Advanced atherosclerosis or thrombosis of iliac vessels can constitute an absolute contraindication for heterotopic kidney transplantation. We report the case of a 42-year-old women with end-stage renal disease due to lupus nephritis and a history of bilateral thrombosis of iliac arteries caused by antiphospholipid antibodies. Occlusion had been treated by the bilateral placement of wall stents which precluded vascular anastomosis. The patient was transplanted with a right kidney procured by laparoscopic nephrectomy from her HLA semi-identical sister. The recipient had left nephrectomy after laparoscopical transperitoneal dissection. The donor kidney was orthotopically transplanted with end-to-end anastomosis of graft vessels to native renal vessels and of the graft and native ureter. Although, the patient received full anticoagulation because of a cardiac valve and antiphospholipid antibodies, she had no postoperative complication in spite of a short period of delayed graft function. Serum creatinine levels three months after transplantation were at 1.0 mg/dl. Our case documents that orthotopical transplantation of laparoscopically procured living donor kidneys at the site of recipient nephrectomy is a feasible procedure in patients with surgical contraindication of standard heterotopic kidney transplantation.
We report the case of a 42-year-old woman who underwent orthotopic renal transplantation for the first time, using a kidney from her sister. The patient had developed end-stage renal disease secondary to lupus nephritis. She had a medical history of bilateral thrombosis of both common and external iliac arteries due to lupus anticoagulant and antiphospholipid antibodies that had required bilateral percutaneous angioplasty with wall stenting. The medical workup had documented thrombosis of both iliac veins and of the lower portion of the lower part of the inferior vena cava as well as extensive atherosclerotic lesions of the abdominal aorta. In addition, she had a history of mitral valve replacement with a St. Jude prosthetic valve and received anticoagulation therapy with acenocoumarol.
The patient had an HLA semi-identical sister who was willing to donate a kidney. The donor workup had documented a slightly lower tubular mass of the right kidney which was chosen for procurement. The “classic” extraperitoneal pelvic transplantation of a kidney graft was contraindicated because of stented iliac arteries and extended atheromatosis of the aorta (Figure
CT angiography image of the receiver pelvic vessels.
CT angiography image of the receiver left renal vessels.
The graft was procured by laparoscopic right donor transperitoneal nephrectomy with utilization of linear stapler Endo-GIA as previously described [
The recipient was placed in a modified lateral decubitus position and Table
Donor and recipient data.
Donor | Recipient | |
---|---|---|
Age (years) | 39 | 42 |
Sex | Female | Female |
BMI | 25.4 | 26.2 |
Side of nephrectomy | Right | Left |
Blood loss | 25 cc | 15 cc |
Operation time (skin-to-skin) | 1 h 35 min | 1 h 45 min |
Hospital stay | 4 days | 13 days |
day of the transplantation | ||
(i) creatinine level (mg/dL) | 0.6 | 3.3 |
(ii) glomerular filtration (mL/min/1.732) | >90 | 15 |
2 weeks after transplantation | ||
(i) creatinine level (mg/dL) | 1.1 | 1.2 |
(ii) glomerular filtration (mL/min/1.732) | 68 | 51 |
1 year after transplantation | ||
(i) creatinine level (mg/dL) | 0.9 | 1.1 |
(ii) glomerular filtration (mL/min/1.732) | 74 | 56 |
The native renal vessels were found to be sufficient and were used for the end-to-end anastomoses with prolene 6/00 for the artery and prolene 5/00 for the vein.
The left native ureter was then spatulated and anastomosed in an end-to-end fashion to the transplant ureter with vicryl 3–0, over double J stent. A lombonephropexy of the graft was performed and a silicone Jackson-Pratt drain was inserted. The abdominal wall was closed using running vicryl 2–0 suture for the peritoneum, interrupted vicryl 0 suture for the muscle, and running vicryl 1 for the aponeurosis, and the skin incisions were closed with intradermal suture. The second warm ischemia time was 17 minutes and blood loss in the recipient was 15 mL.
At the moment of transplantation, the patient had maintenance immunosuppression with azathioprine and steroids for her systemic lupus erythematosus. Basiliximab and tacrolimus were added for prevention of acute graft rejection. The patient had delayed graft function up to day 4 but did not require renal replacement therapy because of the residual function of her native kidney. Anticoagulation consisted first of low molecular weight heparine (enoxaparin 20 mg per day) with resumption of acenocoumarol on postoperative day 6. The only medical complication was a urinary infection with Pseudomonas Aeruginosa treated with ciprofloxacine. The patient left the department two weeks after transplantation with a serum creatinine of 1.2 mg/dL. The double-J stent was removed 4 weeks after transplantation. Three months after transplantation a control angio-MRI showed normal a normal kidney and graft vessels (Figure
MRI angiography image after kidney transplantation in orthotopic position.
We present a first case of orthotopic transplantation of a living-donor kidney using laparoscopic techniques for nephrectomy of both the donor and recipient kidneys in young patients with complex vascular disease contraindicating classical heterotopic transplantation. Our case demonstrates that these surgical procedures permit successful renal transplantation in selected candidates that would otherwise be forced undergo life-long renal replacement therapy.
We chose laparoscopic donor nephrectomy as these technique better aesthetic outcomes, a shortened hospital stay and overall better quality of life as compared to the open procedure while resulting in equivalent graft outcomes [
We chose a laparoscopic technique for recipient nephrectomy to minimize surgical trauma and the risk of bleeding in this patient treated with chronic anticoagulation because of a metallic prosthetic valve and taking in the consideration that the postoperative complications after classic lumbotomy or mini-incision open donor nephrectomy described in 12% of cases [
In summary our case shows that living donor orthotopic kidney transplantation with laparoscopic donor and recipient nephrectomy is a feasible procedure associated with low morbidity and excellent graft outcome that can allow successful transplantation in patients with surgical contra-indications to classical heterotopic transplantation.