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Successful Kidney Transplantation Using a Deceased Donor Graft With Fibromuscular Dysplasia
Successful Kidney Transplantation Using a Deceased Donor Graft With Fibromuscular Dysplasia Hyo-Sin Kim, Soo Jin Na Choi*, and Ho Kyun Lee Department of Surgery, Chonnam National University Medical School, Gwangju, Korea
ABSTRACT All over the world there is serious concern about the shortage of organs available for transplantation. In an effort to address this, transplantation with grafts, which was previously considered a contraindication, are now performed. In some cases, this practice has contributed to increasing the organ pool. Fibromuscular dysplasia (FMD) is the secondmost-common cause of renovascular hypertension and is observed in 2%e6.6% of potential live kidney donors. Kidney with FMD is generally considered to be a contraindication for renal transplantation because renal artery stenosis may progress after transplantation and cause graft loss. Here, we report on a successful case of kidney transplantation using a graft with FMD of a deceased donor who had multiple aneurysms in the renal artery.
T
HE MOST serious concern about kidney transplantation all over the world is that the number of patients waiting for organ transplantation has increased but there are not enough available organs. To solve this problem, attempts have been made to implant marginal grafts, which was previously contraindicated in transplantation; some of these transplantations have been successful. Kidneys with fibromuscular dysplasia (FMD) are generally considered a contraindication for performing kidney transplantations because FMD can progress after implantation [1]. However, there are several reports of kidney transplantations using a graft with FMD being successfully performed [2]. We also report on a successful kidney transplantation using a deceased donor graft with FMD that had had multiple aneurysms in the renal artery.
CASE REPORT A female deceased donor aged 49 years who had brain death due to subarachnoid hemorrhage donated both of her kidneys. Her left side kidney went to a 31-year-old female who had been on peritoneal dialysis for 3 years due to diffuse sclerosis glomerulonephritis and her right kidney went to another hospital. The donor did not have hypertension or diabetes mellitus. The donor’s creatinine level was 1.04 mg/dL and blood urea nitrogen was 19.7 mg/dL. Preoperative abdominal sonography showed no remarkable findings in both kidneys. However, during organ recovery, we found that the left kidney had multiple saccular types of aneurysms and focal stenosis in the proximal renal artery, whereas the other appeared to be normal (Figs 1A, B). In the bench surgery, the affected segment of the proximal renal artery was removed and sent to the pathology 0041-1345/19 https://doi.org/10.1016/j.transproceed.2019.02.057
2842
laboratory for biopsy, while an anastomosis was performed between the grossly unaffected remaining arteries (Fig 1C). The kidney was transplanted to the recipient’s right iliac fossa using arterial and venous anastomosis to the external iliac vessels (Fig 1D). The graft showed good function in the postoperative period. The recipient’s creatinine level decreased from 12.0 mg/dL the day prior to the surgery to 1.0 mg/dL on the seventh postoperative day. The biopsy result at the time of the bench surgery showed the medial type of fibromuscular dysplasia (Fig 2). At almost 5 years of follow up, our patient is in good clinical condition and has returned to work. Her blood pressure is normal without medication. An abdominal color Doppler ultrasound showed a normal aspect of the graft (Fig 3). Her creatinine level was .92 mg/dL with a calculated glomerular filtration rate of 80.102 mL/min/1.73 m2.
DISCUSSION
Fibromuscular dysplasia is the second-most-common cause of renovascular hypertension and is observed in 2.0%e6.6% of potential live kidney donors [3,4]. The pathogenesis is not completely understood, although it is commonly described as a non-atherosclerotic inflammatory vascular disease [5]. The severity of FMD is determined by arterial irregularity and stenosis. The most common type is a mild type of FMDda slight irregularity of the artery without significant
*Address correspondence to Soo Jin Na Choi, MD, Department of Surgery, Chonnam National University College of Medicine. Tel: þ821098203134, Fax: þ82622271635. E-mail: [email protected] ª 2019 Published by Elsevier Inc. 230 Park Avenue, New York, NY 10169
Transplantation Proceedings, 51, 2842e2844 (2019)
A DONOR GRAFT WITH FIBROMUSCULAR DYSPLASIA
2843
Fig 1. (A) Focal stenosis in the proximal renal artery and multiple saccular aneurysm; (B) anastomosis between grossly unaffected artery after segmental resection; (C) engraftment to the recipient right iliac fossa; (D) 3-dimensional computed tomography image after transplantation.
stenosis. The clinical spectrum of FMD ranges from asymptomatic to renal hypertension and chronic renal failure. There have been cases of FMD first discovered in patients over 70 years of age, suggesting that the disease may be asymptomatic for years and only become apparent later in life [6]. For this reason, renal transplantation of FMD graft is considered a contraindication because renal artery stenosis or spontaneous renal artery dissection after transplantation can lead to graft loss. To our knowledge the case reported here represents the first successful kidney transplantation using a deceased donor graft with FMD that had multiple aneurysms in the
Fig 2. Pathologic results showing that the medial type of fibromuscular dysplasia was noted. *Dysplastic muscle layer.
renal artery. The recipient has not experienced any complication from FMD itself for over 5 years. In a non-transplantation setting, surgical angioplasty is considered the ideal treatment of FMD because removal of the affected artery is only possible by surgical resection [7]. However, interventional angioplasty is preferred over surgical angioplasty because surgical angioplasty usually involves performing a bypass between the aortic renal artery with a vessel graft in the patient, which is associated with high morbidity and mortality [8,9]. In a transplantation setting, however, surgical angioplasty can be performed without difficulty or risk of morbidity to the recipient because the detection and surgical correction are performed during the bench surgery, when the graft has a gross abnormal finding [10,11]. In this case, we found multiple aneurysmal changes in the artery of the graft during the bench work; preoperative ultrasonography showed no abnormal findings. The segmental resection of the affected renal artery and anastomosis were performed without difficulty during the bench surgery. Failures to recognize grafts with FMD occasionally occur in living donor kidney transplantation, especially in asymptomatic donors, even after the introduction of more effective evaluation tools (ie, magnetic renal angiography, computed tomographic angiography) [12e15]. It is not easy to detect FMD in this situation, even during bench surgery, because most asymptomatic donors do not have gross abnormal lesions in the graft. Consequently, detection of disease was delayed after transplantation until the manifestation of complications caused by disease progression, such as renal hypertension and spontaneous renal artery
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KIM, NA CHOI, AND LEE
Fig 3. Doppler image of the kidney taken 37 months postoperatively. Doppler showed intact blood flow with no other abnormal findings.
dissection. Nevertheless, in the series of reported cases, these complications have been well treated by surgical or percutaneous transluminal angioplasty or by inserting a stent [12e15]. Therefore, even though the diagnosis of FMD is delayed until after transplantation, the proper treatment should be conducted to ensure graft survival. Another concern in the transplantation setting is the high incidence FMD occurring in the contralateral kidney [16]. The failure to detect disease leads to complications of disease progression in both donors and recipients in living donor transplantation or 2 recipients in deceased donor transplantation [10,17]. Therefore, physicians should be careful to monitor patients when disease was found in any transplanted kidney during the follow-up period and notify the related center and affected individual(s) of the event. The demand for renal transplantation has increased, while at the same time the organ supply all over the world is inadequate. Although transplantation using kidneys with FMD was previously considered a contraindication, we think that renal transplantation using kidneys with FMD could be a feasible option for expanding the donor pool. REFERENCES [1] Andreoni KA, Weeks SM, Gerber DA, Fair JH, Mauro MA, McCoy L, et al. Incidence of donor renal fibromuscular dysplasia: does it justify routine angiography? Transplantation 2002;73: 1112e6. [2] Frezin J, Fusaro F, Reding R, Godefroid N. Kidney transplantation in infantile myofibromatosis and fibromuscular dysplasia: a case report. J Med Case Rep 2015;9:270. [3] Neymark E, LaBerge JM, Hirose R, Melzer JS, Kerlan RK, Wilson MW, et al. Arteriographic detection of renovascular disease in potential renal donors: incidence and effect on donor surgery. Radiology 2000;214:755e60. [4] Blondin D, Lanzman R, Schellhammer F, Oels M, Grotemeyer D, Baldus SE, et al. Fibromuscular dysplasia in living renal donors: still a challenge to computed tomographic angiography. Eur J Radiol 2010;75:67e71.
[5] Olin JW, Gornik HL, Bacharach JM, Biller J, Fine LJ, Gray BH, et al. Fibromuscular dysplasia: state of the science and critical unanswered questions. Circulation 2014;129: 1048e78. [6] Pascual A, Bush HS, Copley JB. Renal fibromuscular dysplasia in elderly persons. Am J Kid Dis 2005;45:e63e6. [7] Palcau L, Gouicem D, Joguet E, Cameliere L, Berger L. Solitary kidney with renal artery aneurysm repaired by ex vivo reconstruction. Vasc Endovascular Surg 2014;48:430e3. [8] Trinquart L, Mounier-Vehier C, Sapoval M. Efficacy of revascularization for renal artery stenosis caused by fibromuscular dysplasia: a systematic review and meta-analysis. Hypertension 2010;56:525e32. [9] Mackrell PJ, Langan EM, Sullivan TM, Gray BH, Taylor SM, Cull DL, et al. Management of renal artery stenosis: effects of a shift from surgical to percutaneous therapy on indications and outcomes. Ann Vasc Surg 2003;17:54e9. [10] Wolters HH, Vowinkel T, Schult M, Heidenreich S, Senninger N, Dietl K-H. Fibromuscular dysplasia in a living donor: early post-operative allograft artery stenosis with successful venous interposition. Nephrol Dial Transplant 2002;17:153e5. [11] Pfeiffer T, Böhner H, Voiculescu A, Sarbia M, Grabensee B, Sandmann W. Even severe renal artery fibromuscular dysplasia is no contraindication for living donor renal transplantation: report of two successful cases with venous grafting of the donor renal artery. Transplant Proc 2002;34:3113e6. [12] Indudhara R, Kenney, Bueschen AJ, Burns JR. Live donor nephrectomy in patients with fibromuscular dysplasia of the renal arteries. J Urol 1999;162(3 Pt 1):678e81. [13] Schreiber MJ, Pohl MA, Novick AC. The natural history of atherosclerotic and fibrous renal artery disease. Urol Clin North Am 1984;11:383e92. [14] Parasuraman R, Attallah N, Venkat KK, Yoshida A, Abouljoud M, Khanal S, et al. Rapid progression of native renal artery fibromuscular dysplasia following kidney donation. Am J Transplant 2004;4:1910e4. [15] Sharma R. Fibromuscular dysplasia of the renal artery in a kidney donor may cause long-term complications. Exp Clin Transplant 2012;10:621. [16] Slovut DP, Olin JW. Fibromuscular dysplasia. New Engl J Med 2004;350:1862e71. [17] Nahas WC, Lucon AM, Mazzucchi E, Scafuri AG, Neto ED, Ianhez LE, et al. Kidney transplantation: the use of living donors with renal artery lesions. J Urol 1998;160:1244e7.
ABSTRACT All over the world there is serious concern about the shortage of organs available for transplantation. In an effort to address this, transplantation with grafts, which was previously considered a contraindication, are now performed. In some cases, this practice has contributed to increasing the organ pool. Fibromuscular dysplasia (FMD) is the secondmost-common cause of renovascular hypertension and is observed in 2%e6.6% of potential live kidney donors. Kidney with FMD is generally considered to be a contraindication for renal transplantation because renal artery stenosis may progress after transplantation and cause graft loss. Here, we report on a successful case of kidney transplantation using a graft with FMD of a deceased donor who had multiple aneurysms in the renal artery.
T
HE MOST serious concern about kidney transplantation all over the world is that the number of patients waiting for organ transplantation has increased but there are not enough available organs. To solve this problem, attempts have been made to implant marginal grafts, which was previously contraindicated in transplantation; some of these transplantations have been successful. Kidneys with fibromuscular dysplasia (FMD) are generally considered a contraindication for performing kidney transplantations because FMD can progress after implantation [1]. However, there are several reports of kidney transplantations using a graft with FMD being successfully performed [2]. We also report on a successful kidney transplantation using a deceased donor graft with FMD that had had multiple aneurysms in the renal artery.
CASE REPORT A female deceased donor aged 49 years who had brain death due to subarachnoid hemorrhage donated both of her kidneys. Her left side kidney went to a 31-year-old female who had been on peritoneal dialysis for 3 years due to diffuse sclerosis glomerulonephritis and her right kidney went to another hospital. The donor did not have hypertension or diabetes mellitus. The donor’s creatinine level was 1.04 mg/dL and blood urea nitrogen was 19.7 mg/dL. Preoperative abdominal sonography showed no remarkable findings in both kidneys. However, during organ recovery, we found that the left kidney had multiple saccular types of aneurysms and focal stenosis in the proximal renal artery, whereas the other appeared to be normal (Figs 1A, B). In the bench surgery, the affected segment of the proximal renal artery was removed and sent to the pathology 0041-1345/19 https://doi.org/10.1016/j.transproceed.2019.02.057
2842
laboratory for biopsy, while an anastomosis was performed between the grossly unaffected remaining arteries (Fig 1C). The kidney was transplanted to the recipient’s right iliac fossa using arterial and venous anastomosis to the external iliac vessels (Fig 1D). The graft showed good function in the postoperative period. The recipient’s creatinine level decreased from 12.0 mg/dL the day prior to the surgery to 1.0 mg/dL on the seventh postoperative day. The biopsy result at the time of the bench surgery showed the medial type of fibromuscular dysplasia (Fig 2). At almost 5 years of follow up, our patient is in good clinical condition and has returned to work. Her blood pressure is normal without medication. An abdominal color Doppler ultrasound showed a normal aspect of the graft (Fig 3). Her creatinine level was .92 mg/dL with a calculated glomerular filtration rate of 80.102 mL/min/1.73 m2.
DISCUSSION
Fibromuscular dysplasia is the second-most-common cause of renovascular hypertension and is observed in 2.0%e6.6% of potential live kidney donors [3,4]. The pathogenesis is not completely understood, although it is commonly described as a non-atherosclerotic inflammatory vascular disease [5]. The severity of FMD is determined by arterial irregularity and stenosis. The most common type is a mild type of FMDda slight irregularity of the artery without significant
*Address correspondence to Soo Jin Na Choi, MD, Department of Surgery, Chonnam National University College of Medicine. Tel: þ821098203134, Fax: þ82622271635. E-mail: [email protected] ª 2019 Published by Elsevier Inc. 230 Park Avenue, New York, NY 10169
Transplantation Proceedings, 51, 2842e2844 (2019)
A DONOR GRAFT WITH FIBROMUSCULAR DYSPLASIA
2843
Fig 1. (A) Focal stenosis in the proximal renal artery and multiple saccular aneurysm; (B) anastomosis between grossly unaffected artery after segmental resection; (C) engraftment to the recipient right iliac fossa; (D) 3-dimensional computed tomography image after transplantation.
stenosis. The clinical spectrum of FMD ranges from asymptomatic to renal hypertension and chronic renal failure. There have been cases of FMD first discovered in patients over 70 years of age, suggesting that the disease may be asymptomatic for years and only become apparent later in life [6]. For this reason, renal transplantation of FMD graft is considered a contraindication because renal artery stenosis or spontaneous renal artery dissection after transplantation can lead to graft loss. To our knowledge the case reported here represents the first successful kidney transplantation using a deceased donor graft with FMD that had multiple aneurysms in the
Fig 2. Pathologic results showing that the medial type of fibromuscular dysplasia was noted. *Dysplastic muscle layer.
renal artery. The recipient has not experienced any complication from FMD itself for over 5 years. In a non-transplantation setting, surgical angioplasty is considered the ideal treatment of FMD because removal of the affected artery is only possible by surgical resection [7]. However, interventional angioplasty is preferred over surgical angioplasty because surgical angioplasty usually involves performing a bypass between the aortic renal artery with a vessel graft in the patient, which is associated with high morbidity and mortality [8,9]. In a transplantation setting, however, surgical angioplasty can be performed without difficulty or risk of morbidity to the recipient because the detection and surgical correction are performed during the bench surgery, when the graft has a gross abnormal finding [10,11]. In this case, we found multiple aneurysmal changes in the artery of the graft during the bench work; preoperative ultrasonography showed no abnormal findings. The segmental resection of the affected renal artery and anastomosis were performed without difficulty during the bench surgery. Failures to recognize grafts with FMD occasionally occur in living donor kidney transplantation, especially in asymptomatic donors, even after the introduction of more effective evaluation tools (ie, magnetic renal angiography, computed tomographic angiography) [12e15]. It is not easy to detect FMD in this situation, even during bench surgery, because most asymptomatic donors do not have gross abnormal lesions in the graft. Consequently, detection of disease was delayed after transplantation until the manifestation of complications caused by disease progression, such as renal hypertension and spontaneous renal artery
2844
KIM, NA CHOI, AND LEE
Fig 3. Doppler image of the kidney taken 37 months postoperatively. Doppler showed intact blood flow with no other abnormal findings.
dissection. Nevertheless, in the series of reported cases, these complications have been well treated by surgical or percutaneous transluminal angioplasty or by inserting a stent [12e15]. Therefore, even though the diagnosis of FMD is delayed until after transplantation, the proper treatment should be conducted to ensure graft survival. Another concern in the transplantation setting is the high incidence FMD occurring in the contralateral kidney [16]. The failure to detect disease leads to complications of disease progression in both donors and recipients in living donor transplantation or 2 recipients in deceased donor transplantation [10,17]. Therefore, physicians should be careful to monitor patients when disease was found in any transplanted kidney during the follow-up period and notify the related center and affected individual(s) of the event. The demand for renal transplantation has increased, while at the same time the organ supply all over the world is inadequate. Although transplantation using kidneys with FMD was previously considered a contraindication, we think that renal transplantation using kidneys with FMD could be a feasible option for expanding the donor pool. REFERENCES [1] Andreoni KA, Weeks SM, Gerber DA, Fair JH, Mauro MA, McCoy L, et al. Incidence of donor renal fibromuscular dysplasia: does it justify routine angiography? Transplantation 2002;73: 1112e6. [2] Frezin J, Fusaro F, Reding R, Godefroid N. Kidney transplantation in infantile myofibromatosis and fibromuscular dysplasia: a case report. J Med Case Rep 2015;9:270. [3] Neymark E, LaBerge JM, Hirose R, Melzer JS, Kerlan RK, Wilson MW, et al. Arteriographic detection of renovascular disease in potential renal donors: incidence and effect on donor surgery. Radiology 2000;214:755e60. [4] Blondin D, Lanzman R, Schellhammer F, Oels M, Grotemeyer D, Baldus SE, et al. Fibromuscular dysplasia in living renal donors: still a challenge to computed tomographic angiography. Eur J Radiol 2010;75:67e71.
[5] Olin JW, Gornik HL, Bacharach JM, Biller J, Fine LJ, Gray BH, et al. Fibromuscular dysplasia: state of the science and critical unanswered questions. Circulation 2014;129: 1048e78. [6] Pascual A, Bush HS, Copley JB. Renal fibromuscular dysplasia in elderly persons. Am J Kid Dis 2005;45:e63e6. [7] Palcau L, Gouicem D, Joguet E, Cameliere L, Berger L. Solitary kidney with renal artery aneurysm repaired by ex vivo reconstruction. Vasc Endovascular Surg 2014;48:430e3. [8] Trinquart L, Mounier-Vehier C, Sapoval M. Efficacy of revascularization for renal artery stenosis caused by fibromuscular dysplasia: a systematic review and meta-analysis. Hypertension 2010;56:525e32. [9] Mackrell PJ, Langan EM, Sullivan TM, Gray BH, Taylor SM, Cull DL, et al. Management of renal artery stenosis: effects of a shift from surgical to percutaneous therapy on indications and outcomes. Ann Vasc Surg 2003;17:54e9. [10] Wolters HH, Vowinkel T, Schult M, Heidenreich S, Senninger N, Dietl K-H. Fibromuscular dysplasia in a living donor: early post-operative allograft artery stenosis with successful venous interposition. Nephrol Dial Transplant 2002;17:153e5. [11] Pfeiffer T, Böhner H, Voiculescu A, Sarbia M, Grabensee B, Sandmann W. Even severe renal artery fibromuscular dysplasia is no contraindication for living donor renal transplantation: report of two successful cases with venous grafting of the donor renal artery. Transplant Proc 2002;34:3113e6. [12] Indudhara R, Kenney, Bueschen AJ, Burns JR. Live donor nephrectomy in patients with fibromuscular dysplasia of the renal arteries. J Urol 1999;162(3 Pt 1):678e81. [13] Schreiber MJ, Pohl MA, Novick AC. The natural history of atherosclerotic and fibrous renal artery disease. Urol Clin North Am 1984;11:383e92. [14] Parasuraman R, Attallah N, Venkat KK, Yoshida A, Abouljoud M, Khanal S, et al. Rapid progression of native renal artery fibromuscular dysplasia following kidney donation. Am J Transplant 2004;4:1910e4. [15] Sharma R. Fibromuscular dysplasia of the renal artery in a kidney donor may cause long-term complications. Exp Clin Transplant 2012;10:621. [16] Slovut DP, Olin JW. Fibromuscular dysplasia. New Engl J Med 2004;350:1862e71. [17] Nahas WC, Lucon AM, Mazzucchi E, Scafuri AG, Neto ED, Ianhez LE, et al. Kidney transplantation: the use of living donors with renal artery lesions. J Urol 1998;160:1244e7.