A 54-year old pre-emptive transplant patient, suffering from adult polycystic kidney disease was deemed suitable for transplantation with his wife as a donor. His co-morbidities include obesity with a BMI of 30 (height 177 cm, weight 93 kg), porphyria carrier (with two previous deep vein thromboses) and treated hypertension. His pre-operative urea was 21.9 mmol/l, creatinine 349 μmol/l and estimated glomerular filtration rate (eGFR) 14 ml/min.
His 47-year-old wife underwent assessment for living donation with no contraindications. She had no significant co-morbidities, a BMI of 23 (height 152 cm, weight 52.5 kg), serum creatinine of 85 μmol/l and eGFR of more than 60 ml/min. Pre-operative CT angiography demonstrated a large 6 cm × 4 cm AML arising from the upper pole of the right kidney.
In addition to the routine consent procedure for a live donor renal transplantation, the donor was also consented for rupture of the AML, recurrence, possible graft damage and/or no transplantation.
The donor underwent a right-side hand assisted retroperitoneoscopic live donor nephrectomy with ex vivo tumour excision (). The operative procedure was unremarkable. The macroscopically tumour free resection margin was reviewed and retrograde insufflation of methylene blue was used to identify calyx lesions. Two lesions were closed using PDS 5/0, followed by closure of the resection surface using BioGlue (CryoLife Inc., USA) to achieve haemostasis.
Donor right kidney after successful hand assisted retro-peritoneoscopic live donor nephrectomy extraction demonstrating AML in the upper pole.
Excision of AML from upper pole of donor kidney.
The recipient's implantation involved a routine kidney transplant approach to the external iliac vessels; reperfusion was homogenic with no bleeding from the resection site.
The patient had prompt kidney graft function with a slow decline of creatinine. He was discharged from hospital on day 4 post transplantation. His transplant ureteric stent was removed 6 weeks after transplantation and he continued on maintenance immunosuppression with prednisolone 5 mg daily and tacrolimus 2 mg twice a day.
At 36 months follow up, the donors creatinine and eGFR are 104 μmol/l and 49 ml/min respectively. While the recipient's serum creatinine is 159 μmol/l and eGFR 40 ml/min. In our department, a routine 3-month biopsy is performed to diagnose early graft rejection. However, the patient is anticoagulated with warfarin due to his previous history of multiple DVT's. The routine post transplant biopsy would therefore, only be indicated if the recipient's renal function significantly declined. This elevated creatinine represents the donor/recipient weight mismatch.
Histology confirmed a 7 cm benign AML tumour, which was larger than the CT angiographic findings.