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Logo of nihpaAbout Author manuscriptsSubmit a manuscriptHHS Public Access; Author Manuscript; Accepted for publication in peer reviewed journal;
 
Transplantation. Author manuscript; available in PMC 2010 December 21.
Published in final edited form as:
PMCID: PMC3005339
NIHMSID: NIHMS250012

Transplantation of En Bloc Pediatric Kidneys When the Proximal Vascular Cuff Is Too Short

Kidneys from donors <10 kg are generally transplanted en bloc to avoid small anastomotic vessel size and increase nephron mass; however, these kidneys remain underused because of low recovery and high discard rates. In the United States, between 1993 and 2002, the recovery rate of donors weighing <10 kg was 42.9% compared with 90.8% for those weighing 10 to <21 kg (1). Compounding low recovery rates, discard rates increase below donor weights of 10 kg. Only 10.5% of kidneys from donors 10 to 20 kg are discarded compared with 40.3% among donors <10 kg (1). The single most common specified reason for the discard of pediatric kidneys is vascular damage (1). We describe a technique for the salvage of en bloc kidneys from a five-month-old donor in which the proximal aortic cuff was cut flush at the level of the renal arteries and the left renal vein was transected.

The en bloc allografts were prepared by ligation of all arterial and venous nonrenal tributaries with 4-0 silk ties. The infrarenal vena cava and aortic segments were oversewn with continuous 6-0 nonabsorbable monofilament suture leaving the suprarenal vascular segments open. The recipient operation was performed through a standard extraperitoneal approach in the right iliac fossa. As a result of the delicate nature of the vena cava, there was difficulty in repairing the cut left renal vein; therefore, the renal veins were sutured separately end-to-side to the external iliac vein. The suprarenal portion of the donor aorta was anastomosed to the external iliac artery end-to-side (Fig. 1).

FIGURE 1
Schematic representation of en bloc transplantation using the suprarenal vessels for revascularization.

Both renal allografts functioned immediately. The creatinine is 1.3 mg/dL at five months posttransplantation. There were no vascular or ureteral complications.

En bloc transplantation of kidney xenografts was originally described by Carrel (2). The technique was first applied in humans by Martin and colleagues (3) who described the method widely performed today comprising end-to-side anastomoses of the infrarenal donor vena cava and aorta to the recipient vessels (4, 5). Alterations of the classic technique such as interposition grafting of the aorta and vena cava to the recipient vessels (6), have also been used. Other techniques have been described to salvage en bloc kidneys when the renal arteries are compromised (79). Merkel and Matalon (7) described excision of a segment of the donor infrarenal vena cava with transposition as a tube graft to the donor suprarenal aorta and interposition of the combined aortic/vena cava in an end-to-end fashion to the recipient artery. More simplified approaches involve the application of suprarenal aortic graft extensions from the donor aorta (8), donor vena cava (8), recipient saphenous vein (8), or iliac vessel from the same donor or ABO-compatible donor (9).

Our technique illustrates an alternative method to salvage en bloc kidneys. Revascularization using the suprarenal aortic cuff avoids an additional anastomosis and does not require the use of venous tissue, which has the potential of becoming aneurysmal. Inversion of the kidneys allows separate renal vein anastomoses or utilization of the suprarenal vena cava cuff for revascularization.

Contributor Information

Liise K. Kayler, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA.

Deanna Blisard, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA.

Amit Basu, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA.

Henkie P. Tan, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA.

Jerry McCauley, Department of Nephrology, University of Pittsburgh Medical Center, Pittsburgh, PA.

Christine Wu, Department of Nephrology, University of Pittsburgh Medical Center, Pittsburgh, PA.

Amadeo Marcos, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA.

Thomas E. Starzl, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA.

Ron Shapiro, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA.

Ernesto Molmenti, Department of Surgery, University of Arizona, Tucson, AZ.

References

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2. Carrel A. Transplantation en mass of the kidneys of the kidneys. J Exp Med. 1908;10:98. [PMC free article] [PubMed]
3. Martin JE, Gonzales LL, West CD, Swartz RA, Sutorius DJ. Homotransplantation of both kidneys from an anencephalic monster to 17 pound boy with Eagle Barrett syndrome. Surgery. 1969;66:603. [PubMed]
4. Nghiem DD. En bloc transplantation of kidneys from donors weighing less than 15 kg into adult recipients. J Urol. 1991;145:14. [PubMed]
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