American Journal of Transplantation 2007; 7: 264 _C
2006 The Authors
Blackwell Munksgaard Journal compilation _C
2006 The American Society of
Letter to the Editor Transplantation and the American Society of Transplant Surgeons
doi: 10.1111/j.1600-6143.2006.01570.x
Transplantation of En Bloc Kidneys from Very Small Pediatric Donors To the Editor: We read with interest the article by Pelletier and colleagues
entitled ‘Recovery and utilization of deceased donor kid-neys
from small pediatric donors’ (1). The authors docu-mented
that in the United States, between 1993 and 2002, recovery
rates of kidneys from donors weighing <10 kg was very low
compared to donors weighing from 10 to 21 kg (42.9% vs.
90.8%, respectively). Further compound-ing low recovery,
discard rates of kidneys from donors weighing 10 kg was
higher than the 10–20 kg subgroup (40.3% vs. 10.5%).
Whereas this report found that donor weight independently
predicted a higher risk of graft loss, there was no significant
difference in long-term graft sur-vival between kidneys from
donors weighing 10 kg trans-planted en bloc compared to
solitary kidney transplants from donors weighing 15–21 kg.
These data suggest that acceptable outcomes can be
obtained with very small pe-diatric donors (≤10 kg).
Over the past year, we have adopted a more aggressive
ap-proach to the utilization of anatomically challenged
kidneys. At the University of Pittsburgh Medical Center, 8
recipients received en bloc kidneys from donors between
21 days of age and 13 months with weights between 4
and 10 kg. Seven of the 8 recipients achieved immediate
graft func-tion and demonstrate mean creatinine levels of
1.2 mg/dL (range 0.9–1.8 mg/dL) at 5 months follow-up
(range 3– 9 months). One pair failed (3 months old, 8.1
kg) because of poor reperfusion characteristics and
subsequent primary nonfunction. Among the 7 recipients with allograft function, 2 pairs of en
bloc kidneys had been recovered with insufficient aor-tic cuff
and were salvaged by utilizing the suprarenal aorta and vena
cava as the sites of arterial and venous anasto-moses,
respectively (2). Another en bloc pair, declined by other
centers because of short ureteral length (4 cm), was
anastomosed to the distal external iliac vessels; the infe-rior
ureter joined to the bladder and the superior ureter to
the native ureter. Lastly, one pair of en bloc kidneys had
been recovered from a 2-month-old donor (5 kg) in which an
aortic intimal flap, induced that the time of cannulae in-
sertion during recovery, resulted in suboptimal perfusion of
the liver and intestine. One kidney demonstrated areas of
under-perfusion; the other appeared completely perfused.
Following en bloc transplantation the under-perfused kid-ney
remained blue and was immediately removed. The re-
maining kidney functioned immediately; the creatinine is 1.8
mg/dL at 4 months posttransplant. Currently en bloc kidney transplants comprise less than
10% of all renal transplants per year in the United States (3). Kidneys from very small pediatric donors are
generally considered ”marginal” kidneys because of the
higher risk of technical failure and/or thrombosis usually
due to the small vessel size. Many of the anatomic
challenges can be overcome; however, once
successfully transplanted, these kidneys have excellent
renal reserve and long-term survival. Greater efforts
should be directed towards the recovery and
transplantation of kidneys from very small donors. Abigail Martin, Antik Basu, Ron Shapiro, Liise Kayler
Department of Surgery The Thomas E. Starzl
Transplantation Institute University of
Pittsburgh Medical Center Pittsburgh, PA,
USA References
1. Pelletier SJ, Guidinger MK, Merion RM et al. Recovery and
utiliza-tion of deceased donor kidneys from small pediatric
donors. Am J Transplant 2006; 6: 1646–1652. 2. Kayler LK, Blisard D, Basu A et al. Transplantation of en bloc
pediatric kidneys when the proximal vascular cuff is too short.
Transplantation (in press). 3. G, Howard RJ. En-bloc kidney transplantation in the United
States: An analysis of United Network of Organ Sharing (UNOS)
data from 1987 to 2003. Am J Transplant 2005; 5: 1513–1517.
264
Top Related