Complications
of Surgical Significance Renal Transplantation
in Pediatric
By Curtis A. Sheldon, Bernard M. Churchill, Anroine E. Khoury, and Gordon A. McLorie Toron to, Ontario l From 1969 to 1966, 303 renal allografts (296 cadaveric) were placed in 215 pediatric recipients. Twenty-three patients (7.6%) had renovascular complications and 16 (5.3%) had nonrenovascular complications. The overall incidence of surgically significant complications was 12.9%. Of these, 54% were felt to be of a technical etiology. The remainder were surgically significant in that their management necessitated operative intervention. Copyright @J1992 by W.B. Saunders Company INDEX tions.
WORDS:
Pediatric
renal transplantation,
complica-
I
MPORTANT anatomic and physiological differences exist between children and adults that influence the surgical approach to renal transpiantation. Because available cadaveric kidneys are most often obtained from adolescents and adults and because the child’s vascular and urinary structures are small and delicate, major size discrepancies may occur that potentiate surgical difficulties. Additionally, there is a greater incidence of anatomic abnormalities of the native urinary tract. Of equal importance are the physiological differences that include a smaller blood volume and a lower cardiac output. Placement of an adult kidney (which may sequester 250 mL of blood’) results in an immediate loss of recipient blood volume and a significant drain of cardiac output. Because some degree of acute tubular necrosis is usual and because this may be associated with increased vascular resistance, the child’s cardiac reserve may become insufficient to adequately perfuse the graft. All these considerations must be addressed in order to minimize the incidence of complications. MATERIALS AND METHODS From January 1969 to April 1986, 303 renal allografts were placed in 215 pediatric recipients. Of these, 290 were cadaveric and 13 were obtained from living related donors. The patients in this series were evaluated by retrospective analysis. All complications encountered that required surgical intervention or resulted in graft loss are included. Patients with medically controlled hypertension are excluded.
RESULTS
Twenty-three patients (7.6%) experienced renovascular complications and 16 (5.3%) had nonrenovascular complications. Of these 39 complications, 21 (54%) were felt to result from a technical failure of transplantation. JaurnalufPediatric Surgery, Vol27, No 4 (April), 1992: pp 485-490
The renovascular complication encountered are outlined in Table 1. Of these 23 complications, 7 were felt to be due to technical failure. One patient who developed renal vein thrombosis did so on the basis of a common iliac vein thrombosis where the iliac vein was twisted and partially occluded by the venous anastomosis. In one, the renal artery was acutely angulated, while a subintimal dissection was encountered in the other. Four patients developed renal artery stenosis necessitating surgical revision or nephrectomy and are felt to be due to technical failure. Three patients received grafts that never perfused, were proven to have patent anastomoses, and were removed at the time of the origina transplant procedure. The relative significance of these complications is demonstrated in Fig 1, which shows the incidence and etiology of vascular graft loss as a function of recipient age. A striking correlation between total vascular graft loss and recipient age (r = .97) was encountered. No such correlation with rejection-mediated graft loss could be demonstrated. Figure 2 outlines the incidence and etiology of vascular graft loss as a function of donor age. Again, no correlation between rejection-mediated graft loss and donor age could be demonstrated. The incidence of vascular graft loss was high (16.7%) with donor age < 2 years, low (3.2%) with donor age > 15 years, and intermediate with donor age 1 to 15 years. The clinical features of 16 patients experiencing nonrenovascuIar complications are outlined in Table 2. DISCUSSION These data represent the experience of multiple surgeons over a 17-year period and, as a result the modalities of management of many of these patients, do not reflect our current management protocols. However, they do demonstrate that with the exception of renal vascular thrombosis, the incidence and
From the Division of Pediahic Urology, The Hospital for Sick Children, Toronto, Ontario. Date accepted: September 5, 1990. Address reprint requests to Curtis Sheldon, MD, Children’s Hospital Medical Center, Director, Pediatric Urology, 3300 Elland Ave, Cincinnati, OH 45229. Copyright Q 1992 by W.B. Saunders Company 0022-3468/92/2704-08$03.00/0 495
SHELDON ET AL
466
Table 1. Renovascular Complications Patient NO.
DOnOr
Recipient Age (vrl
tvpe (n0.t
Complications
c (1) c (1) c (2) c (2)
RAT
Id
1
9.8
42
2
11.5
13
3
18
42
4
7
35
5
1.3
16
c (1)
6
2
3d
2.4
1
c (1) c (2)
RAT
7
RAT
47 d
8
1.3
2
RAT
Id
RAT
3d
12
15
11
13
9
26
14
8
7
C(l) c (1) c (1) c (1) c (2) c (1) c (1)
15
2.6
9
16
3.5
9
6
17
10
4.5
11
2.8
0.1 11
comment
onset
Technical failure: acute angulation
RAT
Id
Technical failure: subintimal dissection
RAT
7d
initial graft function, AT, LA, RT
RAT
5d
Initial graft function, AT, RT, DS
RAT
3d
Precipitating low flow state, RT, DS Initial graft function, RT, OS Anastomosis open on direct visualization -
RAT
Id
RT
RVT
Id
Technical failure: vain twisted, AT
RVT
Id
Precipitating low flow state, LA
WIT
3d
RT
RVT
Id
Anastomosis open on direct visualization,
c (1)
RVT
6d
Initial graft function, RT
3
C (3)
RVT
Id
WC thrombosis, anastomosis open on direct
3
c (1) c (1) c 11) c (1) c (1) c (2) c (1)
RAS
5mo
RT
LA, RT
visualization 17
14
18
a
19
12.5
1
20
13.5
4
21
3
4
22
4.8
0.25
23
1.5
7
RAS
3mo
Attempted repair failed
RAS
3mo
Attmepted repair failed
RAS
15 mo
PTLA-SD. Attempted repair failed
PNP
IO
Anastomosis open on direct visualization
PNP
IO
Anastomosis open on direct visualization
PNP
IO
Anastomosis open on direct visualization
Abbreviations: C, cadaveric; RAT, renal artery thrombosis; WT. renal vain thrombosis; RAS, renal artery stenosis; PNP, primary nonperfusion; IO, intraoperative; AT, attempted thrombectomy;
LA, low anastomosis; RT, rejection therapy; DS, died of sepsis; IVC, inferior vena cava; PTLA-SD,
percutaneous transluminal angioplasty resulting in subintimal dissection.
severity of surgically significant complications are similar to adult series. Renovascular complications encountered in this series included primary nonperfusion, renal artery stenosis, and renovascular thrombosis. Primary non-
I=a 0 0 w
(13)
(33)
(57)
perfusion in all cases involved a recipient under 5 years of age, a donor under 7 years of age, and only occurred with cadaveric allografts. In all cases the recipient was hemodynamically stable at the time of anastomosis, and in all cases the anastomoses were proven to be widely patent by direct inspection. These patients were managed by removal of the graft. This complication is felt to represent failure of either harvesting or storage techniques. These kidneys appeared to have sustained an injury that resulted in an
Total vascular loss Tech&al thrombotic loss Non-technlcal thrombosls Perfusion failure Renal artery stenosis
(95)
(33)
RECIPIENT AGE (YEAR) Fig 1. Vascular graft loss as a function of recipient age in pediatric cadaveric renal transplantation.
Total vascular loss TechnIcal thrombotlc loss Non-technlcal thrombosis Periusion failure Renal artery stenosis
m
(43)
(33)
(35)
(25)
(153)
DONOR AGE (YEAR) Fig 2. Vascular graft loss as a function of donor age in pediatric cadaveric renal transplantation.
PEDIATRIC RENAL TRANSPLANTATION
COMPLICATIONS
467
Table 2. Nonrenovascular Patient No.
Recipient Age W
Donor Age WI
Complications
DOfMX Tvpe
Complication
(no.)
Onset
1
ia
26
C (1)
Obstructed lymphocele
1
2
13
9
C (1)
Obstructed lymphocele
-
mo
Comments Drained, recovery Drained, recovery
3
17
1.6
C (2)
Infected lymphocele
4
15.5
-
P (2)
Necrotic ureter
3mo -
Successful reconstruction, lost to rejection Successful reconstruction, lost to rejection
9
C (1)
Necrotic ureter
5d
22
C (1)
Ureter obstructed by spermatic cord
1 mo
2.2
-
C (2)
Duodenal injury
a
6
6
C (3)
Small bowel obstruction
9
14
3
C (2)
Renal parenchymal rupture
10
a
25
C(l)
11
13
44
C (2)
12
16
9
13
13
5 6 7
1.5 17
IO 2 Yr
Drained, recovery
Reimplanted, ureteral necrosis, graft lost Transplant canceled, repaired, recovery Previous transperitoneal nephrectomy
-
Attempted repair, lost to rejection
Renal parenchymal rupture
ad
Attempted repair, lost to rejection
Renal parenchymal rupture
14d
Attempted repair, lost to rejection
C (1)
IO bleeding
IO
2
C (1)
PO bleeding
2d 12 h
Irreparable hilar harvest injury Anastomotic failure, graft lost
14
a
1
c (1)
PO bleeding
15
17
53
c (1)
Popliteal thromboembolism
Id
CE, T/F, residual LE deficit, kidney function
16
3
21
c (2)
Urinary extravasation
Id
Small, friable, defunctionalized bladder,
Evacuated, no site found
graft lost Abbreviations: C, cadaveric; P, parental; IO, intraoperative; PO, postoperative; CE, catheter embolectomy; T/F, thrombectomy
and fasciotomy;
LE. lower extremity.
increased renovascular resistance that could not be overcome by the child’s cardiac reserve. Because this complication occurred in 5.8% of all recipients ~5 years of age and was never encountered in older children, the injury may not have been sufficient to prevent perfusion had the grafts been placed in older children or adults. Renal artery stenosis represents a technical anastomotic failure in most instances. However, arterial narrowing may be encountered at sites remote from the anastomosis.’ Four patients in this series developed renal artery stenosis sufficient to require surgical revision or to result in allograft loss. Because many patients with medically controlled hypertension do not undergo arteriography and because some arteriograms are indeterminant, the total incidence of renal artery stenosis could not be accurately estimated. All 4 patients received an allograft from a donor _
of Surgical Significance Renal Transplantation
in Pediatric
By Curtis A. Sheldon, Bernard M. Churchill, Anroine E. Khoury, and Gordon A. McLorie Toron to, Ontario l From 1969 to 1966, 303 renal allografts (296 cadaveric) were placed in 215 pediatric recipients. Twenty-three patients (7.6%) had renovascular complications and 16 (5.3%) had nonrenovascular complications. The overall incidence of surgically significant complications was 12.9%. Of these, 54% were felt to be of a technical etiology. The remainder were surgically significant in that their management necessitated operative intervention. Copyright @J1992 by W.B. Saunders Company INDEX tions.
WORDS:
Pediatric
renal transplantation,
complica-
I
MPORTANT anatomic and physiological differences exist between children and adults that influence the surgical approach to renal transpiantation. Because available cadaveric kidneys are most often obtained from adolescents and adults and because the child’s vascular and urinary structures are small and delicate, major size discrepancies may occur that potentiate surgical difficulties. Additionally, there is a greater incidence of anatomic abnormalities of the native urinary tract. Of equal importance are the physiological differences that include a smaller blood volume and a lower cardiac output. Placement of an adult kidney (which may sequester 250 mL of blood’) results in an immediate loss of recipient blood volume and a significant drain of cardiac output. Because some degree of acute tubular necrosis is usual and because this may be associated with increased vascular resistance, the child’s cardiac reserve may become insufficient to adequately perfuse the graft. All these considerations must be addressed in order to minimize the incidence of complications. MATERIALS AND METHODS From January 1969 to April 1986, 303 renal allografts were placed in 215 pediatric recipients. Of these, 290 were cadaveric and 13 were obtained from living related donors. The patients in this series were evaluated by retrospective analysis. All complications encountered that required surgical intervention or resulted in graft loss are included. Patients with medically controlled hypertension are excluded.
RESULTS
Twenty-three patients (7.6%) experienced renovascular complications and 16 (5.3%) had nonrenovascular complications. Of these 39 complications, 21 (54%) were felt to result from a technical failure of transplantation. JaurnalufPediatric Surgery, Vol27, No 4 (April), 1992: pp 485-490
The renovascular complication encountered are outlined in Table 1. Of these 23 complications, 7 were felt to be due to technical failure. One patient who developed renal vein thrombosis did so on the basis of a common iliac vein thrombosis where the iliac vein was twisted and partially occluded by the venous anastomosis. In one, the renal artery was acutely angulated, while a subintimal dissection was encountered in the other. Four patients developed renal artery stenosis necessitating surgical revision or nephrectomy and are felt to be due to technical failure. Three patients received grafts that never perfused, were proven to have patent anastomoses, and were removed at the time of the origina transplant procedure. The relative significance of these complications is demonstrated in Fig 1, which shows the incidence and etiology of vascular graft loss as a function of recipient age. A striking correlation between total vascular graft loss and recipient age (r = .97) was encountered. No such correlation with rejection-mediated graft loss could be demonstrated. Figure 2 outlines the incidence and etiology of vascular graft loss as a function of donor age. Again, no correlation between rejection-mediated graft loss and donor age could be demonstrated. The incidence of vascular graft loss was high (16.7%) with donor age < 2 years, low (3.2%) with donor age > 15 years, and intermediate with donor age 1 to 15 years. The clinical features of 16 patients experiencing nonrenovascuIar complications are outlined in Table 2. DISCUSSION These data represent the experience of multiple surgeons over a 17-year period and, as a result the modalities of management of many of these patients, do not reflect our current management protocols. However, they do demonstrate that with the exception of renal vascular thrombosis, the incidence and
From the Division of Pediahic Urology, The Hospital for Sick Children, Toronto, Ontario. Date accepted: September 5, 1990. Address reprint requests to Curtis Sheldon, MD, Children’s Hospital Medical Center, Director, Pediatric Urology, 3300 Elland Ave, Cincinnati, OH 45229. Copyright Q 1992 by W.B. Saunders Company 0022-3468/92/2704-08$03.00/0 495
SHELDON ET AL
466
Table 1. Renovascular Complications Patient NO.
DOnOr
Recipient Age (vrl
tvpe (n0.t
Complications
c (1) c (1) c (2) c (2)
RAT
Id
1
9.8
42
2
11.5
13
3
18
42
4
7
35
5
1.3
16
c (1)
6
2
3d
2.4
1
c (1) c (2)
RAT
7
RAT
47 d
8
1.3
2
RAT
Id
RAT
3d
12
15
11
13
9
26
14
8
7
C(l) c (1) c (1) c (1) c (2) c (1) c (1)
15
2.6
9
16
3.5
9
6
17
10
4.5
11
2.8
0.1 11
comment
onset
Technical failure: acute angulation
RAT
Id
Technical failure: subintimal dissection
RAT
7d
initial graft function, AT, LA, RT
RAT
5d
Initial graft function, AT, RT, DS
RAT
3d
Precipitating low flow state, RT, DS Initial graft function, RT, OS Anastomosis open on direct visualization -
RAT
Id
RT
RVT
Id
Technical failure: vain twisted, AT
RVT
Id
Precipitating low flow state, LA
WIT
3d
RT
RVT
Id
Anastomosis open on direct visualization,
c (1)
RVT
6d
Initial graft function, RT
3
C (3)
RVT
Id
WC thrombosis, anastomosis open on direct
3
c (1) c (1) c 11) c (1) c (1) c (2) c (1)
RAS
5mo
RT
LA, RT
visualization 17
14
18
a
19
12.5
1
20
13.5
4
21
3
4
22
4.8
0.25
23
1.5
7
RAS
3mo
Attempted repair failed
RAS
3mo
Attmepted repair failed
RAS
15 mo
PTLA-SD. Attempted repair failed
PNP
IO
Anastomosis open on direct visualization
PNP
IO
Anastomosis open on direct visualization
PNP
IO
Anastomosis open on direct visualization
Abbreviations: C, cadaveric; RAT, renal artery thrombosis; WT. renal vain thrombosis; RAS, renal artery stenosis; PNP, primary nonperfusion; IO, intraoperative; AT, attempted thrombectomy;
LA, low anastomosis; RT, rejection therapy; DS, died of sepsis; IVC, inferior vena cava; PTLA-SD,
percutaneous transluminal angioplasty resulting in subintimal dissection.
severity of surgically significant complications are similar to adult series. Renovascular complications encountered in this series included primary nonperfusion, renal artery stenosis, and renovascular thrombosis. Primary non-
I=a 0 0 w
(13)
(33)
(57)
perfusion in all cases involved a recipient under 5 years of age, a donor under 7 years of age, and only occurred with cadaveric allografts. In all cases the recipient was hemodynamically stable at the time of anastomosis, and in all cases the anastomoses were proven to be widely patent by direct inspection. These patients were managed by removal of the graft. This complication is felt to represent failure of either harvesting or storage techniques. These kidneys appeared to have sustained an injury that resulted in an
Total vascular loss Tech&al thrombotic loss Non-technlcal thrombosls Perfusion failure Renal artery stenosis
(95)
(33)
RECIPIENT AGE (YEAR) Fig 1. Vascular graft loss as a function of recipient age in pediatric cadaveric renal transplantation.
Total vascular loss TechnIcal thrombotlc loss Non-technlcal thrombosis Periusion failure Renal artery stenosis
m
(43)
(33)
(35)
(25)
(153)
DONOR AGE (YEAR) Fig 2. Vascular graft loss as a function of donor age in pediatric cadaveric renal transplantation.
PEDIATRIC RENAL TRANSPLANTATION
COMPLICATIONS
467
Table 2. Nonrenovascular Patient No.
Recipient Age W
Donor Age WI
Complications
DOfMX Tvpe
Complication
(no.)
Onset
1
ia
26
C (1)
Obstructed lymphocele
1
2
13
9
C (1)
Obstructed lymphocele
-
mo
Comments Drained, recovery Drained, recovery
3
17
1.6
C (2)
Infected lymphocele
4
15.5
-
P (2)
Necrotic ureter
3mo -
Successful reconstruction, lost to rejection Successful reconstruction, lost to rejection
9
C (1)
Necrotic ureter
5d
22
C (1)
Ureter obstructed by spermatic cord
1 mo
2.2
-
C (2)
Duodenal injury
a
6
6
C (3)
Small bowel obstruction
9
14
3
C (2)
Renal parenchymal rupture
10
a
25
C(l)
11
13
44
C (2)
12
16
9
13
13
5 6 7
1.5 17
IO 2 Yr
Drained, recovery
Reimplanted, ureteral necrosis, graft lost Transplant canceled, repaired, recovery Previous transperitoneal nephrectomy
-
Attempted repair, lost to rejection
Renal parenchymal rupture
ad
Attempted repair, lost to rejection
Renal parenchymal rupture
14d
Attempted repair, lost to rejection
C (1)
IO bleeding
IO
2
C (1)
PO bleeding
2d 12 h
Irreparable hilar harvest injury Anastomotic failure, graft lost
14
a
1
c (1)
PO bleeding
15
17
53
c (1)
Popliteal thromboembolism
Id
CE, T/F, residual LE deficit, kidney function
16
3
21
c (2)
Urinary extravasation
Id
Small, friable, defunctionalized bladder,
Evacuated, no site found
graft lost Abbreviations: C, cadaveric; P, parental; IO, intraoperative; PO, postoperative; CE, catheter embolectomy; T/F, thrombectomy
and fasciotomy;
LE. lower extremity.
increased renovascular resistance that could not be overcome by the child’s cardiac reserve. Because this complication occurred in 5.8% of all recipients ~5 years of age and was never encountered in older children, the injury may not have been sufficient to prevent perfusion had the grafts been placed in older children or adults. Renal artery stenosis represents a technical anastomotic failure in most instances. However, arterial narrowing may be encountered at sites remote from the anastomosis.’ Four patients in this series developed renal artery stenosis sufficient to require surgical revision or to result in allograft loss. Because many patients with medically controlled hypertension do not undergo arteriography and because some arteriograms are indeterminant, the total incidence of renal artery stenosis could not be accurately estimated. All 4 patients received an allograft from a donor _
