多囊腎病接受雙腎移植之經驗

葉則言、蔡正晏、蕭博任、蔡禮賢、張議徽、葉進仲、陳怡儒¹、

賴彬卿¹、張兆祥、楊啟瑞、吳錫金、黃志平

中國醫藥大學附設醫院 泌尿科

中國醫藥大學附設醫院 腎臟科¹

Clinical Outcomes of Dual Kidney Transplantation in

Patients with Polycystic Kidney Disease

Tse-Yen Yeh, Chen-Yen Tsai, Po-Jen Hsiao, Li-Hsien Tsai, Yi-Huei Chang, Chin-Chung Yeh , I-Ru Chen¹, Ping-Chin Lai¹, Chao-Hsiang Chang, Chi-Rei Yang, Hsi-Chin Wu, Chi-Ping Huang

Divisions of Urology , China Medical University Hospital, Taichung, Taiwan

Divisions of Nephrology , China Medical University Hospital, Taichung, Taiwan¹

Introduction:

Expanded Criteria Donor (ECD) represents a recognized category of kidney transplantation donors, established to broaden the donor pool and address the disparity between organ availability and transplantation demand. However, the prognosis for recipients receiving kidneys from ECD donors has been questioned, as the Kidney Donor Profile Index (KDPI) for these donors typically exceeds 85, suggesting a poorer prognosis. Dual kidney transplantation (DKT) has been proposed as a strategy to mitigate the limitations associated with ECD in kidney transplantation. Dual kidney transplantation encompasses various surgical approaches, with kidney placement options including unilateral or bilateral placement and multiple configurations for vascular anastomosis. These choices depend on the patient’s clinical condition and the surgical judgment of the operating physician.

Here, we present the case of a 47-year-old male with autosomal dominant polycystic kidney disease (ADPKD) leading to end-stage renal disease (ESRD), previously managed with peritoneal dialysis, and with a history of hepatitis C, who received a cadaveric kidney transplant from a 62-year-old male donor also positive for hepatitis C.

Case report:

This 47-year-old male patient with a history of Hepatitis C completed antiviral treatment with Maviret from September 18, 2023, to November 20, 2023. He has a history of sustained ventricular fibrillation, for which he underwent electrical cardioversion and CPR, followed by the implantation of an MRI-compatible single-chamber ICD (Medtronic 6935M-62 cm) on October 13, 2024. Coronary angiography conducted on October 5, 2023, revealed patent coronary arteries, and he has experienced no subsequent ventricular tachycardia episodes. The patient has Autosomal Dominant Polycystic Kidney Disease (ADPKD)-related End-Stage Renal Disease (ESRD) and has been on peritoneal dialysis since December 2022, with a urine output of 500-600 mL/day. He was reevaluated for kidney transplantation in 2023 and underwent related surveillance. His blood type is B+, with HLA typing A11, B15, B40, C8, C15, DR11, DR15, DQ3, DQ6. Since October 2023, he has reported no symptoms of palpitations, chest pain, cough, or signs of infection.

The cadaveric kidney donor was a 62-year-old male with a history of Hepatitis C, treated with Epclusa from August 19 to November 11, 2020, and with an undetectable HCV viral load confirmed in August 2024. Following a fall at home on August 3, 2024, he was brought to Taichung Tzu Chi Hospital, where he was declared OHCA after 21 minutes of CPR with ROSC. Given a diagnosis of hypoxic encephalopathy, the family chose organ donation to honor his wishes. The donor's creatinine was recorded at 1.3 mg/dL on August 12, 2024, with a urine output of 450 mL over the last eight hours. HLA typing for the donor included A2, A24, B35, B75, C9, DR4, and DR15, with no evidence of HBV, HIV, or RPR infection. At the time of transplant evaluation, B and T cell crossmatches between the donor and recipient were negative, and no active infections or malignancies were detected.

Given the situation of suboptimal kidney transplantation, a dual kidney transplantation was scheduled and performed on August 15, 2024, using patch anastomoses. The right kidney was positioned upward to accommodate bilateral graft placement. En bloc transplantation was completed over the right iliac fossa, with bilateral renal veins anastomosed to the right external iliac vein via the inferior vena cava, and bilateral renal arteries anastomosed to the right common iliac artery via the aorta.

Post-operatively, the patient exhibited poor graft function, with an elevated creatinine level of 17.81 mg/dL, although urine output was maintained at 900-1000 mL/day. Subsequent abdominal and pelvic MRI revealed partial thrombosis of the distal graft aorta, with complete occlusion at the anastomosis of the graft renal arteries to the aorta, alongside a suspected hematoma compressing the graft IVC, leading to stenosis. Additionally, sharp angulation of the graft artery close to the iliac fossa and ischemia in the anterior portion of the anterior graft kidney were noted. These findings prompted a second operation combined with CVS to perform an embolectomy of the renal artery, during which a renal biopsy of the upper pole of the superficial graft kidney was conducted. Adjustments were also made to reposition the superficial graft kidney downward to avoid vascular angulation. Following the second surgery, creatinine levels decreased to 3.58 mg/dL, with urine output exceeding 2500 mL/day within one week.

With the patient’s condition stabilized, CAPD was discontinued on October 5, 2024. At the two-month post-operative follow-up, laboratory data showed a creatinine level of 2.49 mg/dL, with urine output maintained above 2000 mL/day.

Discussion:

The dual kidney transplantation could definitely expand the group of the donor which was previously considered not suitable for donation. However, whether placing two kidneys bilaterally or unilaterally is controversial in this case, considering the polycystic kidney disease of the recipient. Placing the kidney unilaterally requires only one excision site, making short operation time, which also considered to cause less peri-operative complication. Nevertheless, giving the underlying of this patient, graft thrombus rate was expected to be higher than usual due to restrict space caused by polycystic kidney.

Another topic that warrants discussion is whether this patient requires native kidney nephrectomy. Based on current experience, the criteria for native kidney nephrectomy in patients with polycystic kidney disease (PCKD) include symptomatic PCKD or lesions extending to the iliac crest. However, if both transplanted kidneys are expected to be placed on the same side, additional space will likely be needed to accommodate the two grafts, thus warranting more lenient criteria for performing native kidney nephrectomy. Nevertheless, as noted, the inclusion of native kidney nephrectomy could potentially prolong the surgery duration, require a larger incision, and subsequently increase the risk of peri-operative complications. In terms of outcome, although this patient underwent a secondary procedure to address vascular kinking, the post-operative results remained satisfactory. Therefore, whether native kidney nephrectomy should be performed in this patient remains a point of discussion.

The final topic for discussion is the optimal method of anastomosis for kidneys placed unilaterally. Currently, two widely used approaches for unilateral placement are separate anastomoses and patch anastomoses. Separate anastomoses enable each kidney to function independently, which may improve post-operative renal performance and reduce blood flow-related complications. In contrast, patch anastomoses minimize the need for multiple vascular anastomoses, potentially leading to shorter operative times and a reduction in peri-operative complications.

Conclusions: