Saudi Journal of Kidney Diseases and Transplantation

LETTER TO THE EDITOR
Year
: 2014  |  Volume : 25  |  Issue : 3  |  Page : 651--654

Multiple renal arteries in living donor kidney transplantation: Limits of recipient warm ischemia


Taqi T Khan1, Basem Koshaji1, Suhaib Kamal1, Faheem Akhtar2, Ebadur Rahman2,  
1 Kidney Transplant Surgery, Department of Nephrology and Transplantation, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
2 Transplant Nephrology, Department of Nephrology and Transplantation, Prince Sultan Military Medical City, Riyadh, Saudi Arabia

Correspondence Address:
Dr. Taqi T Khan
Kidney Transplant Surgery, Department of Nephrology and Transplantation, Prince Sultan Military Medical City, Riyadh
Saudi Arabia




How to cite this article:
Khan TT, Koshaji B, Kamal S, Akhtar F, Rahman E. Multiple renal arteries in living donor kidney transplantation: Limits of recipient warm ischemia.Saudi J Kidney Dis Transpl 2014;25:651-654


How to cite this URL:
Khan TT, Koshaji B, Kamal S, Akhtar F, Rahman E. Multiple renal arteries in living donor kidney transplantation: Limits of recipient warm ischemia. Saudi J Kidney Dis Transpl [serial online] 2014 [cited 2021 Jun 15 ];25:651-654
Available from: https://www.sjkdt.org/text.asp?2014/25/3/651/132225


Full Text

To the Editor,

We read with interest the comments by Einollahi et al [1] about the paper that compared the outcomes in living donor kidney recipients who received allografts with single renal artery (SRA) and multiple renal arteries (MRAs). [2] This study had found a higher incidence of delayed graft function (DGF) in recipients with MRAs because of the expected increase in the vascular anastomosis or warm ischemia time (WIT). [2]

Einollahi et al agree that anastomosing MRAs can increase recipient WIT and possibly contribute to the increased incidence of DGF, but, surprisingly, they found no significant differrence in the WITs between MRAs and SRAs in their own study. [3] This appears unrealistic unless the authors converted all the multiple arteries into a single lumen during cold storage back table dissection before implantation. Further confusion is created because the reported WIT is in seconds and not minutes, which can only be donor WIT and not recipient WIT. Additionally, despite the complex reconstruction of the lumina of these multiple arteries into one lumen, the cold ischemia is only ±30 min. We implanted all our multiple arteries independently and found that anastomosing a second artery adds an average of 15 min to the total WIT [4] this is unavoidable, unless, as stated above, a single lumen is fashioned in every allograft with MRAs. This may be difficult to achieve in cases where the origin and course of the two or three arteries is separated by a significant distance, making it impossible to bring them together to create a single lumen without jeopardizing the entire inflow as shown in [Figure 1]a, b and c.{Figure 1}

There is contradiction in their discussion about acute rejection, because despite short WIT and cold ischemia, the incidence of acute rejection was significantly higher in their recipients with MRAs compared with SRAs. This is difficult to explain given the fact that vital information about the incidence of DGF is not available. The likely explanation is perhaps that the incidence of DGF in the MRA group was higher and resulted in more acute rejection because there is good evidence that DGF is associated with higher rates of acute rejection [5],[6] and DGF is logically perhaps the only connection between MRAs and acute rejection. If true, but not because of prolonged WIT, the question as to why there was more DGF will remain unexplained.

Contrary to the authors' technique, we anastomose all MRAs separately and do not convert to a single lumen. Admittedly, it adds an extra 15 min to the recipient WIT, but we consider it safe and appropriate because no recipient developed poor early graft function, nor have we encountered renal artery stenosis in any of our 13 recipients with MRAs. [4] The WIT in all MRAs was between 50 and 85 min, and was tolerated well in all patients with immediate graft function. [4] Similarly, in the last 15 months, we used 21 donor kidneys with MRAs including two grafts with three arteries without any complications (unpublished data). We open clamps after anastomosing the proximal two arteries to external iliac and then connect the third and most distal artery to the inferior epigastric artery. Creating a single imperfect lumen in MRAs with size disparity or distance can make them susceptible to thrombosis and other complications, and is the reason why we prefer to implant them separately to provide the best chance of success.

Einollahi et al admit but do not explain why MRAs with three arteries had unfavorable outcomes in their recipients. Did these grafts develop arterial thrombosis or acute rejection and were eventually lost? This is contrary to their final statement that using grafts with MRAs is safe with acceptable results, but they should qualify this by adding that this applies only to MRAs with two arteries. We feel that an additional 15 min of WIT is safe, well tolerated and without complications, and in case of three arteries, the distal most artery can be anastomosed to the inferior epigastric after reperfusion without further prolonging WIT.

References

1Einollahi B, Nourbala MH, Fatahi MR. Favorable outcomes of living donor kidney transplantation following use of grafts with multiple renal arteries. Saudi J Kidney Dis Transpl 2013;24:578-9.
2Kamali 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.
3Abbaszadeh S, Nourbala MH, Alghasi M, et al. Does renal artery multiplicity have impact on patient and allograft survival rates? Nephrol-Urol 2009;1:45-50.
4Khan TF, Said MT, Kamal S et al. Prevention of poor early graft function using open nephrectomy, and minimizing the risk of procedure related factors. Uro Today Int J 2013June;6(3):art 30.http://dx.doi.org/10.3834/ uij.1944-5784.2013.06.04.
5Tyson M, Castle E, Andrews P, et al. Early graft function after laparoscopically procured living donor kidney transplantation. J Urol 2010;184:1434-9.
6Noguiera JM, Haririan A, Jacobs SC, et al. The detrimental effect of poor early graft function after laparoscopic live donor nephrectomy on graft outcomes. Am J Transplant 2009;9:337-47.