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 Table of Contents  
ORIGINAL ARTICLE
Year : 2014  |  Volume : 27  |  Issue : 3  |  Page : 514-517

Recipient surgical complications of renal transplantation in children: our initial experience


1 Department of Urology, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Urology, Faculty of Medicine, Cairo University, Cairo, Egypt

Date of Web Publication26-Nov-2014

Correspondence Address:
Fouad Zanaty
Department of Urology, Faculty of Medicine, Menoufia University, Menoufia
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-2098.145494

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  Abstract 

Objectives
The aim of the study was to evaluate the operative and early postoperative surgical complications of renal transplantation in pediatric recipients.
Background
Renal transplantation is considered the treatment of choice in children with end-stage renal disease; however, it is still associated with several surgical complications.
Patients and methods
From July 2010 to January 2013, 50 consecutive pediatric kidney transplants were studied. Immediately before transplantation, a thorough history and physical examination with appropriate laboratory and radiological evaluation were performed to search for any medical or surgical problems that contraindicate the transplantation. We removed the kidney from a living donor through an open surgical technique. The kidney graft was placed extraperitoneally in the right iliac fossa. The arterial anastomoses were performed to the lower aorta or right common iliac artery. The venous anastomoses were performed to the lower inferior vena cava or the right common iliac vein. Our ureteral reimplantation technique was an extravesical, Lich-Gregoir technique. A ureteral stent was placed. We evaluated the ischemia time and any intraoperative or postoperative surgical complications.
Results
Our patients included 36 boys (72%) and 14 girls (28%). Kidneys came from live-related donors in all cases (27 mothers, 19 fathers, two aunts, one uncle, and one brother). At transplantation, the mean recipient age was 9.9 years (range 3-17 years) and mean body weight was 20.9 kg (range 11-45 kg). The graft was placed in an extraperitoneal position in the right iliac fossa in all cases (100%). In cases of single arterial anastomoses (94%), the mean ischemia time was 53.51 ± 11.68 min. In cases of double arterial anastomoses (6%), the mean ischemia time was 68.33 ± 5.77 min. There was significant association between single or double arterial anastomosis and ischemia time, where double arterial anastomosis had longer ischemia time (P = 0.004). There was no intraoperative surgical complication in most of our patients (98%) except in one case (2%) in which the kidney has been transplanted upside down due to misdirection of the upper pole from the lower pole of the kidney. Postoperatively, there were no surgical complications in most of our patients (92%), but there were three cases with high debit urine leaks (6%), and unfortunately there was a case of graft renal vein thrombosis (2%). The mean serum creatinine at 6 months post-transplant was 0.6 mg/dl (range 0.4-0.9 mg/dl). There were no cases of hyperacute rejection. All donors are alive with a good renal function after first 6 months postoperatively.
Conclusion
Our initial surgical experience with renal transplantation carried a low (but clinically significant) risk for vascular and urological recipient complications that increased morbidity, but improvements in our surgical techniques and experience decreased these complications.

Keywords: recipient, renal transplantation


How to cite this article:
Zanaty F, Shoman A, Shoukry A, El Shemy M, Marzouk M, Roaf HA, Eldeen AG, El Gawad O, Eissa M. Recipient surgical complications of renal transplantation in children: our initial experience. Menoufia Med J 2014;27:514-7

How to cite this URL:
Zanaty F, Shoman A, Shoukry A, El Shemy M, Marzouk M, Roaf HA, Eldeen AG, El Gawad O, Eissa M. Recipient surgical complications of renal transplantation in children: our initial experience. Menoufia Med J [serial online] 2014 [cited 2020 Feb 24];27:514-7. Available from: http://www.mmj.eg.net/text.asp?2014/27/3/514/145494


  Introduction Top


Before 1980, infants and small children with end-stage renal disease (ESRD) were generally not considered for transplantation and only selected patients were chosen for dialysis. Recently, renal transplantation is considered the treatment of choice in children with ESRD; however, it is still associated with several surgical complications [1] . The outcomes of renal transplantation have improved significantly in the last 15 years [2] . Advances in medical and nutritional management in children with ESRD and improvements in anesthetic and surgical techniques coupled with major advances in postoperative care have increased overall survival of children undergoing kidney transplantation [3] . A successful renal transplantation improves the quality of life and reduces the mortality rate of patients when compared with maintenance dialysis [4] .


  Patients and methods Top


From July 2010 to January 2013, 50 consecutive pediatric kidney transplants were studied in the Department of Pediatric Urology, Abo Al Resh Hospital, Faculty of Medicine, Cairo University. Immediately before transplantation, a thorough history and physical examination with appropriate laboratory and radiological evaluation were performed. Laboratory evaluation for both donor and recipient includes complete urine analysis, complete blood picture, serum creatinine, liver function tests, random blood sugar, prothrombin time, ABO blood group, donor recipient cross-match test, and serologic testing for HIV, hepatitis virus, cytomegalovirus infection, and syphilis. Radiological evaluation for donor includes abdominal plain radiography and intravenous urography, which provide anatomical and functional information of the whole urinary tract, pelvi-abdominal ultrasound to exclude significant renal or abdominal abnormalities and to evaluate renal site, size, cortical echo pattern, renal congenital anomalies, cystic renal disease or renal obstructive and infective disease of the kidney, radioisotope renography to determine split renal function, and finally three-dimensional computed tomographic angiography to define the renovascular anatomy and to detect multiple vascular pedicles. Radiological evaluation for recipient includes plain radiography, pelvi-abdominal ultrasound, and voiding cystourethrogram, which afford useful information about the presence and extent of vesicoureteral reflux, the size of the bladder, and anomalies such as trabeculations or diverticula. The surgical procedures initiated simultaneously in two adjacent operating rooms - one team works on the nephrectomy, whereas the other prepares the recipient area for grafting. We removed the kidney from a living donor through an open surgical technique, using an extrapleural extraperitoneal flank incision with removal of the 11th rib. The kidney was dissected carefully to preserve all renal arteries, renal veins, and the periureteral blood supply. After the renal vessels were securely ligated and divided, the kidney was removed and placed in a basin of frozen saline slush to decrease renal metabolism. The renal artery was cannulated and flushed with cold heparinized normal saline solution. We kept the kidney transplant cool by wrapping it in a sponge containing crushed saline ice or by dripping an ice-cold electrolyte solution on it until the vascular anastomoses were completed. In recipient, the kidney graft was placed extraperitoneally in the right iliac fossa. The incision used in all our patients was pararectal with retroperitoneal access (Gibson incision). In small children, this was accomplished by extension to the right costal margin. The anterior wall of the aorta and the cava was exposed and dissected free. The arterial anastomoses were performed to the lower aorta or right common iliac artery with a double-ended 6-0 polypropylene suture in an end-to-side manner. The venous anastomoses were performed to the lower inferior vena cava or the right common iliac vein with a running 5-0 or 6-0 polypropylene suture. Observation of urine within a couple of minutes and pink, firm, well-perfused kidney were reassuring signs of transplantation success. Our ureteral reimplantation technique was an extravesical, Lich-Gregoir technique. First, the ureter is cut to appropriate length and spatulated while ensuring adequate preservation of periureteral tissue that contains the ureteral blood supply. The lateral aspect of the bladder is mobilized and the site for the anastomosis is identified. A ureteral stent was placed. All transplant recipients were seen postoperatively by both transplantation surgical team and the transplant nephrology team. We collected demographic information, including age at surgery and sex, for all patients. We evaluated the type of vascular anastomosis, the ischemia time, intraoperative and postoperative surgical complications, postoperative serum creatinine, and early graft survival. Results were collected, tabulated, and statistically analyzed by IBM personal computer and statistical package SPSS version 11 (SPSS Inc., Chicago, Illinois, USA). Unpaired t-test was used to compare quantitative parametric data between two groups (SD <50% mean). The Mann-Whitney U-test (nonparametric test) was used for comparison between two groups not normally distributed having quantitative variables (SD >50% mean). Significance was defined with a P-value less than 0.05.


  Results Top


From July 2010 to January 2013, 50 primary consecutive pediatric kidney transplants were studied. These patients included 36 boys (72%) and 14 girls (28%). Kidneys came from live-related donors in all cases using the classic open surgical technique (27 mothers, 19 fathers, two aunts, one uncle, and one brother). Average donor age was 34.8 years (range between 21 and 50 years). The mean recipient age at transplantation was 9.9 years (range 3-17 years) and their mean body weight was 20.9 kg (range 11-45 kg). The graft was placed in an extraperitoneal position in the right iliac fossa in all cases (100%). Arterial anastomoses were performed to the recipient distal aorta in 36 cases (72%) and to the right common iliac artery in 11 cases (22%). There was double arterial anastomosis to distal aorta and right common iliac artery in three cases (6%). The inferior vena cava was the site of venous anastomosis in 39 cases (78%) and the right common iliac vein was the site of venous anastomosis in 11 cases (22%). In cases of single arterial anastomoses (94%), mean ischemia time was 53.51 ± 11.68 min. In cases of double arterial anastomoses (6%), mean ischemia time was 68.33 ± 5.77 min. There was significant association between single or double arterial anastomosis and ischemia time, where double arterial anastomosis had longer ischemia time (P = 0.004) ([Table 1]). There was no intraoperative surgical complication in most of our patients (98%) except in one case (2%) in which the kidney has been transplanted upside down due to misdirection of the upper pole from the lower pole of the kidney ([Table 2]). Postoperatively, there were no surgical complications in most of our patients (92%), but there were three cases with high debit urine leaks (6%), and unfortunately there was a case of graft renal vein thrombosis (2%) ([Table 3]). The mean serum creatinine at 6 months post-transplant was 0.6 mg/dl (range 0.4-0.9 mg/dl). There were no cases of hyperacute rejection. All donors are alive with a good renal function after first 6 months postoperatively.
Table 1: Relationship between intraoperative ischemia time and number of arterial anastomosis (single or double)


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Table 2: Recipient intraoperative complications


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Table 3: Early recipients' postoperative surgical complications


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  Discussion Top


Pediatric renal transplantation is an excellent option for the treatment of uremic children, but complications following kidney transplantation remain an important clinical problem that may increase morbidity and hospitalization [5] . In our study, the mean age at transplantation was 9.9 years (range 3-17 years) and their mean body weight was 20.9 kg (range 11-45 kg). We excluded children with body weight less than 10 kg to avoid perioperative difficulty and to avoid graft loss due to vascular thrombosis. According to Norman and colleagues, the use of adult donors for transplantation in children less than 8-10 kg is technically impossible. There is an unbalance between the vascular resistance of the grafted kidney and the capacity of the fragile cardiovascular system of the child to perfuse it [6] . In addition, Sharma et al. [7] reported that adult donor kidneys can be used in children weighing 10 kg or more while being aware of the higher risk for vascular thrombosis and using adequate perioperative hydration and anticoagulation. Many pediatricians prefer to maintain infants on a regular dialysis program and to postpone the transplant by 1-2 years until the size of the recipient offers a better chance of success. In cases of single arterial anastomoses (94%), mean ischemia time was 53.51 ± 11.68 min. Total ischemia time in our technique was almost equivalent to warm and cold ischemia time. Warm ischemia time was considered from the moment of ligation of the artery to the flushing of preservation solution into the kidney in the side table. Pacholczyk et al. [8] stated that total ischemia time should not exceed 1 h. In cases of double arterial anastomoses (6%), mean ischemia time was 68.33 ± 5.77 min. There was significant association between single or double arterial anastomosis and ischemia time, where double arterial anastomosis had longer ischemia time (P = 0.004) ([Table 1]). According to Mazzucchi et al. [9] , it is clear that ischemia time is longer in transplants with multiple arteries. In our work, there was no intraoperative surgical complication in most of our patients (98%) except in one case (2%) in which the kidney has been transplanted upside down due to misdirection of the upper pole from the lower pole of the kidney and vascular reanastomosis was performed. A disappointing observation on completion of the vascular anastomoses would be finding the transplant ureter pointing in the wrong direction. This error is more likely to occur with a living donor kidney in the absence of the full length of the renal vein and the absence of the aortic patch on the artery [10] . Navarrete [11] reported that, to facilitate the correct position of the kidney, the surgeon who is handling the kidney and sectioning the vessels is the same one performing the grafting. A better option for this complication is to ensure that this error does not occur. Postoperatively, high debit urine leaks occurred in three cases (6%) due to technical errors. Lymph and urine can be differentiated from each other by creatinine determinations. Lymph has a creatinine concentration that is the same as that of serum, and urine has a creatinine concentration higher than that of serum and approaching that of bladder urine. A retrograde cystogram documented leakage at the ureteroneocystostomy site. All cases were managed by revision of ureteroneocystostomy with double J insertion within the first 5 days post-transplant with good outcome. Mangus et al. [12] stated that ureteral leaks are reported in 1-3% of renal transplants. These three cases were in the first year of our initial experience. After improving of our surgical techniques, there were no further cases of urinary leakage during the ensuing years. Unfortunately, there was a case of transplant renal vein thrombosis (2%) in a 4-year-old boy. The clinical condition includes pain, swelling of the renal graft, and early graft dysfunction with acute reduction of urine output. Doppler ultrasound and MAG3 nuclear renography were performed within 48 h of transplant to document graft perfusion, and they revealed an absence of venous flow and abnormal arterial signal with enlargement of the renal graft. The patient was returned to the operating room on the fourth day for emergent revision, but graft nephrectomy was the result. According to Giustacchini et al. [13] , transplant renal vein thrombosis is a marked, early vascular complication following renal transplantation, with a reported prevalence of 0.5-4%. Our incidence of graft thrombosis compares favorably with that of Sheldon et al. [14] , in which 16 of 303 grafts were lost due to this complication (5.3%). Hence, this type of vascular complication usually leads to graft loss and prevention is the best available treatment option. Finally, mean serum creatinine at 6 months post-transplant was 0.6 mg/dl (range 0.4-1.7 mg/dl). According to Hariharan et al. [15] , 1-year serum creatinine levels below 1.5 mg/dl are predictive of excellent long-term graft survival.


  Conclusion Top


Our initial surgical experience with renal transplantation carried a low (but clinically significant) risk for vascular and urological recipient complications that increased morbidity, but improvements in our surgical techniques and experience decrease these complications.


  Acknowledgements Top


Conflicts of interest

None declared.

 
  References Top

1.Haberal, M, et al. Renal transplantation in children. Transplant Proc 2000; 32 :520-521.  Back to cited text no. 1
    
2. Tyden, G, et al. Renal transplantation in children less than two years old. Transplantation. 1997; 63 :554-558.  Back to cited text no. 2
    
3. Hariharan, S, et al. Improved graft survival after renal transplantation in the United States, 1988 to 1996. N Engl J Med 2000; 342 :605-612.  Back to cited text no. 3
    
4. Einollahi, B, et al. Patient and graft outcome after living donor renal transplantation in Iran: more than 15-year follow-up. Transplant Proc 2003; 35 :2605-2606.  Back to cited text no. 4
    
5. Humar A, AJ Matas. Surgical complications after kidney transplantation. Semin Dial 2005; 18 :505-510.  Back to cited text no. 5
    
6. The American Society of Transplant Physicians. In: L Turka D Norman editors Pediatric renal transplantation. Primer on transplantation. Oregon: Blackwell Publishers; 1999. 54-57.  Back to cited text no. 6
    
7. A Sharma, Ramanathan R, M Posner, RA Fisher. Pediatric kidney transplantation: a review. Transpl Res Risk Manag 2013; 5 :21-31.  Back to cited text no. 7
    
8. Pacholczyk, MJ, et al. Transplantation of kidneys harvested from non-heart-beating donors: early and long-term results. Transpl Int 1996; 9 :S81-S83.  Back to cited text no. 8
    
9. Mazzucchi, E, et al. Surgical complications after renal transplantation in grafts with multiple arteries. Int Braz J Urol 2005; 31 :125-130.  Back to cited text no. 9
    
10.Allen, RDM. SJ Knechtle, PJ Morriseditors. Vascular complications after kidney transplantation. Kidney transplantation: principles and practice. Philadelphia: Elsevier; 2008. 439-461.  Back to cited text no. 10
    
11.Navarrete RV. Renal transplantation with living-donor surgical strategies: a view with 40 years of experience. Eur Urol 2009; 56 : 38-39.  Back to cited text no. 11
    
12.Mangus RS, BW Haag, CB Carter. Stented Lich-Gregoir ureteroneocystostomy: case series report and cost-effectiveness analysis. Transplant Proc 2004; 36 :2959-2961.  Back to cited text no. 12
    
13.Giustacchini, P, et al. Renal vein thrombosis after renal transplantation: an important cause of graft loss. Transplant Proc 2002; 34 :2126-2127.  Back to cited text no. 13
    
14.Sheldon, CA, et al. Complications of surgical significance in pediatric renal transplantation. J Pediatr Surg 1992; 27 :485-490.  Back to cited text no. 14
    
15.Hariharan, S, et al. Post-transplant renal function in the first year predicts long-term kidney transplant survival. Kidney Int 2002; 62 : 311-318.  Back to cited text no. 15
    



 
 
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  [Table 1], [Table 2], [Table 3]



 

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Introduction
Patients and methods
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