| Abstract|| |
The aim of our study was to compare the surgical complications and short-term outcome of renal transplants with single and multiple renal artery grafts. We reviewed the records of 105 kidney transplantations performed consecutively at our institution from July 2006 to May 2010. The data of 33 (31.4%) renal transplants with multiple arteries were compared with the 72 transplants with single artery (68.6%), and the incidence of surgical complications, post-transplant hypertension, acute tubular necrosis, acute graft rejection, mean creatinine level, and patient and graft survival was analyzed. We further subdivided the study recipients into three groups: group A (n = 72) with one-renal-artery allografts and one-artery anastomosis, group B (n = 6) with multiple-artery allografts with single-artery anastomosis, and group C (n = 27) with multiple-artery allografts with multiple arterial anasatomosis, and compared their outcome. No significant differences were observed among the recipients of all the three groups regarding early vascular and urological complications, post-transplant hypertension, acute tubular necrosis, acute rejection, creatinine level, and graft and patient survival. The mean cold ischemia time in groups B and C was significantly higher (P <0.05). One patient in group A developed renal vein thrombosis resulting in graft nephrectomy. None of the patients with multiple renal arteries developed either vascular or urological complications. In conclusion, kidney transplantation using grafts with multiple renal arteries is equally safe as using grafts with single renal artery, regarding vascular, urological complications, as well as patient and graft survival.
|How to cite this article:|
Ashraf HS, Hussain I, Siddiqui AA, Ibrahim M N, Khan MU. The outcome of living related kidney transplantation with multiple renal arteries. Saudi J Kidney Dis Transpl 2013;24:615-9
|How to cite this URL:|
Ashraf HS, Hussain I, Siddiqui AA, Ibrahim M N, Khan MU. The outcome of living related kidney transplantation with multiple renal arteries. Saudi J Kidney Dis Transpl [serial online] 2013 [cited 2015 Sep 5];24:615-9. Available from: http://www.sjkdt.org/text.asp?2013/24/3/615/111087
| Introduction|| |
Renal transplantation is the treatment of choice for the majority of patients with end-stage renal disease.  During the last three decades, the graft and patient survival rates have significantly improved due to refinements in surgical techniques as well as with the introduction of new and more potent immunosuppressive regimens. , Although kidney transplantation with multiple renal arteries has been performed in certain centers, kidney transplantation with multiple renal arteries from living kidney donors remains a controversial and challenging issue due to higher risks of vascular and urological complications.  Multiple renal arteries are found in 18%-30% unilaterally and 10% bilaterally in potential kidney donors.  Now several vascular, surgical, and microsurgical techniques of intra-corporeal and ex vivo vascular anastomosis procedures have been used to transplant grafts with multiple renal arteries, achieving the same results as that of grafts with single renal arteries. , The organ shortage is still a worldwide problem, and using renal grafts with multiple renal arteries can be one approach to expand the donor pool for kidney transplantations and overcome this problem.
In this retrospective study, we analyzed the outcome of recipients of living-donor kidney transplantations using allografts with multiple renal arteries.
| Materials and Methods|| |
We reviewed the records of our 105 live-related kidney transplants performed at our institution during the period from July 2006 to March 2010. There were 33 (31.4%) grafts with multiple arteries and 72 (68.6%) with single renal arteries. The patients were subdivided into three groups according to their vascular reconstruction technique: group A (n = 72) (68.6%) comprised recipients with single-renal-artery allografts anastomosed end-to-side with external or end-to-end with internal iliac artery in a single anastomosis pattern, group B (n = 6) (5.7%) comprised recipients with multiple-renal-artery allografts anastomosed end-to-end with internal iliac or end-to-side to external iliac artery with single anastomosis (multiple renal arteries were converted to single artery after bench reconstruction), and group C (n = 27) (25.7%) comprised recipients of multiple-renal-artery allografts, implanted with multiple arterial anastomosis.
Open donor nephrectomies were performed through extra-peritoneal flank incision in all cases. Vascular anastomoses were performed to external iliac vein, common, external or internal iliac artery. Urinary tract continuity was established by modified Lich Gregoriel technique of extravesical ureteroneocystostomy over a double J (DJ) stent.
All patients received standard triple drug immunosuppressive therapy comprising calcineurin inhibitors (5-7 mg/kg), azathioprine (1.5-2 mg/kg), and steroids. Doppler ultrasonography was routinely performed on the 3 rd or 4 th postoperative day to evaluate the vascular flow as well as urinary system.
We analyzed the incidence of vascular and urological complications, acute tubular necrosis, post-transplant hypertension, delayed graft function, and patient survival, comparing to recipients in the different groups.
Delayed graft function was defined as the need of at least one dialysis session after renal transplant. Patients were considered to have high blood pressure if they were on at least one anti-hypertensive medicine or they had blood pressure more than 150/90 mmHg. The incidence of rejection was based on the first biopsy-proven rejection episode. Follow-up of the patients varied from 12 to 48 months. The patients were followed at the out-patient department weekly for the first month, then monthly for six months, followed by three-monthly for the entire life.
| Results|| |
Of the 33 patients who received allograft with multiple renal arteries, the male/female ratio was 26/7. The mean age of the patients was 31.5 ± 9.7 years (range: 20-60 years) and their mean follow-up was 20-25 months (range: 12-58 months). The demographic data of patients and vascular reconstruction pattern are described in [Table 1] and [Table 2], respectively.
|Table 1: Demographic data and characteristics of patients of all three groups.|
Click here to view
No significant difference was observed in the warm ischemia time between groups, but the patients in groups B and C had significantly longer cold ischemia time when compared to the patients in group A (P = 0.09) as shown in [Table 3]. As a measure of graft function, we compared the mean creatinine values among the three groups, i.e. at six 12 months post-transplant, which did not differ significantly (P = 0.41). There was no patient with acute tubular necrosis (ATN) or acute rejection in groups A and B, while biopsy-proven acute rejection was observed in one patient from group C.
The graft survival rates at 12 months post-transplant were 94.2% in group A, 100% in group B, and 95.5% in group C. The patient survival rates at 12 months were 96.1%, 100%, and 95.5% in groups A, B, and C, respectively.
The incidence of pre-transplant hypertension was 79% in group A, 89% in group B, and 81.4 % in group C. The incidence of hypertension decreased slightly in all the three groups, but not significantly as shown in [Figure 1].
|Figure 1: The incidence of hypertension pre- and post-transplant in three groups.|
Click here to view
The rate of urological complications in our series is shown in [Table 4]. We found no difference in regard to the incidence of ureteral obstruction or late stricture and anastomotic or bladder leakage among the three groups (P >0.10). Complications of lower pole arterial injury resulting in ureteral necrosis or calyceal cutaneous fistula were not observed in any group.
| Discussion|| |
In Pakistan, renal transplantation is mostly dependent on live related renal donors, while cadaveric donor program is still in infancy. The joint family system in Pakistan is also gradually declining, which decreases the donor pool. Members of family having same blood groups cannot be refused on anatomical or technical grounds. There are several theoretical disadvantages of transplanting a kidney with multiple renal arteries, which are prolonged cold or warm ischemia time, increased rate of ATN and acute rejection episodes, and delayed graft function. Multiple donor renal arteries have been reported to be associated with high rate of arterial stenosis and thrombosis. , Especially, polar arteries may cause infarction, infection, and urological complications resulting in calyceal or ureteric fistulas and ureteral necrosis. 
The introduction of extra-corporeal microsurgical bench reconstruction of multiple arteries has resulted in better outcome of renal transplantation with multiple renal arteries. ,, The reported incidence of multiple renal arteries varies between 18% and 30%.  Our series revealed 35.4% cases with multiple renal arteries. This huge rate of multiple renal arteries in our donors may be due to small sample size.
Revascularization of graft can be achieved simultaneously after the arterial engraftment is completed or sequentially using sequential technique. The main renal artery is revascularized first and vascular clamps are released, resulting in partial revascularization of the allograft. Then the other artery is anastomosed at appropriate site, maintaining partial perfusion of kidney through the main artery. We found no differences between both techniques regarding the incidence of ATN and other complications. These findings are consistent with other reports. , Although warm ischemia time was almost the same for all the groups, cold ischemia time was significantly higher in groups with multiple renal arteries. However, this prolonged ischemia time did not negatively influence the graft function in our series, which is quite consistent with other studies. ,
Benedetle et al  compared 163 renal grafts with multiple renal arteries and 83 grafts with single renal arteries and found no differences in acute rejection, creatinine levels, surgical complications, graft survival, and graft function between the two groups. Many other studies revealed the same results. ,,,,
We also found no significant differences among all groups regarding acute rejection, hypertension, post-transplant creatinine levels, surgical complications, and graft and patient survival. In contrast, Osman et al  reported unfavorable results.
Previously, it was considered that multiple renal arteries were associated with high rate of post-transplant vascular complications. Some studies concluded that grafts with multiple renal arteries had higher rate of vascular complications than single arterial grafts. .
In our study and many others, there was no association between multiplicities of renal arteries and the risk of vascular complications. ,,,, The incidence of new-onset hypertension was not different among our three groups as revealed by other studies. We conclude that kidney transplantation using grafts with multiple renal arteries is equally safe as using grafts with single renal artery regarding vascular, urological complications, and patient and graft survival.
| References|| |
|1.||Ali-El-Dein B, Osman Y, Shokeir AA, Shehab El-Dein AB, Sheashaa H, Ghoneim MA. Multiple arteries in live donor renal transplantation: Surgical aspects and outcomes. J Urol 2003;169:2013-7. |
|2.||Kok NF, Dols LF, Hunink MG, et al. Complex vascular anatomy in live kidney donation: Imaging and consequences for clinical outcome. Transplantation 2008;85:1760-5. |
|3.||Desai MR, Ganpule AP, Gupta R. Outcome of renal transplantation with multiple versus single renal arteries after laparoscopic live donor nephrectomy: A comparative study. Urlogy 2007;5:824-7. |
|4.||Baºaran O, Moray G, Emiroðlu R, Alevli F, Haberal M. Grafts and patients outcome among recipients of renal grafts with multiple arteries. Transplant Proc 2004;36:102-4. |
|5.||Makiyama K, Tanabe K, Ishida H, et al. Successful renovascular reconstruction for renal with multiple renal arteries. Transplantation 203;75:823-32. |
|6.||Oesterwitz H, Strobelt V, Scholz D, Mebel M. Extracorporeal microsurgical repair of injured multiple donor kidney arteries prior to cadaveric allotransplantation. Eur Urol 1985;11: 100-5 . |
|7.||Guerra EE, Didoné EC, Zanotelli ML, et al. Renal transplant with multiple arteries. Transplant Proc 1992;24:1868. |
|8.||Aguiló J, Rodriguez O, Gaete J, Galleguillos I. Vascular anastomosis in renal transplants. Int Angiol 1991;10:39-43. |
|9.||Singh PB, Goyal NK, Kumar A, et al. Renal transplantation using live donors with vascular anomalies: A salvageable surgical challenge. Saudi J Kidney Dis Transpl 2008;19:554-8 |
|10.||Ali-El-Dein B, Osman Y, Shokeir AA, Shehab El-Dein AB, Sheashaa H, Ghoneim MA. Multiple renal arteries in live donor renal transplantation: Surgical aspects and outcomes. J Urol 2003;169:2013-17. |
|11.||Jafri SS,,Younas M., Chughtai MN. Surgical aspects and outcomes of kidney transplantation with multiple renal arteries. Annals 2009;15: 88-92. |
|12.||Abbaszadeh S, Nourbala MH, Alghasi M, Sharafi M. Does renal artery multiplicity have impact on patient and allograft survival rates? Int J Nephrol Urol 2009;1:45-50. |
|13.||Benedetti E, Troppmann C, Gillingham K, et al. Short- and long-term outcomes of kidney transplants with multiple renal arteries. Ann Surg 1995;221:406-14. |
|14.||Wang L, He F, Shi M, Lu Y, Yang Y. Treatment of multiple arteries in renal transplantation from living related donors. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 2008;22:582-5. |
|15.||Bakirtas H, Guvence N, Eroglu M, et al. Surgical approach to cases with multiple renal arteries in renal transplantation. Urol Int 2006; 76:169-72. |
|16.||Gawish AE, Donia F, Samhan M, Halim MA, Al-Mousawi M. Outcome of renal allograft with multiple arteries. Transplant Proc 2007; 39:1116-7. |
|17.||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;69:824-7. |
|18.||Mazzucchi E, Souza AA, Nahas WC, Antonopoulos IM, Piovesan AC, Arap S. Surgical complications after renal transplantation in grafts with multiple arteries. Int Braz J Urol 2005;31:125-30. |
|19.||Osman Y, Shokeir A, Ali-el-Dein B, et al. Vascular complications after live donor renal transplantation: Study of risk factors and effects on graft and patient survival. J Urol 2003;169:859-62. |
|20.||Han D, Choi S, Kin S. Microsurgical reconstruction of multiple arteries in renal transplantation. Transplant Proc 1998;30:3004-5. |
|21.||Singh PB, Goyal NK, Kumar A, et al. Renal transplantation using live donors with vascular anomalies: A salvageable surgical challenge. Saudi J Kidney Dis Transpl 2008;19:554-8 |
|22.||Aydin C, Berber I, Altaca G, Yigit B, Titiz I. The outcome of kidney transplants with multiple renal arteries. BMC Surg 2004;4:4. |
|23.||Eduardo M, Auro A, Souza, Willian C, Surgical complications after renal transplantation in grafts with multiple arteries. Int Braz J Urol 2005;31:125-30. |
Hafiz Shahzad Ashraf
Department of Kidney Transplant Surgery, Shaikh Zayed Post Graduate Medical Institute and National Institute of Kidney Diseases, Lahore
[Table 1], [Table 2], [Table 3], [Table 4]