era of organ shortage, moderately hypertensive donors with renal artery stenosis may be used provided the risks and benefits are explained. Both the donor and the recipient will need to be on close and long-term follow-up.
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Correspondence Address:
Sandeep Guleria
Department of Surgical Disciplines, 5th Floor, Teaching Block, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110 029
India
[Figure 1], [Figure 2] |
