Perspective, Arch Transplant Vol: 6 Issue: 1
Impact on graft function and outcome: A prospective cohort study
Dilushi Rowena Wijayaratne*
Received date: 01 December, 2021, Manuscript No. AT-22-57466
Editor assigned date: 06 December, 2021, PreQC No. AT-22-57466 (PQ);
Reviewed date: 20 December, 2021, QC No AT-22-57466;
Revised date: 27 December, 2021, Manuscript No. AT-22-57466
Published date: 03 January, 2022, DOI:10. 4172/AT.1000117
Citation: Dilushi Rowena Wijayaratne (2022) Impact on Graft Function and Outcome: A Prospective Cohort Study. Arch Transplant 6:1.
Keywords: Multiple Renal Arteries, Live Donor Renal Transplant
The presence of Multiple Renal Arteries (MRA) in prospective renal donors was once considered a relative contraindication to Live Donor Renal Transplantation (LDRT). This presumed technical difficulty in anastomosis and potential for in- creased vascular and secondary urological complications resulted in many potential healthy donors being overlooked for more favorable renal anatomy in deceased donors or alternate live donors . However, the increasing disparity between the escalating demand for renal transplantation and relatively stagnant supply of deceased donor organs has made it prohibitive for potential live donors to be declined based on arterial anatomy. Despite the technical faculties and potential complications of transplanting donor kidneys with MRA, these organs are increasingly accepted to maximize the pool of acceptable donors. With increasing expertise in vascular reconstruction and surgical technique, the acceptance rate of donors with MRA has increased universally among transplant centers. The impact of such complex donor arterial anatomy on the graft function and overall outcome remains an area of interest with limited available data .
The deceased donor program in Sri Lanka is still in its infancy with relatively poor donor rates compared to other countries. While definite forward strides have been made to increase deceased organ donation in the country over the last decade, LDRT presently remains the mainstay of transplantation in Sri Lanka . The National Institute of Nephrology Dialysis and Transplantation (NINDT) is currently the only dedicated transplant hospital in the country, and has been undertaking routine deceased and live donor transplants since 2010. This study was conducted by the Vascular and Transplant Unit of the NINDT to compare the short and mid-term outcomes of LDRT from accepted live donors having Single Renal Arteries (SRA).
Transplant surgeon and Vascular
We conducted a prospective cohort study of all LDRT performed between March 2010 and March 2016 by the Vascular and Transplant Unit of the NINDT. All successive adult (< 14 years) LDRT performed by the unit during the study period were included . All pediatric (<14 years) transplants and all adult deceased donor transplants were excluded. No live donors were declined on the basis of arterial anatomy during this period. The study population was divided in to two groups; MRA and SRA. The surgical unit comprised of a single specialist Trans- plant surgeon to perform the donor operation and a specialist to perform the recipient operation. All recipient operations were performed by the same surgeon .
All live donor evaluations were done according to internationally accepted standard guidelines. All live donors underwent a rigorous medical, ethical and psychological evaluation based on the local guidelines and protocols laid out by the Ministry of Health, Sri Lanka . The side of donor nephrectomy was decided based on a combination of clinical parameters, renal arterial anatomy and differential renal function. Renal arterial anatomy was defined based on computerised tomographic angiography. No donors were declined based on arterial anatomy during the study period. Most donor nephrectomies were performed by open surgery . A few hand-assisted laparoscopic nephrectomies were done where facilities were available. The choice was based mainly on availability of laparoscopic nephrectomy facilities in the hospital. All such laparoscopic nephrectomies were of kidneys with SRA . The donor and recipient operations were always carried out concurrently in adjoining operating theatres. Histamine Tryptophan Ketogluterate (HTK) solution was used in all transplants for back-table flushing of the kidney and storage until recipient anastomosis.
Vascular Anastomosis of Renal Grafts
Unlike renal veins which have multiple intracranial anastomoses, allowing them to be ligated more freely, renal arteries are end arteries. Ligation or injury to these arteries can render the supplied area ischemic, resulting in infarction. Therefore, reconstruction of all donor renal arteries other than small capsular branches is mandatory to obtain maximal graft outcome . The vascular anastomosis of renal grafts with MRA requires careful planning and reconstruction compared to the graft with a SRA. Whereas a SRA will only require a single anastomosis, grafts with MRA require either back-table reconstruction to make a common donor artery ostium or separate anastomosis of the individual arteries to the recipient.
Recipients of grafts with MRA appear to have similar long-term outcomes com- pared to those of SRA. Although an increased incidence of perioperative vascular and urological complications has been observed in the past, this is largely limited to studies that looked at deceased donor grafts with numerous confounding variables such as increased cold ischaemia times and preservation damage. Nevertheless, the use of an aortic patch often circumvents any technical difficulty associated with deceased donor grafts having multiple arteries. In contrast, live donors having multiple arteries require careful planning and reconstruction. In the setting of a rising demand for renal allografts, donor grafts with MRA may be accepted safely with meticulous surgical reconstruction and close surveillance post-transplant . The observed short and medium-term graft outcomes show no significant difference to single artery grafts.
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