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Horseshoe Kidneys: An Underutilized Resource in Kidney Transplant
Abstract
Although the number of patients awaiting renal transplant is rapidly increasing, the donor pool has remained relatively stable. Horseshoe kidneys, a common renal fusion anomaly, can provide a useful solution to the ever increasing gap between supply and demand.
These kidneys can be transplanted, en bloc, into a single recipient or divided and transplanted into 2 recipients.
We report 2 cases of successful kidney transplants.
The first is a split horseshoe kidney, transplanted into a single recipient, and the second, a horseshoe kidney from a donor after cardiac death split and transplanted into a single recipient. The second case is the first reported case of a horseshoe kidney transplant from a donor after cardiac death. We also performed a review of the literature of horseshoe kidneys with the hope of raising awareness of the necessity and promise of such transplants.
... A horseshoe kidney (HSK) is the most frequent renal fusion anomaly (1 in 400 to 800) [1][2][3][4][5][6][7][8][9][10] that involves abnormal migration of both kidneys with concomitant polar fusion. In over 90% of the cases this fusion occurs at the lower poles and as a result, two separate excretory renal units are maintained. ...
... This may lead to abnormalities in the collecting system, therefore: urinary tract infections, vesicoureteral reflux, recurrent kidney stones and hydronephrosis, may frequently be observed [2,[5][6][7]. Variation in the origin, number and size of the renal arteries and veins is well known and described as well, with only 30% of all HSK having a single renal artery on each side [5,[7][8][9]. ...
... Given the high likelihood of complex anatomical variation of HSK, both vascular and of the excretory system, the experience with these kidneys for living donation remains limited. The first split transplant of a HSK was performed by Politano in 1963 [3,8,10] and since then successful transplantation of both en-bloc and split horseshoe kidneys from The donated kidney was transplanted extraperitoneally in the right iliac fossa, with the renal vein and renal artery anastomosed to the external iliac vein and artery respectively. A ureteroneocystostomy over a 6 Fr. ...
We present the case of a living-donor nephrectomy of a horseshoe kidney. The recipient was a 33-year-old male with a history of end-stage renal disease secondary to IgA nephropathy. The donor was his 33-year-old partner who on preoperative cross-sectional imaging was found to have a horseshoe kidney with a single artery, vein and ureter. The donor operation was performed using a laparoscopic hand-assisted technique with transection of the interpolar fibrotic band using a stapler device. The backtable organ preparation was performed in a standard fashion with addition of a reinforcing hemostatic suture of the stapled fibrotic band. The donated kidney was transplanted extraperitoneally in the right iliac fossa of the recipient. The patient had an unremarkable postoperative course and was discharged home on post operative day 2 with normalizing renal function. To our knowledge, this is the first living donor nephrectomy of a horseshoe kidney performed using a laparoscopic hand-assisted technique.
... Kidney transplantation is the treatment of choice for patients with end-stage renal disease, but its use is limited as a result of the shortage of organ donors. 1 Liberal use of kidneys can provide a useful solution to the increasing gap between organ supply and demand. 2 De Capri described in 1522 the first case of a horseshoe kidney. In 1963, Politano transplanted the first case of a horseshoe kidney, which has not been published, and Nelson in 1975 published the first transplantation of a divided horseshoe kidney donor graft. 2 Horseshoe kidneys can be transplanted either into a single recipient en bloc or after division of the renal isthmus or into two recipients after division. ...
... In 1963, Politano transplanted the first case of a horseshoe kidney, which has not been published, and Nelson in 1975 published the first transplantation of a divided horseshoe kidney donor graft. 2 Horseshoe kidneys can be transplanted either into a single recipient en bloc or after division of the renal isthmus or into two recipients after division. 2, 3 We present a case of a 53-year-old woman with endstage renal disease secondary to interstitial fibrosis who had been maintained on hemodialysis for 3 years and was admitted to our center for a kidney transplantation. ...
... The number of patients awaiting a kidney transplant continues to rise. 2 Organs previously deemed unacceptable for transplant are being used with increased regularity exposing surgeons to new technical 3, 4 and ethical challenges. Because of the technical challenge, horseshoe kidney transplantation should remain in experienced hands. ...
... However, the techniques for such transplants, described as sequential unilateral [4][5][6], sequential bilateral [7,8], and en bloc unilateral [9][10][11][12], are still controversial, hence the use of this dual-kidney transplant model was very restricted, and 6643 kidneys with a kidney donor profile index from 88% to 92% or with a donor age > 66 years of age recovered during the 2010-2015 period were discarded [13]. Since en bloc horseshoe kidneys have been transplanted since 1975 [14], it is theorized that this model can be applied to the transplantation of the MAK; hence, the global experience of horseshoe kidney transplantation is reviewed with particular attention to the donor selection [15][16][17][18][19][20][21][22][23][24][25][26], the anatomy of the kidneys [27][28][29][30][31][32][33][34][35][36][37][38], the technique of transplantation [25][26][27][28][39][40][41][42][43][44][45][46][47][48][49], and the results [22,23]. Since no review has been published since 2002, and the use of horseshoe kidneys is neither tracked by the United Network for Organ Sharing (UNOS) nor by the Scientific Registry of Transplant Recipients (SRTR) databases, it is hoped that this review can provide an analysis of all cases of horseshoe kidneys reported to date and derive a surgical approach that can be applied to both the horseshoe kidneys and the MAK. ...
... Electronic databases were searched for case reports of transplantation of the horseshoe kidneys from 1975 to April 2022. There were 131 pairs of horseshoe kidneys, which were procured worldwide [44][45][46][47][48][49]. Fifty-three pairs of horseshoe kidneys were transplanted en bloc to a single recipient, and 78 pairs were divided at the isthmus with their blood supply separated and transplanted as single units to 131 recipients. ...
Background: The shortage of organs has called for the use of two marginal adult kidneys (MAKs) with a low nephron mass as dual adult kidneys transplanted to a single recipient. The operative techniques of the transplantation of these kidneys are still debated. Since the horseshoe kidneys have been transplanted as early as 1975, it is theorized that the technique of the en bloc transplantation of the horseshoe kidney may be applied to the MAKs. Material and Methods: The world literature search during the period 1975–2021 on the use of deceased-donor horseshoe kidneys was reviewed. The selection of the donors, the anatomy of the kidneys, the principles of organ recovery, the transplantation procedure, and the results were discussed. Finally, this technique of en bloc transplantation was applied successfully to seven pairs of MAKs and is described herein. The dual adult kidneys were simultaneously vascularized by the donor aorta and vena cava, which were anastomosed, respectively, to the recipient iliac artery and vein. Results: A total of 131 case reports of deceased horseshoe kidney donors were reviewed, of which 53 en bloc kidneys were transplanted successfully to a single recipient, and the remaining 78 were divided and transplanted as single units to 131 recipients. Twenty-five single kidneys were discarded. At the time of publication, all horseshoe kidneys had a good renal function. In the series of seven pairs of MAKs transplanted en bloc, the operative time was 3 h. There were no primary nonfunctions, no vascular thromboses, no urinary leakages, and no wound infections. Only two patients required temporary dialysis despite an average of 28.4 h of cold ischemia time. No hydronephrosis and lymphocele was experienced. Both patient and graft survival were 100%. At the time of follow-up at 36 months, serum creatinine levels averaged 1.8 mg/dL (range 1.4–1.9). Conclusions: This technique of en bloc renal transplantation using the donor aorta and vena cava for revascularization can be applied to both the horseshoe kidneys and the MAK, and improve organ utilization.
... Pirmąją tokio tipo transplantaciją aprašė Nelsonas ir Palmeris 1975 metais [4]. Iki 2010 m. buvo aprašyti tik 55 pasagos formos inkstų transplantacijos atvejai [5]. 15 iš jų buvo transplantuoti en bloc, 2 buvo gyvų donorų padalinti pasagos formos inkstai, o likę 38 inkstai buvo padalinti ir persodinti skirtingiems recipientams. ...
... Prieš naudojant pasagos formos inkstą transplantacijai, reikia atsižvelgti į jo dydį (dėl nefronų masės), inkstų kraujagyslių anomalijas, urologinę anatomiją. Tik trečdalis tokių inkstų turi normalias arterijas [5]. Jei inkstą krauju aprūpina vadinamosios funkcinės arterijos (arterijos, neturinčios anastomozių), didelė tikimybė, kad vystysis išemija. ...
Reikšminiai žodžiai: pasagos formos inkstas, inksto transplantacija. Pasagos formos inkstas – įgimta inkstų anomalija, kai inkstai susijungę apatiniais (95 proc.) arba viršutiniais poliais. Pasagos formos inkstas pasitaiko 1 iš 600–800 žmonių. Tokie inkstai pasižymi sudėtingesne anatomija, todėl jų transplantacija yra techniškai sunkesnė, tačiau įmanoma. Straipsnyje aprašoma, mūsų žiniomis, pirmoji pasagos formos inksto transplantacija Lietuvoje. Inkstas persodintas iš 38 metų vyro, mirusio dėl smegenų edemos, dviem recipientams – 28 metų moteriai bei 53 metų vyrui, sergantiems 5 stadijos lėtine inkstų liga. Po operacijos abiem pacientams išsivystė ūminis transplantato epakankamumas, tačiau po gydymo būkles pavyko stabilizuoti. Nors abu pacientai patyrė pooperacinių komplikacijų, negalima teigti, kad jos sietinos su inkstų anatomija. Dėl anatominių ypatumų pasagos formos inkstų transplantavimas yra susijęs su didesne komplikacijų rizika, todėl svarbu atidžiai atrinkti persodinimui tinkamus transplantatus ir pasirinkti geriausią operacijos metodą. Svarbu atkreipti dėmesį į inkstų vaskuliarizaciją, šlapimo kolektorinę sistemą, inkstus jungiančios sąsmaukos storį ir sandarą.
... Transplantation of a horseshoe kidney was first reported by Nelson and Palmer in 1975 [2]. Following their report, a few reviews of horseshoe kidney transplantation have been published [3,4]. The horseshoe kidney from a deceased donor can be transplanted en bloc or split for 1 or 2 recipients after division. ...
... Some authors claim that results from horseshoe kidney transplantation appear to be similar to those of normal kidney transplantation [3]. On the other hand, some authors have reported that horseshoe kidney transplantation is associated with a higher percentage of primary nonfunction [4], and the results of transplants using horseshoe kidneys are worse than those for normal kidneys [5]. ...
We report a case of renal transplantation using a horseshoe kidney from a living, genetically unrelated donor. The recipient was a 60-year-old man with diabetic nephropathy, and the donor was the 63-year-old wife of the recipient with a horseshoe kidney free of complications. Computed tomography showed two renal arteries and one renal vein on the left side, and the isthmus was perfused by several accessory arteries and veins. To demarcate the boundary of the isthmus, the left renal artery was ligated and cannulated for in situ perfusion. Furthermore, the isthmus was clamped, and the boundary of the isthmus was confirmed. The kidney was divided at the left margin of the perfused boundary. The cut ends of the isthmus were closed by sutures. The left kidney was transplanted into the right iliac fossa of the recipient. Asymptomatic fluid collection occurred on the cut surface at the isthmus of the donor, and this fluid decreased in due course. On the other hand, the recipient experienced no surgical complication or rejection, while maintaining serum creatinine levels of 2.00-2.20 mg/dL over a 22-month follow-up period. Horseshoe kidneys may be used for transplantation in selected cases after a detailed preoperative evaluation.
... Oneyear graft survival did not diff er between the normal and horseshoe kidney groups. Another review published in 2010 analyzed 28 case reports on horseshoe kidney transplants [12]. In 15 cases, kidneys were transplanted en bloc, and in the remaining cases, horseshoe kidneys were separated. ...
... On the other hand, fusion at the upper pole as it was seen in our case, is very rare. Transplanting a horseshoe kidney demands technical expertise because an average, normal vascular anatomy occurs only in the 33% of these cases [12]. Caution is needed during organ harvesting. ...
Horseshoe kidney is a fusion anomaly found in approximately one in 400-600 people. Due to vascular and ureteral variations, transplantation with a horseshoe kidney presents a technical challenge. In our case, the isthmus connected the upper poles and contained parenchyma. It consisted of three renal arteries, five veins collected to the inferior vena cava, and two ureters and pyelons. It was implanted en bloc to the left side retroperitoneally. During the early period, cellular and humoral rejection was confirmed and treated. For a urine leak, double J catheters were implanted into both ureters. Later, the first catheter was removed. Subsequently, urinary sepsis developed, necessitating graftectomy. The uncommon anatomy of ureters and antibody-mediated rejection (AMR) may both be factors for a ureter tip necrosis led to an infected urinoma. After other Hungarian authors, we also report a horseshoe kidney transplantation that was technically successful. However, after an adequately treated but severe acute humoral rejection, the patient developed sepsis, and the kidney had to be removed. We conclude that transplantation with horseshoe kidney is technically feasible but may increase the risk for urinary complications and resultant infections. Careful consideration of risk and benefit is advised when a transplant professional is faced with this option.
... The first case reports of transplanted horseshoe kidneys were described in 1975 by Nelson and Palmer [1]. A recent review found only 55 reported cases of transplanted horseshoe kidney in the literature [2]. Of these cases, 15 were transplanted en bloc. ...
... Several factors must be considered when deciding to utilize a horseshoe kidney for transplantation including renal size (a surrogate for nephron mass), renal vascular anomalies, and urologic anatomy. Only one-third of horseshoe kidneys have normal renal arterial supply [2]. As the kidney is supplied by functional end arteries, failure to preserve inflow to the kidney will result in ischemia. ...
. Horseshoe kidney is a congenital anomaly that presents unique challenges for the transplant surgeon. The mere presence of horseshoe kidney should not preclude consideration for transplantation. . A 33-year-old women suffering from end-stage renal disease underwent deceased donor renal transplant with a divided horseshoe kidney. We present a postoperative complication and the technical strategy for transplant salvage. The patient currently has excellent graft function. . Horseshoe kidneys do present challenges for successful transplantation. Though case reports of successful transplantation are increasing, we present a technical complication and successful transplant salvage strategy. Technical descriptions in the literature of successful back-table preparation strategies should help more transplant surgeons to begin to utilize this resource. . This study concludes that horseshoe kidneys can be successfully used for transplantation and provides a technical strategy to salvage the transplant after a unique complication associated with these donor kidneys.
... Dobiveni rezultati u obje grupe uspoređivani su sa standardnom populacijom te nije nađena nikakva razlika u kratkoročnim ili dugoročnim rezultatima transplantacije uključujući preživljenje i komplikacije54 . I druge studije su pokazale kako je broj komplikacija te preživljenje i pacijenata i presatka jednako onima u standardnoj populaciji[53][54][55][56][57] .MINIMALNO INVAZIVNI ZAHVATIU TRANSPLANTACIJI BUBREGA Posljednjih dvadesetak godina minimalno invazivni zahvati postaju sve češći i postaju metoda izbora u liječenju određenih bolesti. Isto se događa i u Ž. Fučkar et al.: Kirurški dosezi transplantacije bubrega u Rijeci medicina fluminensis 2020, Vol. ...
Riječki transplantacijski program započeo je eksperimentalnom kirurgijom i organizacijom centra za dijalizu na Odjelu za urologiju Klinike za kirurgiju na Sušaku. Uz pomoć vlastitog iskustva i boravkom u vanjskim centrima izvrsnosti ostvareni su uvjeti za početak rada s kandidatima za transplantaciju bubrega. Tako je 30. siječnja 1971. godine u našem centru učinjena prva uspješna transplantacija bubrega u Hrvatskoj i tadašnjoj Jugoslaviji. Slijedile su godine u kojima je transplantacija bubrega postala rutinski operacijski zahvat, ali zahvat koji je uvijek zahtijevao angažman multidisciplinarnog tima. Tijekom pet desetljeća predanog rada s kirurške strane su uvedena brojna unaprjeđenja transplantacijskoga programa, od kojih su mnoga po prvi put učinjena u Hrvatskoj i u zemljama u okruženju. To su, primjerice, ortotopne transplantacije bubrega, en-bloc transplantacija bubrega, transplantacija uz korištenje urinarne derivacije i supstitucije vijugom tankog crijeva, dvostruka transplantacija bubrega te transplantacija potkovičastog bubrega. U ovom preglednom radu prikazat ćemo kirurške posebnosti našega transplantacijskog programa.
... Since Nelson and Palmer [4] reported the first case of trans planting horseshoe kidney, about 55 horseshoe kidney trans plantation cases have been reported worldwide. Of these cases, 15 were transplanted en bloc [5]. Recently, the case of a horse shoe kidney divided from a live donor and successfully transplanted into a recipient has been reported [6]. ...
Transplantation of the horseshoe kidney can be performed en bloc or split into 2 grafts according to the vascular anomaly and the existence of the urinary collecting system in isthmus. From 2011 to 2014, there were 3 horseshoe kidney transplantations in Korea and transplantations were performed at 2 different centers. The transplantations were carried out successfully for all recipients without complications. All recipients have shown good graft kidney function after transplantation. No severe complication was revealed during follow-up period. We described the surgical technique used in the en bloc method to overcome various vascular anomalies and difficulties in choosing cannulation site and postoperative complications. En bloc transplantation of a horseshoe kidney is a useful strategy for patients with end-stage renal disease, and can provide favorable outcomes compared to the transplantation of a normal kidney.
... As a consequence, horseshoe kidney is completely asymptomatic in the vast majority of subjects, eventhough carriers of this peculiar condition may experience kidney stones, hydronephrosis and urinary tract infections at greater frequency than those subjects with two distinct kidneys [2,4,5]. Since no microscopic changes are present in nephron structure in horseshoe kidney, it can be used for renal transplants [6]. The opportunity of observing the histological picture of a horseshoe kidney of a fetus carrying 18 trisomy, is the aim of this report. ...
A case of horseshoe kidney is reported in a 11 week-old fetus affected by trisomy 18. Macroscopic examination did not show any other pathological change. The histological picture of the fused-kidney was characterized by architectural and glomerular changes. At x 100 magnification, large areas of metanephric mesenchyme, characterized by spindle cells surrounded by a loose oedematous stroma, were detected in the deep cortex and in the medulla. At higher power, multiple glomerular changes were observed. Maldeveloped glomeruli showed enlarged capsular spaces, adhesions between vascular tuft and capsular cells, podocytes in multiple layers, and large glomerular bodies formed by two vascular tufts. Our data confirm previous reports on glomerular changes in horseshoe kidney, and reinforce the hypothesis that horseshoe kidney should not be considered a simple fusion problem, but a complex developmental abnormality, possibly involving glomerular development.
... HSK can be transplanted into a single recipient, en bloc, or divided in the renal isthmus and transplanted into 2 patients. [18] Careful anatomic inspection of these kidneys and consideration of the donor and recipient parameters are key factors to the success of the transplant. ...
The horseshoe kidney is a congenital fusion anomaly of the kidneys with an incidence of 0.25% in the general population. We present an anatomical and histological study of a horseshoe kidney with abnormal vascular supply found during a routine dissection at a formalin-fixed male human body at the School of Medicine of the University of Caxias do Sul. This horseshoe kidney was joined at the lower poles by an isthmus of parenchymatous tissue. The vascular and excretory system is also discussed. We also present an embryologic review and the clinical and surgical importance of this anomaly.
... HSK can be transplanted into a single recipient, en bloc, or divided in the renal isthmus and transplanted into 2 patients. [18] Careful anatomic inspection of these kidneys and consideration of the donor and recipient parameters are key factors to the success of the transplant. ...
... после трансплантации представлен на рис. 7. Несмотря на то что первая трансплантация подковообразной почки была выполнена в 1975 г. R.P. Nelson и J.M. Palmer [8], подковообразная почка является недостаточно используемым ресурсом при посмертном донорстве органов [7]. Однако данные обзора литературы и наше наблюдение демонстрируют возможность достижения удовлетворительного результата у обоих пациентов, получивших по половине подковообразной почки. ...
The experience of horseshoe kidney transplant operations is significantly restricted. Transplant surgeons often refuse to use horseshoe kidney due to a number of serious abnormalities of vessels and upper urinary tract in these organs. However, the constant shortage of donor organs and an increase in patients on the waiting list for kidney transplantation make us reconsider our approach to the selection of donor organs. The aim of this work was to demonstrate our result of horseshoe kidney transplantation.
... From a surgical point of view, anatomic variations that can affect transplant feasibility, graft viability, and especially long term function must be taken in consideration [9]. When vascular or urinary abnormalities are present and there is no other suitable living donor, the alternative may be to sign in the patient in a cadaveric organ donor program with the disadvantages that this entails: large lists, long waiting time, urgent surgery and poor compatibility [10]. Chronic organ shortage and increased number of patients waiting for a transplant sometimes makes it necessary to use marginal donors or donors with vascular or urinary abnormalities, which are a surgical challenge, while not losing sight of donor and patient safety. ...
Introduction:
The use of a horseshoe kidney in renal transplant remains controversial, when it is found in the evaluation of a living donor, anatomical, surgical and ethical issues are involved.
Presentation of case:
An uncomplicated horseshoe kidney was detected in a 51-year-old woman who was the only suitable donor for her 30-year-old son. Kidneys were fused in the inferior pole and no vascular or urinary abnormalities were detected during imaging evaluation. The surgical procedure was approved by the hospital transplant committee. A laparotomy was performed by means of a medial upper incision. The isthmus of the kidney was divided using a harmonic scalpel and the left segment was used; it had 2 arteries too distant to create a common one, thus anastomosed separately. The renal vein was side-to-side anastomosed to the right external iliac vein and a Lich-Gregoir ureteral implant was made. There were no intraoperative or postoperative complications in the donor who currently remains asymptomatic. Recipient developed a delayed graft function (DGF), and was discharged on the 12th day after surgery. After 24 months of surgery, renal function has remained stable with a serum creatinine of 128μmol/L (1.45mg/dL).
Discussion:
There are 7 reports of a horseshoe kidney from living donors in 8 patients without morbidity and a good long term outcome of all recipients.
Conclusion:
If we anticipate a low operative risk and there is a suitable anatomy, we may consider the use of horseshoe kidneys from living donors a viable alternative.
Kidney retrieval is often just part of a more complex procedure such as multiorgan procurement in which different surgical teams are involved. A good knowledge of the individual phases of the procedure and of the possible anatomical variations is crucial. In this chapter, we will describe the surgical technique used for kidney retrieval, discussing both en bloc and single kidney harvest.
Due to the ever-increasing discrepancy between organs availability and the number of patients awaiting transplant, marginal donors are considered for organ procurement, especially older donors.
The special caution requested in these cases due to atheromatous vessels and the risk of vascular injury is emphasized. A very important step before transplantation is bench surgery; its aims are discussed in detail.
Increasing interest has also been focused in the last years on the modalities of preserving the kidney. Alternative methods to the standard cold storage and its apparent advantages in terms of early graft function are mentioned; inherent readings are also suggested.
Definitive diagnostics and strict procedures during kidney donor qualification are required. Nowadays, precise and accurate imaging techniques are at hand for every diagnostician. However, many studies have described intraoperative occurrence of horseshoe kidney. Although the harvesting procedure in the case of horseshoe kidney is not technically difficult, graft separation for successful renal transplantation is a challenge. The complex anatomy of malformed organs causes issues during kidney separation. This procedure may lead to damage of the collecting urinary system as well as vascularization damage. Separate graft transplantation is probable when a thin isthmus in a horseshoe kidney is present. Otherwise, poor graft function may occur. We present a technique for horseshoe kidney separation with the use of methylene blue for vascularization determination. The above-mentioned procedure was performed with the methylene blue solution dose injected into a single renal graft artery. Even with the malformed organ's thick isthmus, the exact incision line was identified, exposing vascular perfusion asymmetry and allowing precise renal graft separation.
Organ transplantation remains the only life-saving therapy for many patients with organ failure. Despite the work of the Organ Donation and Transplant Collaboratives, and the marked increases in deceased donors early in the effort, deceased donors only rose by 67 from 2006 and the number of living donors declined during the same time period. There continue to be increases in the use of organs from donors after cardiac death (DCD) and expanded criteria donors (ECD). This year has seen a major change in the way organs are offered with increased patient safety measures in those organ offers made by OPOs using DonorNet. Unfortunately, the goals of 75% conversion rates, 3.75 organs transplanted per donor, 10% of all donors from DCD sources and 20% growth of transplant center volume have yet to be reached across all donation service areas (DSAs) and transplant centers; however, there are DSAs that have not only met, but exceeded, these goals. Changes in organ preservation techniques took place this year, partly due to expanding organ acceptance criteria and increasing numbers of ECDs and DCDs. Finally, the national transplant environment has changed in response to increased regulatory oversight and new requirements for donation and transplant provider organizations.
Owing to the shortage of organ donors, there is renewed interest in donation after cardiac death (DCD), formerly referred to as nonheart-beating donation. From January 1984 until August 2000, 382 renal transplants were performed from DCD donors. These were compared with 1089 renal transplants performed from donation after brain death (DBD) donors. The mean warm ischemic time in DCD donors was 16.5 min. There was no statistical difference in cold ischemic time, rate of primary nonfunction, or graft loss in the first 30 days after transplantation. The rate of delayed graft function (DGF) was higher for DCD donors (27.5% vs. 21.3%; p = 0.016) and discharge creatinine was higher in DCD donors (1.92 mg/dL vs. 1.71 mg/dL; p = 0.001). There was no statistical difference in the 5-, 10-, or 15-year allograft survival when DCD donors were compared with DBD donors (64.8%, 44.8%, 27.8% vs. 71.3%, 48.3%, 33.8%; p = 0.054). Likewise, no statistical difference in the rate of technical complications was seen. Our long-term data indicate that the results of renal transplantation from DCD donors are equivalent to long-term allograft survival from DBD donors despite an increase in the rate of DGF. Organ procurement organizations, transplant centers, and hospitals should work to expand the implementation of DCD policies.
The number of patients awaiting a renal transplant is increasing. The shortage of organs demands the exploration of alternative organ sources such as kidneys with congenital anatomical anomalies. The horseshoe kidney is the most common renal anatomical anomaly and is able to be transplanted en bloc or split after procurement with good results. The decision whether to divide a horseshoe kidney depends on several factors. The most important feature is the number and position of the renal vessels. The second is the collector system anatomy. In this study we present two technically successful cases of renal transplantation using horseshoe kidneys en bloc with good results. Both cases have normal renal function. Horseshoe kidney transplantation offers good results and therefore should be considered as an option for cadaver kidney transplantation.
The shortage of deceased donor kidneys and livers for transplantation has prompted the use of organs from donors deceased after cardiac death (DCD). We used the UNOS database to examine patient and graft survival following transplantation of DCD organs compared to those following grafts from donors deceased after brain death (DBD; for livers, grafts from donors < 60 years old were labeled '< 60 yrs'). Of 44035 deceased donor kidney transplant recipients, 1177 (3%) received a DCD kidney. There was no difference in patient or graft survival at 5 years (DCD vs. DBD: 81.3% vs. 80.8% and 66.9% vs. 66.5%; p = 0.70 and p = 0.52 respectively). Of 24688-deceased donor liver transplant recipients, 345 (1.4%) were from DCD donors and 20289 (82%) were from '< 60 yrs' DBD donors. Three-year patient and graft survival were inferior in the DCD group (DCD vs. '< 60 yrs' DBD: 77% vs. 80% and 65% vs. 75%; p = 0.016 and p < 0.0001 respectively) but were comparable to current alternatives, '>/= 60 yrs' DBD livers (donor age >/= 60) and split livers. DCD livers are a reasonable option when death is imminent. Our study demonstrates good outcomes using DCD kidneys and livers and encourages their use.
Experience with horseshoe kidney transplantation is limited. Horseshoe kidney may be underutilized for transplantation because of the greater incidence of vascular and other associated urological anomalies. Nowadays, owing to a greater number of patients waiting for a kidney donation and to a shortage of organs donated, more suitable organ acceptance criteria have been formulated. The aim of this paper is to present the first Iranian experience with horseshoe kidney transplantation.
HORSESHOE kidney is considered to be one of the more common congenital urological anomalies, with an incidence of 1:300 to 1:1,800.1 Most individuals with a horseshoe kidney survive to old age without complications. The use of such kidneys for renal transplantation has been generally avoided because of their frequent anomalous vasculature, occasional association with other renal anomalies, and a predisposition to urine stagnation, infection, and calculus formation. We could find only one previous report of a renal transplant of a horseshoe kidney.2 We report here another case of a horseshoe kidney used for renal transplantation into two recipients.Report of a Case
The donor was a 21-year-old man who died following a motorcycle accident. He had no history of urinary tract disease. His BUN level was 12 mg/dL; serum creatinine level, 1.0 mg/dL; urine volume, 100 mL/hr. Urine culture had no growth, and urinalysis results were within normal
The incidence and etiology of horseshoe kidneys and their structural abnormalities are discussed. Previously, patients with horseshoe kidneys have been considered undesirable donors for renal transplantation. Two cases of horseshoe kidney transplantation are presented, apparently, the first reported utilization of such a donor for transplantation, along with important aspects of surgical technique.
A case of successful en bloc transplantation of a horseshoe kidney into a single recipient is reported. The literature is briefly reviewed. The use of horseshoe kidneys in transplantation is recommended in selected cases.
Transplantation of a horseshoe kidney rarely has been reported. We report a case of successful en bloc transplantation of a horseshoe kidney. The kidney could not be divided because of a complex vascular situation in the isthmus region. The recipient was discharged from our hospital with normal kidney function 12 days postoperatively. We recommend the use of kidneys with anatomical malformations for transplantation.
Report of a case in which a horseshoe kidney was divided and transplanted into two recipients. The literature on transplantation of horseshoe kidneys is reviewed. This renal anomaly is not a contra-indication to its use for transplantation.
H ORSESHOE kidneys are frequently supplied by multiple renal arteries, some of which may have an anomalous origin related to embryologic development. The radiologist should be familiar with the variations in blood supply, because com- plete angiographic demonstration of all the vessels is necessary. Since horseshoe kid- neys are frequently the site of obstruction, infection and calculus formation, a knowl- edge of the vascular anatomy is of impor- tance to the surgeon. We have reviewed the embryology, vascular anatomy, angiography and surgi- cal aspects of horseshoe kidneys with a detailed study of the blood supply in 14 patients. EMBRYOLOGY
We transplanted 6 anatomically abnormal kidneys: a horseshoe kidney that after division was transplanted into 2 recipients; 1 kidney with ureteral stones and hydronephrosis; 1 ectopic and 1 hydronephrotic kidney; 2 kidneys with extensive ureteric lesions, donated as free organs. All these kidneys ultimately had normal function in the recipients, long-term in 4.2 patients died but in neither was the death caused by the renal abnormality.
A horseshoe kidney was retrieved en bloc with the aorta and inferior vena cava, divided at the isthmus and transplanted into 2 recipients. This anomaly is not a contraindication to cadaver kidney donation.
Experience with horseshoe kidney transplantation is limited. Horseshoe kidney may be underutilized for transplantation because of the greater incidence of vascular and other associated urological anomalies. Nowadays, owing to a greater number of patients waiting for a kidney donation and to a shortage of organs donated, more suitable organ acceptance criteria have been formulated. The aim of this paper is to present the first Iranian experience with horseshoe kidney transplantation.
We report on the successful en bloc transplantation of a horseshoe kidney from an elderly, hypertensive multiple organ donor. To our knowledge the use of a horseshoe kidney from a multiple organ donor has not been reported previously.
Horseshoe kidney is probably the most common renal fusion anomaly. Horseshoe kidneys have been successfully transplanted en bloc into a single recipient or, alternatively, they have been divided and implanted into 2 patients. Despite these facts the use of horseshoe kidney allografts for transplantation is rare. We report a case of the successful transplantation of an en bloc horseshoe kidney into a single recipient. The evaluation of fused kidneys for transplantation, technical considerations and previously reported cases are discussed.
Due to the current shortage of organ donors a coalescence of surgical techniques has been applied in an attempt to use all compatible organs that may have been discarded due to anatomical variations, disease or damage, and to transplant them into higher surgical risk recipients. Selected cases have been chosen that illustrate some of these techniques, and the various types of recipients and donor kidneys. Cases 1 and 2 illustrate applications of the orthotopic technique of renal transplantation, as well as reconstructive measures that may be necessary for success. Renal transplantation in perhaps one of the more commonly encountered difficult recipients, the patient with severe atherosclerotic vascular disease, is addressed by cases 1 and 3. The use of unusual donor organs, such as horseshoe kidneys and pediatric donor en block kidneys, is particularly pertinent in the attempt to transplant all viable organs and is demonstrated in cases 4 and 5. These cases illustrate the application of various surgical techniques in which either a difficult recipient or a damaged and/or diseased donor kidney may have otherwise precluded renal transplantation.
We report the case of a transplantation of a horseshoe kidney to 2 recipients after isthmic section of the kidney. A review of the literature since 1975 mentions only 14 cases of transplantation of a horseshoe kidney. In the absence of a significant urological clinical history of the donor, the presence of a horseshoe kidney, in the case of multiorgan harvesting, does not represent a contraindication for transplantation.
To increase the awareness of the successful use of horseshoe kidneys in renal transplantation.
Two donors were found to have horseshoe kidneys; these were divided at the midline and transplanted into four recipients.
All four recipients had a delayed return of renal function; all eventually functioned with no complications related to the horseshoe kidney.
Transplantation of horseshoe kidneys has been performed infrequently but they should be considered as suitable for transplants, considering the shortage of cadaver donors and, when possible, should be divided at the isthmus and the halves transplanted into two recipients.
The incidence of horseshoe kidneys is between 1 in 300 and 1 in 1600. Horseshoe kidneys may be either transplanted into two recipients after division of the kidney, or used for en bloc transplantation into one recipient.
We report two cases of adult-to-child and child-to-adult transplantation of horseshoe kidneys. Embryology and associated abnormalities are outlined, and previous case reports reviewed.
One transplant was successful and one transplant failed due to an unrecognized C peptide deficiency.
Horseshoe kidneys are acceptable as donor organs in renal transplantation.
The horseshoe kidney is the most common anatomical renal variation. It represents a fusion anomaly, mainly at the lower poles, occurring between the 4th and 6th week of gestation. Horseshoe kidneys display a great variation in origin, number and size of the vasculature. Transplantation of these deviant kidneys can be done en bloc or they can be split into two halves and transplanted into two recipients, depending on the number of vessels and the anatomy of the urinary collecting system. A literature review reveals 31 case histories, published between 1975 and 1998. Of these 21 were transplanted into 38 recipients after division and ten were implanted en bloc. Nineteen grafts (41%) showed immediate function and 21 grafts (46%) showed delayed function. Thrombosis and acute rejection, leading to non-function was seen in six grafts (13%). The overall success rate was 87%) with a mean follow-up of 22 months. The results of horseshoe kidney transplantation are good. provided that attention is paid to certain technical details. Because of donor scarcity, horseshoe kidneys should be used for transplantation.
The dire shortage of cadaveric kidneys has led to a gradual expansion of donor criteria in the transplant community. The use of kidneys with anatomical fusion anomalies is uncommon and has not been well defined in the literature. We evaluated the surgical strategies and postoperative outcomes of transplanting cadaveric kidneys with congenital fusion anomalies.
Three cadaveric kidneys with congenital fusion anomalies were procured and transplanted between May 1994 and November 1999. None of the 3 donors had any significant urological history. All fusion anomalies were identified during the organ procurement process.
Anomalies included 1 L-shaped cross-fused ectopic and 2 horseshoe kidneys. All 3 kidneys were procured en bloc. One horseshoe kidney with a narrow isthmus was split and the 2 kidneys were transplanted into separate recipients, while the other horseshoe kidney was transplanted en bloc into a single recipient. The L-shaped kidney was transplanted en bloc into 1 patient. All transplants were successful with a serum creatinine of 1.1 to 1.9 mg/dl.
To our knowledge we present the initial case of transplantation of an L-shaped kidney. Cadaveric kidneys with congenital fusion anomalies may be transplanted successfully using various individual technical strategies based on the specific renal anatomy. As such, these kidneys may be used to maximize the increasingly inadequate donor pool.
Horseshoe kidney is probably the most common renal fusion anomaly. With the continuous donor shortage, transplant surgeons tend to accept donors previously considered unsuitable. We present a successful case of en bloc horseshoe kidney transplant in a single recipient. The literature is reviewed. The use of horseshoe kidneys in transplantation is recommended in selected cases.
Experience with donor horseshoe kidneys for transplantation is very limited. Currently, horseshoe kidneys may be underutilized for transplantation because of the greater incidence of vascular anomalies, associated renal anomalies, and predisposition to renal disease.
In this report, we review five transplantations using horseshoe kidneys: the largest reported institutional experience. In addition, a review of all published cases in the English literature is performed.
All five patients underwent successful renal transplantations with a median follow-up of 35 months. One patient lost his kidney from recurrent disease soon after transplantation.
With appropriate reconstruction of the vessels, careful division of the isthmus, and avoidance of ureteral obstruction, long-term data revealed good graft survival of donor horseshoe kidneys in renal transplantation.
Horseshoe kidney is the most common anatomical renal variation. It represents a fusion anomaly, usually of the lower poles. Horseshoe kidneys can be transplanted en bloc or after division of the renal isthmus. We constructed a decision cascade for horseshoe kidney transplantation.
A worldwide survey of transplantation clinics and foundations was performed to discover cases of horseshoe kidney transplantation. In each case data were collected on horseshoe kidney anatomy and post-transplantation results. The number of renal arteries and veins was correlated with primary nonfunction due to technical failure.
From 1975 to 2000, 23 horseshoe kidneys were transplanted en bloc, while 57 were split and transplanted into 97 recipients. Primary nonfunction was observed in 4.3% and 13.4% of en bloc and divided transplanted kidneys, respectively. Postoperatively a urinary fistula formed after renal isthmus division in 2 cases. An increased number of renal vessels was not associated with an increased risk of primary nonfunction.
Horseshoe kidney anatomy should be closely inspected after explantation. The decision to split a horseshoe kidney should be based on urinary collecting system anatomy in the renal isthmus and on the number as well as the position of the renal vessels. Horseshoe kidneys can and should always be considered for transplantation.
The limits of organ donation from heart-beating (HB) donors reached a plateau illustrated by the number of postmortem kidneys for transplantation. Programs such as the European Donor Hospital Education Program (EDHEP) and Donor Action have helped to stop a further decrease in the number instead of an expected increase. For kidneys, heart, liver, and lungs one must also explore the use of marginal donors as a possible additional source. Examples are donors with a horseshoe kidney, those at both ends of the age spectrum, and those with medical contraindication such as diabetes. We have enlarged our kidney donor pool considerably with non-heart-beating(NHB) donors. Because we preserve these kidneys in a preservation machine, we are able to perform viability testing. With glutathione S-transferase (GST) as a measure of tubular damage, we now decide whether to transplant based on GST values. For other organs, NHB donation does not seem to be an option other than for the liver when the warm ischemia time is short.
Even though the number of patients awaiting renal transplant is rapidly increasing, the donor pool remains relatively stable. In an attempt to increase this pool, marginal kidneys and kidneys with congenital anatomical variations are being used. Horseshoe kidneys, being the most common renal fusion anomaly, can provide a useful solution to the ever-increasing gap between demand and supply. These kidneys have been successfully transplanted en bloc into a single recipient or, alternatively they have been divided and transplanted into 2 recipients. We report a case of the successful transplantation of an en bloc horseshoe kidney into a single recipient. To the best of our knowledge this is the first of its kind in the U.K. The relevant literature is also reviewed with the aim of raising awareness about the necessity and promising outcomes of such transplants.
Nowadays, owing to a greater number of patients waiting for a kidney donation and to a shortage of organs donated, more suitable organ acceptance criteria have been formulated. Horseshoe kidney transplantations have become feasible giving good allograft outcomes. The aim of this paper is to illustrate the split technique in horseshoe kidney transplantation and to report long-term results.
During the period from February 2004 to February 2005, two horseshoe kidneys were harvested from multiple organ retrieval. The surgical features and outcomes of these 2 cases are described separately. Mean follow-up time was 12.3 months.
Organs that were previously said to be marginal are being used more regularly and the more suitable selection does not exclude elderly donors with or without underlying diseases. Horseshoe kidney transplantation requires greater skills and experience of the surgeons compared to conventional kidney transplantation. This kind of renal abnormality has to be considered a feasible option for transplantation. Good long-term results are reported.
Owing to the limited donor pool at transplant centers, grafts may be taken from marginal donors with congenital abnormalities, one of the most common of which is a fusion abnormality. Horseshoe kidneys may be transplanted to a single recipient en bloc or to 2 recipients after division. In our clinic, 3 grafts (1 obtained from a living donor and 2 from a deceased donor) were successfully transplanted to 3 patients. In select patients, horseshoe kidneys may be used for transplant. Copyright © Başkent University 2007 Printed in Turkey. All Rights Reserved.
Most reports of donation after cardiac death (DCD) donors are exclusive to kidney transplantation and report high rates of delayed graft function (DGF).
From April 1, 2003, to October 3, 2007, we performed 53 kidney transplantations and 4 simultaneous kidney-pancreas transplantations from DCD donors. All DCD donor kidneys were managed with pulsatile perfusion preservation, and all simultaneous kidney-pancreas transplantation donors were managed with extracorporeal support.
Of 53 DCD kidney transplantations, 44 (83%) were from standard criteria donors (SCD) and 9 (17%) from expanded criteria donors (ECD). With a mean followup of 12 months, actual patient and kidney graft survival rates were 94% and 87%, respectively. Patient and graft survival rates were 100% in the 4 simultaneous kidney-pancreas transplantations. Incidence of DGF was 57% (60% without versus 20% with extracorporeal support, p = 0.036). Comparison of the 53 DCD donor kidney transplantations with 316 concurrent donation after brain death (DBD) donor adult kidney transplantations (178 SCD, 138 ECD) revealed no differences in demographics or outcomes, except that the DCD donor group had fewer ECDs (17% DCD versus 44% DBD; p = 0.0002), fewer 0-antigen mismatch kidney transplantations (7.5% DCD versus 19% DBD; p = 0.05), and more kidneys preserved with pulsatile perfusion (100% DCD versus 52% DBD; p < 0.0001). Incidences of DGF (57% DCD versus 19% DBD; p < 0.0001) and acute rejection (19% DCD versus 10% DBD; p = 0.10) were higher in the DCD donor group, which resulted in a longer initial length of stay (mean 11 days DCD versus 8.0 days DBD; p = 0.006).
Despite a high incidence of DGF in the absence of extracorporeal support and greater initial resource use, comparable short-term results can be achieved with DCD and DBD donor kidney transplantations.