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Table of Contents
CASE REPORT
Year : 2022  |  Volume : 16  |  Issue : 4  |  Page : 444-446

Transplantation in a recipient with crossed renal ectopia and donor with early branching of the left renal artery - A case report


1 Department of Urology, JN Medical College, KLE Academy of Higher Education and Research, Belagavi, Karnataka, India
2 Department of Urology, JN Medical College, KLE Academy of Higher Education and Research; Department of Urology, KLES Kidney Foundation, KLES Dr. Prabhakar Kore Hospital and Medical Research Centre; Department of Biotechnology, KAHER”s Dr. Prabhakar Kore Basic Science Research Center, V. K. Institute of Dental Sciences Campus, Belagavi, Karnataka, India
3 Department of Urology, KLES Kidney Foundation, KLES Dr. Prabhakar Kore Hospital and Medical Research Centre, Belagavi, Karnataka, India
4 Department of Surgery, JN Medical College, KLE Academy of Higher Education and Research, Belagavi, Karnataka, India

Date of Submission05-May-2021
Date of Acceptance02-Feb-2022
Date of Web Publication30-Dec-2022

Correspondence Address:
Prof. Rajendra B Nerli
Department of Urology, JN Medical College, KLE Academy of Higher Education and Research, JNMC Campus, Belagavi - 590 010, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijot.ijot_43_21

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  Abstract 


Comprehensive preoperative evaluation of potential donors is crucial for selecting the right donor. Early segmentary arterial branching is present in 10%–12% of cases. Expert surgeons require at least 1 cm of main donor renal artery to clamp and properly anastomose the artery in the recipient. We report a case of live-related renal transplantation wherein the recipient had a crossed renal ectopia and the donor had early branching of the left renal artery (<5 mm from the aorta).

Keywords: Early branching, renal ectopia, transplantation


How to cite this article:
Nerli RB, Chandra S, Ghagane SC, Dixit NS, Muzumdar A, Donkar P. Transplantation in a recipient with crossed renal ectopia and donor with early branching of the left renal artery - A case report. Indian J Transplant 2022;16:444-6

How to cite this URL:
Nerli RB, Chandra S, Ghagane SC, Dixit NS, Muzumdar A, Donkar P. Transplantation in a recipient with crossed renal ectopia and donor with early branching of the left renal artery - A case report. Indian J Transplant [serial online] 2022 [cited 2023 Feb 3];16:444-6. Available from: https://www.ijtonline.in/text.asp?2022/16/4/444/364623




  Introduction Top


The incidence of crossed renal ectopia is 1 in 1000–7500.[1] In most of the cases, fusion with the opposite-sided kidney occurs on one side of the abdomen, and this fusion occurs early in embryogenesis such that both renal moieties ascend on the same side. Usually, the upper pole of the crossed kidney fuses with the lower pole of the normal kidney, although rarely the crossed kidney may be most cranial.[1] Kidney transplantation using donors with crossed renal ectopia has been described. There are reports of transplantation with a nonfused kidney[2] as well as those with dual transplant.[3] However, there is no report of a crossed renal ectopia in a recipient.

Comprehensive preoperative evaluation of potential donors is crucial for selecting the right donor, with adequately functioning kidneys, and the best surgical approach for harvesting the organs so as to prevent donor-related complications and to assure good recipient graft function. Early segmentary arterial branching is present in 10%–12% of cases.[4],[5] We report a case of live-related renal transplantation wherein the recipient had a crossed renal ectopia and the donor had early branching of the left renal artery (<5 mm from the aorta). Native nephrectomies of the right and the crossed left kidney were performed so as to facilitate dual renal artery (of the donor) anastomosis with the common iliac artery of the recipient.


  Case Report Top


A 29-year-old male was diagnosed to have end-stage renal disease and was advised to undergo live-related donor transplantation. Pretransplant ultrasonography as well as computed tomography had revealed a crossed renal ectopia with the left kidney fused to the lower pole of the right kidney [Figure 1]a and [Figure 1]b. His 55-year-old mother was the live donor and her pretransplant renal angiography had revealed an early branching of the left renal artery [Figure 1]c and [Figure 1]d.
Figure 1: (a and b) Computed tomography scan of the recipient shows crossed-fused renal ectopia. (c and d) Renal angiograph of the donor shows early division of the left renal artery. The arrow in Figure a andb shows site of renal fusion in crossed fused ectopia. The arrow in Figure c and d shows early branching of R-artery.

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In view of the early branching of the left renal artery, it was planned to anastomose the renal artery to the common iliac artery. The recipient was explored with the classical Gibson's incision. The common iliac artery and vein were cleared along with the external iliac artery and vein. The bed for the graft appeared small as the crossed over kidney was significantly occupying the space. Intraoperatively, a decision was made to perform nephrectomies of the fused kidneys. The nephrectomies were performed. The donor's kidney was harvested and the small stem of the renal artery was observed. A 3-mm long thick atheroma was noted at its origin. The atheroma was excised leaving the two divisions of the renal artery (anterior and posterior) to be separately anastomosed with the iliac artery. The donor's vein was anastomosed to the common iliac vein and the two renal arteries to the common iliac artery [Figure 2]a, [Figure 2]b, [Figure 2]c. The perfusion was adequate and the graft function was immediate. The postoperative period was uneventful and serum creatinine came down to 0.79 mg% at the time of discharge.
Figure 2: (a) Intraoperative image of donor nephrectomy shows early division of left renal artery. (b and c) Intraoperative image shows renal vein anastomosis to the common iliac vein and the two renal arteries anastomosed with common iliac artery. The arrow in Figure a is early branching of Rt. artery. The arrow in Figure b is Rt. artery and Rt. vein. c. double renal artery

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  Discussion Top


The continuing shortage of both live and deceased donor kidneys has inspired transplant programs to search for innovative ways to increase the number of potential donor kidneys. Many centers are now commonly using en bloc pediatric kidneys, kidneys with acute renal failure, and two extended donor criteria kidneys in a single recipient.[6] Horseshoe kidneys too are now routinely used as both dual and split single transplants, with results almost equivalent to deceased donor transplantation (83.3% graft survival at 5-year follow-up).[7] The combination of ectopia and fusion is not a common anomaly and is termed crossed-fused renal ectopia (CFRE). Most patients with this anomaly remain asymptomatic, and the diagnosis is made at the time of autopsy or imaging done for another indication.

The variations in the renal arteries include the level of origin, caliber, obliquity, number, and precise relation. Major variations of the renal artery which have clinical relevance include early branching into segmental arteries before reaching hilum and accessory renal artery.[5] The number, course, and branching of renal arteries are important in planning for live donor nephrectomy, as this has an impact on renal transplant surgery. Weld et al.[8] suggested that the donors with early division/branching of renal artery would not be an ideal or a suitable candidate for transplantation as the surgeon would not have a long pedicle for anastomosis of renal artery. Early segmentary arterial branching is present in 10%–12% of cases.[5] Dissecting in the retrocaval area is considered difficult because of the possibility of injuring major vessels. A segmentary bifurcation behind the inferior vena cava is considered as double artery because it is usually not possible to safely section the common trunk. In the case of the left kidney, early segmentary arterial branching is defined as segmental branching <1–1.5 cm from the origin of the left renal artery. Expert surgeons require at least 1 cm of main renal artery to clamp and properly anastomose the artery in the recipient.[5] In our case, we excised the atheromatic end of the left donor renal artery and the two divisions of the renal arteries were anastomosed to the recipient common iliac artery. The recipient's CFRE was creating a small bed for the renal transplantation and hence was removed so as to make adequate bed.

Declaration of patient consent

The authors certify that 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.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Watson CJ, Harper SJ. Anatomical variation and its management in transplantation. Am J Transplant 2015;15:1459-71.  Back to cited text no. 1
    
2.
Rosenthal JT, Khetan U. Transplantation of cadaver kidneys from a donor with crossed non-fused renal ectopia. J Urol 1989;141:1184-85.  Back to cited text no. 2
    
3.
Ojo P, Ranga KV, Brown M, Hull D, Charpentier KP. Transplantation of a unilateral fused kidney with inferior ectopia: Revascularization utilizing donor aorta and vena cava. Conn Med 2008;72:585-8.  Back to cited text no. 3
    
4.
Kawamoto S, Montgomery RA, Lawler LP, Horton KM, Fishman EK. Multi-detector row CT evaluation of living renal donors prior to laparoscopic nephrectomy. Radiographics 2004;24:453-66.  Back to cited text no. 4
    
5.
Nerli RB, Sushant D, Ghagane SC, Nutalpati S, Mohan S, Dixit NS, et al. Lymphocele complications following renal transplantation. Indian J Transplant 2019;13:273.  Back to cited text no. 5
  [Full text]  
6.
Mekeel KL, Daley SM, Andrews PE, Moss AA Heilman RL, Mazur MJ, et al. Successful transplantation of a split crossed fused ectopic kidney into a patient with end-stage renal disease. J Transplant 2010;2010:383972.  Back to cited text no. 6
    
7.
Stroosma OB, Scheltinga MR, Stubenitsky BM, Kootstra G. Horseshoe kidney transplantation: An overview. Clin Transplant 2000;14:515-9.  Back to cited text no. 7
    
8.
Weld KJ, Bhayani SB, Belani J, Ames CD, Hruby G, Landman J. Extrarenal vascular anatomy of kidney: Assessment of variations and their relevance to partial nephrectomy. Urology 2005;66:985-89.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2]



 

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