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Table of Contents
CASE REPORT
Year : 2019  |  Volume : 13  |  Issue : 4  |  Page : 297-299

En-bloc kidney transplant from an 11-month-old pediatric donor to an adult recipient: Case report and review of literature


Department of Renal Transplant Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Date of Submission14-Aug-2019
Date of Acceptance26-Nov-2019
Date of Web Publication31-Dec-2019

Correspondence Address:
Dr. Sarbpreet Singh
Department of Renal Transplant, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijot.ijot_34_19

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  Abstract 


The huge disparity between the number of end-stage renal disease patients awaiting renal transplant and the available donor organs can be overcome by increasing the utilization of donor organs from deceased donors. The use of kidneys from a deceased pediatric donor is technically challenging because of the smaller size of the donor organ, leading to a higher incidence of graft thrombosis apart from concerns of low nephron load resulting in early graft failure. We present a case of en-bloc kidney transplant from an 11-month-old to a 38-year-old female recipient. The cold ischemia was 250 min and operative time was 300 min. The 1st day urine output was 6.7 l with serum creatinine dropped to 0.9% mg on postoperative day 3.

Keywords: Deceased donor, en-bloc kidney, increased utilization of deceased donor, low nephron load, pediatric donor


How to cite this article:
Pandey GS, Sharma A, Kenwar DB, Seth A, Singh S. En-bloc kidney transplant from an 11-month-old pediatric donor to an adult recipient: Case report and review of literature. Indian J Transplant 2019;13:297-9

How to cite this URL:
Pandey GS, Sharma A, Kenwar DB, Seth A, Singh S. En-bloc kidney transplant from an 11-month-old pediatric donor to an adult recipient: Case report and review of literature. Indian J Transplant [serial online] 2019 [cited 2020 Apr 8];13:297-9. Available from: http://www.ijtonline.in/text.asp?2019/13/4/297/274608




  Introduction Top


Kidney transplant is the treatment of choice for patients with end-stage renal disease (ESRD). There remains a huge disparity between the number of ESRD patients awaiting renal transplant and the available donor organs; therefore, strategies are required to increase the utilization of donor organs from deceased donors. The use of kidneys from a pediatric donor is technically challenging because of the smaller size of the donor organ, leading to a higher incidence of graft thrombosis apart from concerns of low nephron load resulting in early graft failure. The first en-bloc pediatric kidney transplant (EBKT) in an adult was done in 1972, followed by single pediatric kidney transplant (SPKT) in 1990.[1],[2] Some of the recent published studies have also shown pediatric kidneys to be suitable for matched adult recipients when used appropriately as en-bloc or single kidney transplant.[3],[4] However, the use of these organs remains scarce in our country. Here, we present a case of EBKT from an 11-month-old pediatric kidney to a 38-year-old female recipient.


  Case Report Top


Donor details

The donor was an 11-month-old male who was declared brain dead after sustaining head injury following a fall from height. Abdominal ultrasound revealed normal abdominal viscera with both kidneys measuring 6 cm. The donor weighed 9 kg and had a serum creatinine of 0.3 mg/dl. At the time of organ retrieval, the donor was on triple inotropes with a urine output of 20 mL/h.

Recipient details

The recipient was a 38-year-old female patient having ESRD from an unknown cause and was on dialysis for the past 8 years. She had a history of abdominal tuberculosis and was on antitubercular therapy. Her body weight was 51 kg with a body mass index of 19.92 kg/m2. The complement dependent cytotoxicity cross-match was negative.

Operative details

A standard midline incision was used from the xiphisternum till the pubis symphysis. The lower abdominal aorta was cannulated with a short 7-F vascular sheath and was secured with sutures. Upper aortic control was obtained after exposure through the lesser sac. Both kidneys were retrieved en bloc with the aorta and vena cava from the level of the celiac axis till the iliac bifurcation. The ureters were dissected till their entry into the urinary bladder. Upper margins of the aorta and inferior vena cava (IVC) were closed with 6-0 prolene during bench dissection [Figure 1]. The branches of the aorta and IVC were either sutured or tied. The size of the right kidney was 6 cm × 4 cm and the left kidney was 6.2 cm × 4.2 cm. The diameter of the aorta and IVC was 3 and 5 mm, respectively. The extraperitoneal approach was used for implanting the kidneys. Lower margins of the aorta and IVC were anastomosed end to side to the external iliac artery and vein of the recipient respectively using 6-0 prolene. The patient had brisk diuresis after declamping. Double barreling of both the ureters was done and then anastomosed with the bladder by the modified Lich-Gregoir technique using polydioxanone suture No. 5 suture over double J (DJ) stents. The cold ischemia was 250 min and operative time was 300 min.
Figure 1: (a) En-block kidneys after back-table preparation. RK: Right kidney, LK: Left kidney, IVC: Inferior vena cava, U: Ureter. (b) En-block kidneys after implantation into the right iliac fossa. RK: Right kidney, LK: Left kidney, IVC: Inferior vena cava, U: Ureter, UB: Urinary bladder

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Perioperative course

The patient was induced with antithymocyte globulin and was started on triple immunosuppression of tacrolimus, mycophenolate, and prednisolone. The 1st day urine output was 6.7 L, with serum creatinine dropping to 0.9 mg% on postoperative day (POD) 3. The patient received anticoagulation with heparin initially, followed by oral warfarin for 6 weeks. The perfusion fluid grew Escherichia coli sensitive to piperacillin-tazobactam, which was given for 1 week. The DJ stents were removed on POD 13. At 10-month follow-up, the patient has a serum creatinine of 0.48 mg/dl. Diethylenetriaminepentaacetic acid scan done at 7 months posttransplant showed a glomerular filtration rate (GFR) of 53.5 mL/min with a split function of 25.1 mL/min and 28.4 mL/min.

The patient consent has been taken for participation in the study and for publication of clinical details and images. Patients understand that the names, initials would not be published, and all standard protocols will be followed to conceal their identity.


  Discussion Top


The use of pediatric kidneys for transplantation in adult recipients in our country remains extremely low, and there is no report of successful transplantation in the published literature from a donor younger than 1 year of age in India. The use of pediatric organs is associated with risks of vascular thrombosis, hyperfiltration injury, and low nephron mass in addition to the technical difficulties involved in the anastomosis of smaller pediatric vessels in an adult recipient.[5],[6]

Surgical experience and technique have been identified as major factors influencing the outcome of pediatric EBKT,[7] and many different techniques have been described in the literature to reduce vascular complications.[8],[9] Both the kidneys were used en bloc in this patient to address the challenges of the small caliber of pediatric vessels as well as low nephron mass. It has been reported that comparable graft survival and complication rates can be achieved by EBKT with these small kidneys.[10] Data from the scientific registry of organ transplantation have also shown that transplanting en-bloc kidneys into adult recipients results in equivalent patient and graft survival, compared with adult cadaveric kidneys except for an increase in vascular thrombosis.[11] Vascular thrombosis resulting in graft loss has been reported more often when single kidney without aortic cuff was used for transplantation as compared to EBKT, but, overall, similar graft survival (86% vs. 79%) and incidence of acute rejection (21% vs. 21%) have been observed in EBKT and SPKT, respectively. However, delayed graft function has been reported more commonly (25% vs. 0%; P = 0.0542) when a single pediatric kidney was used as compared to EBKT.[12] The long-term graft survival of EBKT is also better than pediatric single kidney transplants and is similar to adult donor kidney transplants.[7],[9],[11],[12] Overall, the 5-year graft survival has been reported to be better with EBKT when compared with standard, deceased, and living-donor transplants (92%, 70%, and 88%, respectively).[13]

There were no clear guidelines in the past regarding when to choose EBKT versus solitary kidney transplant from pediatric donors, but EBKT is now advocated for donors <2 years of age and weighing <10 kg.[14] EBKT was performed in this report based on this recommendation, and the recipient with the lowest body weight was chosen for transplant among the waitlisted patients to minimize mismatch. There have been concerns regarding the donor–recipient weight mismatch, and historically, pediatric kidneys were offered to children or to adults with low weight as a way to provide adequate nephron mass. This was done to avoid the hyperfiltration injury which could cause hypertension, proteinuria, and glomerulosclerosis, and ultimately, lead to graft failure.[15] It has been observed that a recipient with a high body surface area (BSA >2.2 m2) who receives a kidney from a small donor has a 43% increased risk of late graft failure as compared to a matched donor–recipient pair. Similarly, a medium-sized recipient receiving a kidney from a small donor has a 16% increased risk of late graft failure.[16] Contrarily, many studies have also shown that pediatric graft kidneys undergo compensatory hypertrophy and achieve normal GFR, with some suggesting an even better estimated GFR than those of standard criteria donor.[3],[9],[12]

The patient in this case report was kept on heparin followed by oral anticoagulation for 2 weeks, as vascular thrombosis remains a significant problem in pediatric donor renal transplants. Many factors such as lower blood pressure, smaller size of vessels, and vessel or kidney torsion are implicated in vascular thrombosis. In pediatric donors, the absence of aortic patch and donor age <12 months have also been cited as additional risk factors.[12],[17],[18] However, routine anticoagulation has not proven to be of benefit in reducing graft thrombosis.[7],[13] The diagnosis of acute rejection with pediatric kidneys is also a major concern. The small size of these kidneys makes doing allograft biopsies more difficult but is usually not required as the current rates of acute rejection are quite low[3] (6% with EBKT compared to 9% in that of SKT[9]).

Various techniques have been described in the literature for anastomosis of the ureter with the bladder. In the present case, double-barreled ureters were anastomosed to the bladder over two DJ stents by the modified Lich-Gregoir technique. Other techniques include implantation of bladder patch of trigone area including both the ureters.[19],[20] Ureterocystostomy of pediatric kidneys is at an increased risk of developing complications with an incidence ranging between 2.5% and 11% because of the short length of the ureter and tenuous blood supply.[12] Various complications reported are perforation of the renal pelvis during DJ stent insertion, urine leak, and stricture at the ureterocystostomy site. In the present case, no surgical complications were noted. Avoiding hilar dissection, gentle handling of blood vessels along with placement kidneys relatively closer to the bladder to avoid tension on ureterocystostomy anastomosis can minimize such complications.


  Conclusion Top


EBKT can be successfully utilized to reduce surgical complications and improve long-term outcomes with small pediatric donors. It offers an opportunity to expand the limited donor pool. Donor–recipient matching based on BSA may provide a better outcome with regard to graft survival.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed

Financial support and sponsorship

Nil.

Conflicts of interest

There are nao conflicts of interest.



 
  References Top

1.
Meakins JL, Smith EJ, Alexander JW. En bloc transplantation of both kidneys from pediatric donors into adult patients. Surgery 1972;71:72-5.  Back to cited text no. 1
    
2.
Banowsky LH, Lackner J, Kothmann R, Wright FH. Results of single kidneys from donors aged 9 to 60 months: Results in 144 adult recipients. Transplant Proc 1997;29:3271-3.  Back to cited text no. 2
    
3.
Hirukawa T, Suzuki H, Niimura F, Fukagawa M, Kakuta T. En bloc cadaver kidney transplantation from a 9-month-old donor to an adult recipient: Maturation of glomerular size and podocyte in the recipient. Transplant Direct 2017;3:e130.  Back to cited text no. 3
    
4.
Zhang R, Paramesh A, Florman S, Yau CL, Balamuthusamy S, Krane NK, et al. Long-term outcome of adults who undergo transplantation with single pediatric kidneys: How young is too young? Clin J Am Soc Nephrol 2009;4:1500-6.  Back to cited text no. 4
    
5.
Mahdavi R, Arab D, Taghavi R, Gholamrezaie HR, Yazdani M, Simforoosh N, et al. En bloc kidney transplantation from pediatric cadaveric donors to adult recipients. Urol J 2006;3:82-6.  Back to cited text no. 5
    
6.
Satterthwaite R, Aswad S, Sunga V, Shidban H, Mendez RG, Bogaard T, et al. Outcome of en bloc and single kidney transplantation from very young cadaveric donors. Transplantation 1997;63:1405-10.  Back to cited text no. 6
    
7.
Sánchez-Fructuoso AI, Prats D, Pérez-Contín MJ, Marques M, Torrente J, Conesa J, et al. Increasing the donor pool using en bloc pediatric kidneys for transplant. Transplantation 2003;76:1180-4.  Back to cited text no. 7
    
8.
Troppmann C, Perez RV. Transplantation of pediatric en bloc kidneys when the proximal vascular cuff is too short: The aortorenal aortic lid. Transplantation 2007;84:1064-5.  Back to cited text no. 8
    
9.
Bhayana S, Kuo YF, Madan P, Mandaym S, Thomas PG, Lappin JA, et al. Pediatric en bloc kidney transplantation to adult recipients: More than suboptimal? Transplantation 2010;90:248-54.  Back to cited text no. 9
    
10.
Al-Shraideh Y, Farooq U, El-Hennawy H, Farney AC, Palanisamy A, Rogers J, et al. Single vs. dual (en bloc) kidney transplants from donors ≤5 years of age: A single center experience. World J Transplant 2016;6:239-48.  Back to cited text no. 10
    
11.
Hobart MG, Modlin CS, Kapoor A, Boparai N, Mastroianni B, Papajcik D, et al. Transplantation of pediatric en bloc cadaver kidneys into adult recipients. Transplantation 1998;66:1689-94.  Back to cited text no. 11
    
12.
Mohanka R, Basu A, Shapiro R, Kayler LK. Single versus en bloc kidney transplantation from pediatric donors less than or equal to 15 kg. Transplantation 2008;86:264-8.  Back to cited text no. 12
    
13.
Sharma A, Fisher RA, Cotterell AH, King AL, Maluf DG, Posner MP. En bloc kidney transplantation from pediatric donors: Comparable outcomes with living donor kidney transplantation. Transplantation 2011;92:564-9.  Back to cited text no. 13
    
14.
Danovitch GM. Handbook of Kidney Transplantation. 6th ed. Philadelphia: Lippincott Williams and Wilkins; 2017. p. 624.  Back to cited text no. 14
    
15.
Kayler LK, Magliocca J, Kim RD, Howard R, Schold JD. Single kidney transplantation from young pediatric donors in the United States. Am J Transplant 2009;9:2745-51.  Back to cited text no. 15
    
16.
Kasiske BL, Snyder JJ, Gilbertson D. Inadequate donor size in cadaver kidney transplantation. J Am Soc Nephrol 2002;13:2152-9.  Back to cited text no. 16
    
17.
Sureshkumar KK, Reddy CS, Nghiem DD, Sandroni SE, Carpenter BJ. Superiority of pediatric en bloc renal allografts over living donor kidneys: A long-term functional study. Transplantation 2006;82:348-53.  Back to cited text no. 17
    
18.
Bresnahan BA, McBride MA, Cherikh WS, Hariharan S. Risk factors for renal allograft survival from pediatric cadaver donors: An analysis of united network for organ sharing data. Transplantation 2001;72:256-61.  Back to cited text no. 18
    
19.
Kato T, Selvaggi G, Burke G, Ciancio G, Zilleruelo G, Hattori M, et al. Partial bladder transplantation with en bloc kidney transplant-the first case report of a 'bladder patch technique' in a human. Am J Transplant 2008;8:1060-3.  Back to cited text no. 19
    
20.
Milonas D, Skarupskiene I, Aniulis P, Stramaityte I, Dalinkeviciene E, Stankuviene A. En bloc kidney transplantation from a 24 month-old donor to an adult recipient: Case presentation and literature review. Cent European J Urol 2017;70:123-7.  Back to cited text no. 20
    


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