Abstracts

KIDNEY TRANSPLANTATION EN-BLOC WITH LIVER AND MULTIVISCERAL ORGANS IN PATIENTS WITH INSUFFICIENT VENOUS ACCESS: A TECHNICAL CHALLENGE

Geoffrey Bond, Kyle Soltys, Rakesh Sindhi, Ron Shapiro, George Mazariegos. University of Pittsburgh Medical Center, Thomas E Starzl Transplantation Institute, Pittsburgh, PA.

Background: Standard implantation of a kidney allograft is performed utilizing the iliac artery and vein, or in the young and cases of difficult access the aorta and inferior vena cava (IVC). Rarely patients can present with thrombosed iliac veins and IVC, making implantation impossible through routine measures. This scenario may be encountered in patients with hypercoaguable states or patients with multiple previous venous catheters. We present a series of cases in which the kidney was implanted as part of en-bloc liver or multivisceral transplantation for technical reasons.

Materials: Three pediatric patients underwent en-bloc liver-kidney (n=1) or multivisceral-kidney(n=2) transplantation. Both of the multivisceral transplants were retransplants, now also with renal dysfunction from the underlying disease and complication of the immunosuppression. The other patient had congenital hepatic fibrosis and polycystic kidney disease and needed both liver and kidney transplants, the kidney having to be done en-bloc as the only means of venous drainage.

Methods: Extensive experience with multivisceral transplantation and donor procurement led to the familiarity of obtaining visceral arterial inflow via an aortic conduit and venous outflow via the portomesteric system through the donor liver to the native cava at the hepatic vein level to reach the systemic venous circulation. An extension of this is to include the kidney with the organ complex, receiving its arterial supply from the donor aorta and obtain venous outflow via the donor IVC to native IVC at the hepatic vein level.

Results: All 3 patients are alive and well with functioning kidneys. The donor ureters were recovered in their entirity and could be drained into the bladder, although ureterto-ureterostomy was an alternative. One of the kidneys was even transplanted against a positive crossmatch and 100% PRA, and although there were early immunological complications with the intestinal component of the composite allograft, the kidney has faired well with no hyperacute rejection and has good function.

Conclusion: This novel and innovative technique of including the kidney with other abdominal transplant organs to obtain both arterial inflow and in particular venous outflow, has allowed for patients to be satisfactorily transplanted whom otherwise could not have been done.

Top Updated 9/20/06