5. You were offered kidneys from a 54-year-old female DCD donor who suffered from SAH (grade 5). According to the GP notes, this donor has mild diet-controlled DM, no proteinuria, and no history of hypertension. Her baseline S Cr was 86 µmol/L and 78 µmol/L before retrieval. She had excellent urine output (110mls/h during the last hour and 2.8 L over the last 24 hours). During retrieval, the surgeon reported to you a horseshoe kidney (see below).
- Please comment on the picture above
- Would you accept this donor?
- If yes, what is your advice to the retrieval team?
- If yes, how do you plan for transplantation?
- What are the risks associated with these kidneys?
Dear All
Do you think that transplanting these kidneys is associated with a higher risk of rejection, infection, and stone formation?
I have noticed some of my colleagues addressing these risks. There is a difference in complications of horseshoe kidney in a normal individual and complications associated with their transplantation
we should keep in mind one important issue the there is no communication between excretory system of both kidneys before division which is done by injecting colored fluid such as (methylene blue or propofol in ureter and check if there is leak from the crossing area or not.
multiple arterial supply .
Hi Dr Saad,
We would use methylene blue to detect leak (during bench surgery) in ureteric system after repair and propofol to look for leakage in arterial or venous system.
infection yes, as the most common complication reported is urinary leakage, most likely due to the anterior situation of the urinary pelvis.
DGF can be seen frequently rather than rejected. Acute tubular necrosis was the most likely explanation for the DGF seen in this, perhaps due to the clamping of the arteries to limit the place for transaction causing warm ischemia.
Yes Prof. Ahmad
The risk in hoarse shoe kidney is : VU reflux, recurrent infections and nephrolithiasis, malignanacy.
The risks after transplantation are : higher acute antibody mediated rejection, sepsis, stones , willm’s tumor at the isthmus, ureteric leak, UPJ obstruction, and developement of polycystic kidney disease.
incidence of rejection yes as any tissue damage during surgery can lead to rejection
infection possible and abnormality in thr anatomy of collecting system can lead to infection
stone formation may be in long term possible complication .
References:
The above picture is a horseshoe kidney which is joint at the lower pole with an isthmus.. There are 2 different ureters.. Although graft vessels appear normal…There are high incidence of blood vessel abnormalities posing challenges for vascular anastomosis…
Yes I will accept the donor
Vascular anastomosis is present in about 67% of the kidneys of horseshoe kidneys…Enbloc harvesting of the horseshoe kidney with long segments of aorta, venecava and iliac vessels…Due to increase in the prevalence of multiple accessory arteries perfusion should be done by placing the cannula in the common iliac artery to avoid lack of perfusion in small areas of the kidney suppled by accessory arteries…ureter length should be taken into account as they are associated with short ureters in the pelvis…Hence one should be vigilant about the urinary leaks….
There are reports of dividing the isthmus and anastomosis before transplantation. But this depends on the thickness of the isthmus and vessels and ureters crossing the vessels….Enbloc transplantation reduces the ischemia time and ipsilateral placement of the enbloc kidney is advicable due to small length of vessels…
There is increased incidence of cold ischemia time and warm ischemia time with Horseshoe kidney….This may predispose to delayed graft funciton and affect the long term outcome…But it may still be beneficial to an elderly patient with poor vascular access where benefit of transplant is still better
There is increased incidence of urinary leaks and on the long term increase in the risks of UTI, stones and malignancy which needs monitoring
Please comment on the picture above
Horse-shoe kidneys connected at lower poles
Would you accept this donor?
The potential donor is ECD with mild DM . Excellent RFTs and UOP
I shall accept this donation
If yes, what is your advice to the retrieval team?
Dual kidney transplant
Ureters should be inserted very close to UB
If yes, how do you plan for transplantation?
Close observation of renal vasculature and Ureters are inserted v.close to UB
Detection of any coagulation disorder or cardiac disorder .
What are the risks associated with these kidneys?
En block transplantation is the best option in such cases to preserve vasculature and avoid complications of isthmusectomy
Results and outcomes of horseshoe kidney transplant is close to normal kidneys but risk of thrombosis may be higher
Although the surgical complications are high, but no contra indications
1) Please comment on the picture above
Horseshoe shape kidneys with fusion at both lower pole of kidneys.
2) Would you accept this donor?
Yes after transplant surgeon assessment.
No if lack of expert for challenging kidney transplant with anatomical anomaly.
3) If yes, what is your advice to the retrieval team?
Transplant en block and avoid injury to lower pole.
4) If yes, how do you plan for transplantation?
Transplant kidney en block.
recipient with good CVS function.
short cold ischemic time.
5) What are the risks associated with these kidneys?
acute rejection.
urine leak.
bleeding.
long cold ischemic time
Horse show kidneys can be accepted for donation either separate or enbloc but needs expert surgeons
Comment on the picture above:
This is a horseshoe kidney,joint at the lower pole with an isthmus and two separate ureters and a lack of adequate peri-ureteral fat/tissue preservation. Also, renal vessels and graft retrieval appears non-meticulous.
Would you accept this donor?
I will accept this donor
If yes, what is your advice to the retrieval team?
Horseshoe kidney pose multiple technical challenges due to abnormal vascular anatomy in 67% of subjects (1). Advises for retrieval team include (1):
If yes, how do you plan for transplantation?
What are the risks associated with these kidneys?
Increased complexity associated with retrieval and transplanting such kidneys separately or en bloc anticipates more cold and warm ischemia time ,vascular, ureteric and wound related complications. However, if due care is taken during graft retrieval and implanting, graft outcomes are comparable to standard donor kidneys.(3)
References:
Please comment on the picture above
This a horse-shoe kidney connected at the lower pole with double ureters.
Would you accept this donor?
Trnaplanting horse shoe kidneys requires an expert vascular and urology surgeon because of complex vascular anatomy and ureteral and collecting systems. This kidney had been retrieved outside the donor which creates a technical challenge for the surgical team and the recipient.It should be accepted if suitable recipient and expert surgical team are available.
If yes, what is your advice to the retrieval team?
It can be transplanted as a whole (en bloc if it has a thick isthmus)) or after separation (if thick isthmus).
If yes, how do you plan for transplantation?
En bloc retrieval with long segments of aorta, IVC and iliac vessels.
What are the risks associated with these kidneys?
Risks include urine leak, sepsis, ureteric complications, vascular complications and rejection.
Q1- Picture shows a horseshoe kidney (fusion of kidneys in lower pole)
with two separate ureters.
Q2- To overcome organ shortage, kidneys with anatomical abnormalities are accepted for donation after counseling with vascular surgeon and urologist because of vascular and urinary tract challenges during transplantation. They can be transplanted as en block or as separate kidneys.
Q3- Identification of horseshoe kidney vessels (both arteries and veins and the accessory ones) and safety of collecting system during separation would be difficult and needs a lot of caution to prevent urinary leakage. These kidneys are harvested en block with long segments of aorta, IVC and iliac vessels.
Q4- Try to decrease both cold and warm ischemic time. Induction immunosuppression with antibodies if ischemic time was prolonged duo to technical problems and delay CNI initiation if DGF.
Q4- Urinary complications such as urinary leak duo to abnormal anatomy are common which would be resulted in urinoma or urosepsis. ATN that would result in DGF is another complication in these kidneys because of difficult technical transplantation. Acute cellular or even antibody mediated is another challenge.
1. Nemes B, Kanyári Z, Zádori G, Zsom L, Berhés M, Hamar M, Kóbor K, Péter A. Horseshoe kidney transplantation. Interv Med Appl Sci. 2015 Jun;7(2):85-9.
2. De Pablos-Rodríguez, P., Suárez, J. F., Riera Canals, L., Sanz-Serra, P., & Vigués, F. (2021). Horseshoe kidney splitting technique for transplantation. Urology Case Reports, 37, 101604.
3. Corcoran, Anthony T.; Shapiro, Ron; Kayler, Liise K.. Transplantation of a Horseshoe Kidney. Transplantation 83(6):p 828-829, March 27, 2007.
Horse shoe kidney fused at the lower pole with two separate urinary systems with the isthmus in the midline.
This donor can be accepted, the renal function is adequate and the donor has no comorbidities.
Available data about transplanting horse shoe kidney suggest it can be used to increase donor pool and overcome shortage of organs, however the data is limited
Transplanting horseshoe kidney is technically difficult and challenging due to complex vascular anatomy
En block implantation is suggested for kidneys with wide isthmus and thick parenchymal bridge.
Other technique is surgical division if pyelons are separated
Uretrography may be needed to determine if the 2 pyelons are separated or not
These kidneys are associated with higher risk of surgical complications as the procedure is technically difficult
Urine leakage and is difficult to treat
increased risk of urinary tract infection
higher risk of urinary tract obstruction due to stones (due to stasis and infection) or external compression by aberrant vessel.
Nemes B, Kanyári Z, Zádori G, Zsom L, Berhés M, Hamar M, Kóbor K, Péter A. Horseshoe kidney transplantation. Interventional Medicine and Applied Science. 2015 Jun;7(2):85-9.
Pontinen T, Khanmoradi K, Kumar A, Kudsi H, Chewaproug D, Zaki R, Ortiz J. Horseshoe kidneys: an underutilized resource in kidney transplant. Experimental and Clinical Transplantation: Official Journal of the Middle East Society for Organ Transplantation. 2010 Mar 1;8(1):74-8.
Raj GV, Auge BK, Assimos D, Preminger GM. Metabolic abnormalities associated with renal calculi in patients with horseshoe kidneys. J Endourol 2004; 18:157.
The figure illustrates a horseshoe kidney. This is a fusion anomaly of the kidney where they are connected by an isthmus of fibrous tissue or parenchyma.
The organ for donation presents a good performance for acceptance. However, given the risks of complications from the horseshoe kidney, it is interesting that the recipient is well chosen, both for the need of the kidney (waiting time, sensitivity, vascular network) , as well as with regard to psychological issues (ability to tolerate possible hospitalizations and other mishaps in the post-transplant) and social (availability of communication, mobility to reach the service in emergencies).
Beware of the risk of vascular injuries that could make it difficult to implant the kidney. It is recommended to remove long segments of the aorta, vena cava and iliac vessels. And also, do not make heroic attempts to separate the kidney to try to benefit more than one patient as a recipient.
There would be no changes with respect to conventional pre- or peri-transplantation protocols, but post-transplantation would try to be more rigorous with regard to the diagnosis and intervention of urinary and infectious complications.
Horseshoe kidney transplantation is a great challenge due to technical difficulties, mainly vascular. The fusion anomaly can lead to an increase in the number of renal arteries, veins collected to the inferior vena cava, ureters, among others, and the need for their separation. The possibility of carrying out the transplant en bloc facilitates its success, but if it is necessary to separate parts of the same, it would increase the cold ischemia time and its associated risks.
Thus, it becomes an organ with great technical difficulties for transplantation, increasing the risk of urinary complications and infections .
REFERÊNCIAS:
– Horseshoe kidney transplantation. Interventional Medicine & Applied Science, Vol. 7 (2), pp. 85–89 (2015)
– Kidney transplantation utilizing a horseshoe kidney. Kidney International (2019) 96, 1427; https://doi.org/10.1016/j.kint.2019.07.001
Comment on the picture:
Autopsy of horseshoe kidney identified by the fusion of both renal systems at the isthmus causing failed ascent and rotation. The main aetiology is due to a congenital anomaly occurring due to abnormal fusion of the kidneys in fetal life.
This donor acceptance is based on the coexisting shortage of organs. The unusual anatomy, tenuous vascular supply particularly to the lower pole of kidney, anomalies in the urinary collecting system and the large size of the allograft result in an increased incidence of complications, making the transplantation operation pretty challenging necessitating highly expert surgical team to get the minimal complications.
Proper Counciliing of the recipient is a must for the increased incidence in the perioperative period and recurrent infections later on.
Your advice to the retrieval team is to proceed via en bloc transplantation of horseshoe kidney technique. Although these kidneys can be transplanted either en bloc or can be transplanted separately to two different recipients after isthmusectomy provided they have suitable anatomy of the vascular and collecting systems, better results were found with adopting en bloc technique compared to the ischemic injury to the lower pole of at least one kidney due to its shared vascularity after isthmusectomy. In addition to the development of ischemia other reports showed increased incidence of urinary leak in the transplanted kidneys after isthmusectomy. So, division of the horseshoe kidney can result in rendering one of the kidneys nonusable due to these injuries.
On retrieval, adequate placing of the cold perfusion cannula was placed in the right common iliac artery to ensure good flow in the abnormal lower polar branch supplying the lower poles and isthmus. The horseshoe kidneys are to be procured en bloc with the intact aorta and inferior vena cava (IVC).
The incision ought to be longer than usual so as to extend up to few centimeters below the right costal margin so as to easily adapt the larger en bloc horseshoe kidney.
Partial closure of wound using a biological mesh in order to reduce tension in the wound and prevent increased intra-abdominal pressure secondary to the large allograft size.
Intraoperative and follow-up Doppler ultrasound to assess perfusion of the kidneys including the isthmus.
Plan for transplantation would start by proper selection of the recipient having some criteria as spacious abdomen, good cardiac output, no coagulopathy, and the ability to maintain satisfactory blood pressure to ensure good perfusion to this large-sized graft.
Heavy induction using ATG, considering triple regimen of immunosuppressive therapy (tacrolimus, MMF and steroid based).
A preoperative CT scan with contrast to be done for our donor to assess the vascularity of the liver and the horseshoe kidneys.
The risks associated with these kidneys:
The development of intra-abdominal and renal allograft compartment syndrome.
Vascular complications, urinary leak, cosmetically larger wound.
The high incidence of delayed graft function postoperatively.
Recurrent infections.
Reference:
Case Rep Transplant. 2021; 2021: 2286831.
Published online 2021 Aug 11. doi: 10.1155/2021/2286831
I will check the communication between to kidneys then proceed accordingly.
will check with methylene blue injecting, if any leak!
Please comment on the picture above
· This is a horse shoe shaped kidney which is a rare anatomical abnormality with a prevalence of 1/400 to 1/800 and incidence of 0.25% in the general population. It more common in males than females(2:1).
· In the picture we can see the fusion of the lower pole of the 2 kidneys with an isthmus(fibrous tissue or parenchyma). This fusion causes failure of ascent and rotation. The picture shows There are 2 separate ureters.
Would you accept this donor?
· ECD female, DCD secondary to SAH. She has good urine output and renal functions. However, she has a horse shaped kidney discovered at the time of retrieval.
· In view of organ shortage, I will accept this kidney to expand the donor pool. However, this represents a surgical challenge in view of vascular and ureteric collecting system anatomic complexity and require an expert surgeon used to deal with such cases. Transplanting HSK has reasonable results and the one-year graft survival was similar to normal kidneys.
If yes, what is your advice to the retrieval team?
· Need awareness of the vascular anomalies (multiple renal arteries or veins) and the complexity of the urinary collecting system associated with horse shoe kidney
· To use cold perfusion cannula in the right common iliac artery to ensure good flow in the abnormal lower polar branch supplying the lower poles and isthmus.
If yes, how do you plan for transplantation?
What are the risks associated with these kidneys?
· Technical failure
· large recipient incision
· PNF and DGF
· Bleeding risks
· Increased risk for urinary complications like urine leak and fistulas
· Increased risks of infections and nephrolithiasis.
References:
1.Nghiem D et al. Transplantation of the Horseshoe Kidneys: A Model For Dual Adult Kidney Transplantation. Uro 2022;2:157-165.
2. Nemes B, Kanyári Z, Zádori G, Zsom L, Berhés M, Hamar M, Kóbor K, Péter A. Horseshoe kidney transplantation. Interv Med Appl Sci. 2015 Jun;7(2):85-9.
3. Kang M, Kim YC, Lee H, et al. Renal outcomes in adult patients with horseshoe kidney. Nephrol Dial Transplant 2021; 36:498.
Please comment on the picture above:
First time to me to se like this kidney, this is nice case for discusion.
Horseshoe kidney conected in the lower part.
I can accepted if we have good Tx surgon and good team to deal with this kidney because the risk of thrmbosis is very high.
The ATN and even the thrmbosis on table is very high compared to normal shape kidney.
There is alot of associated risk (Thrmobosis,infection,rejection,leak,stone formation)
_ The above photo shows horseshoe kidney with 2 ureters.
_ I can accept the kidney In spite of higher risk of vascular complications, complex vascular anomalies and expected ureteric complications.
_ The advice is that during retrieval take care to avoid injury of renal pelvis and vascular injury during dissection. In addition, it is better to be tranplnated en bloc to single recipient, to avoid uretric leak or urinary fistula formation after isthmusectomy.
Using a patch from the aorta and IVC to ensure safe vascular anastomosis.
_ in case of transection and transplantation into 2 different recipients, use of methylene blue dye to exclude ureteric leak and use of propofol to exclude vascular leak is essential. Well experienced team in such transplantation is needed to avoid severe bleeding or injury to lower pole vessels.
_ risk associted with transplanting such kidneys include:
Repeated infections, urolithiasis and more predisposed to risk of rejection due to vascular injury. In addition, urine leakage from anteriorly located renal pelvis.
Risk of malignancy in isthmus after Transplantation and development of PUJO is high.
*A picture of :Horseshoe kidney with fusion in both their lower poles and 2 separate ureters. Horseshoe kidney is a common urinary congenital abnormality.
*Yes ,I will accept this donor .The donor is diet controlled diabetic with no proteinuria.
*Better to retrieve as DKT to a single recipient. Care should be taken about altered complex vascular anatomy and urinary collecting systems .Take into consideration complications of horse-shoe kidneys as sepsis and hydro-nephrosis, stones,urinary leak ,malignancy
and incidence of PUJ obstruction
Transplantation better than still on long waiting list due to organ shortage.
* My advice to the retrieval team :It is better to transplant this kidney as en bloc better than or can be transplanted separately to different recipients to avoid lower pole injury due to common vasculature when doing isthmusectomy and avoid splitting complications as bleeding.
* Plan for transplantation? Horseshoe kidney consider technical challenge which need excellent expert transplantation vascular and urologist team. In deceased donors , arterial cannula through External iliac or common iliac should be inserted, decreasing cold ischemia time as possible. Good recipient selection with good cardiac condition.
Reference
Bodhisatwa Seng., Iftikhar Khan.: En Bloc Transplant. of Horseshoe Kidney from Deceased Donor: An Unusual Transplantation Utilizing Kidneys with Congenital Fusion Abnormality,Case Rep Transplant. 2021.
Haluk Mehmet Mo., Dirk Uhl., Armin Thel.,Hans-Michael Tautenhahn, Michael Bart.,etal.,: Horseshoe kidney for transplant.: Technical considerations, Scandinavian Journal of Urology,2013; 47:1, 76-79
This is a horseshoe kidney communicating at lower pole. The communicating part look relatively small with very small which may indicate that the parenchyma is communicating. There is 2 ureters and 2 hila.
This offer should be accepted but pending the surgeon assessment of the vascular anatomy and how to transplant it? in one recipient or two.
Has to be careful to preserve the anatomy, take it as one block, take good patch of aorta and IVC. Separation to be considered but to be done in the back table.
If vascular anatomy is favourable, as same to be from the picture, they can be transplanted to two recipients.
Technically challenging surgery with following risk:
Ureteric leak
Urinary tract infection and
Stone formation.
Reference :
Interventional Medicine & Applied Science, Vol. 7 (2), pp. 85–89 (2015)
*During preoperative evaluation of a living kidney donor multiple abnormalities can be found.
*There are three abnormalities that can be found in a horseshoe kidney: ectopia, malrotation and vascular changes
*With these anatomical considerations in mind, the experience from horseshoe kidney cadaveric donors encouraged us to consider its use in living donors, and the decision was made mainly on an anatomical basis.
*The most common complication reported is urinary leakage ,Acute tubular necrosis was the most likely explanation for the DGF seen in this,
there is a good long term function of the graft and the mean follow time is 22.75 months
3. Aikawa M., Hashiba T., Dobashi Y., Inoue S., Kuzuhara K., Otsubo O. A case report of use of horseshoe kidney as renal transplant from live donor [In Japanese] Nihon Hinyokika Gakkai Zasshi. 1998;89:62–65. [PubMed] [Google Scholar
5. Goyal A., Gaitonde K., Sagade S.N., Shah B.V., Kamat M.H. Transplantation of horseshoe kidney from living-related donors: report of two cases. Transplant. Proc. 2003;35:32–34. [PubMed] [Google Scholar
14. Natsis K., Piagkou M., Skotsimara A., Protogerou V., Tsitouridis I., Skandalakis P. Horseshoe kidney: a review of anatomy and pathology. Surg. Radiol. Anat. 2014;36:517–526.[PubMed] [Google Scholar]
Horse shoe kidney with double ureter and kidneys connected by isthmus in lower lobe.
. Yes I will accept we will must include MDT including transplant surgeon and urologist for vascular and urological abnormalities.
– assessment by transplant surgeon and urologist ‘
. Considering dual Kidney Transplantation
Decrease graft function and survival
Urine leakage
Infection
Surgical complication post transplant.
.
horseshoe kidneys with double ureter.
Transplanting horseshoe kidneys is challenging and has higher complication rates due to the unusual anatomy of the vascular and urinary collecting systems.
Most centers avoid using these kidneys for transplantation.
However, if chosen carefully, these organs can be used successfully to reduce organ shortage.
So I will accept this horseshoe kidneys if the vascular anatomy& urinary collecting systems of are not complicated for transplantation.
-most of complications of horseshoe kidneys are hydronephrosis, infection, and stones occur in up to 40% of patients .
Transplantation of horseshoe kidney is challenging due to the complexity of the vascular supply and anomalous collecting system .
-These kidneys can be transplanted either en bloc or can be transplanted separately to two different recipients after isthmusectomy.
–isthmusectomy could have resulted in ischemic injury to the lower pole of at least one kidney due to its shared vascularity.
-recommended cannulation of the common iliac arteries to avoid injury to the lower polar vessels and ensure proper cold perfusion through them.
select a recipient who had a spacious abdomen, had good cardiac output, was not coagulopathic, and could maintain satisfactory blood pressure to ensure good perfusion to this large-sized graft.
-It may be transplanted En bloc or splitted to 2 different recipients.
complications if splitting are high it includes bleeding & urinary fistula.
•What are the risks associated with these kidneys?
-higher incidence of sepsis
-acute antibody mediated rejection
-stones and ureteric leakge
– UPJ obstruction.
-malignancy.
Bodhisatwa Sengupta, Iftikhar Khan.En Bloc Transplantation of Horseshoe Kidney from Deceased Donor: An Unusual Transplantation Utilizing Kidneys with Congenital Fusion Abnormality,Case Rep Transplant. 2021.
Please comment on the picture above
Complete fusion of both kidneys in lower pole with bilateral two ureters
Horseshoe kidney.
Would you accept this donor?
This donor DCD with ECD 54 year old DM with horseshoe kidney and good renal function
Horseshoe kidney is the most common urinary congenital abnormality. In a deceased donor When it is found at the time of operation, it can be divided and transplanted into two different recipients or as a unit in a single receptor; depending on the vascular and urinary anatomy.
When faced with the option whether or not to accept horseshoe kidney for transplantation, the increased risk for urinary complications should be kept in mind.
And in order to increase the pool of donor and the benefit of transplant over waiting also Due to the organ shortage, efforts to overcome the anatomic challenges of horseshoe kidneys are worthwhile. I will accept this donor but we need MDT ad expert both urologist and vascular surgeon to complete this operation safely in order to improve the recipient life .
If yes, what is your advice to the retrieval team?
If yes, how do you plan for transplantation?
Due to common vascular and ureteral variations, transplantation of a horseshoe kidney presents a technical challenge.
Horseshoe kidneys can be transplanted en bloc or separated first and then transplanted separately
Transplanting a horseshoe kidney demands technical expertise because an average, normal vascular anatomy occurs only in the 33% of these cases.
Caution is needed during organ harvesting.
In cadaveric donors, arterial perfusion cannula should be placed in the common or the external iliac artery to avoid injury of accessorial arteries. Recommendations was harvesting horseshoe kidney en bloc with long segments of aorta, vena cava, and iliac vessels.
Insertion of double j .
Decreasing total ischemic time
Using immunosuppressive basiliximab ,omycophenolate and intravenous infusion of methylprednisolone .
What are the risks associated with these kidneys?
The most common complication reported is urinary leakage ; which later led to sepsis ,most likely due to the anterior situation of the urinary pelvis. Ureteric complications after renal transplantation are often difficult to manage.
Acute tubular necrosis was the most likely explanation for the DGF seen in this, perhaps due to the clamping of the arteries to limit the place for transection causing warm ischemia, or as a result of the prolonged total ischemia time caused by the need for more arterial anastomoses during back table surgery.
Reference
Transplantation of a horseshoe kidney from a living donor: Case report, long term outcome and donor safety
Jaime Manuel Justo-Janeiro, Eduardo Prado Orozco, […], and Jesús Mier Naylor
Horseshoe kidney transplantation
Balázs Nemes, Zsolt Kanyári, […], and Antal Péter
This horseshoe kidney.
Yes .
technique of the en bloc removal avoid injury to vasculature, the distal donor aorta and
the distal vena cava are retrieved with kidney.
right iliac extraperitoneal approach was performed in a standard transplant procedure,
en bloc DKT transplantation , simultaneously vascularized by the donor aorta and vena
cava, anastomose, respectively, to the recipient iliac artery and vein of recipient.(1)
primary nonfunctions.
vascular thromboses.
urinary leakages.
wound infections.
vascular injuries.
injuries to the collecting system nonamenable to repair.
References:
1-Dai D. Nghiem. Transplantation of the Horseshoe Kidneys: A Model for Dual Adult
Kidney Transplantation .Uro 2022, 2, 157–165. https://doi.org/10.3390.
The above picture is of horse shoe kidney. Both kidneys are fused at lower poles. An isthmus is visible which is narrow and they are in many cases fibrous and non functional.
‘One ureter each can be seen coming out from kidney which are traversing from front of the isthmus.
The donor has mild diabetes which is controlled with no other risk factors. She has horse shoe kidney and horse shoe kidney transplantation is quite challenging both medically and surgically. Hence if center has expertise in the same I shall go ahead with transplantation.
SURGICAL CHALLENGES:
MEDICAL CHALLANGES
ADVICE TO THE RETRIEVAL TEAM
REF
horseshoe kidney with double ureters, the kidneys are connected at the lower pole.
In horseshoe kidneys, vascular, ureteral, and collecting system abnormalities are common and from a surgical point of view it will be a challenge so, I need to discuss with my transplant surgeon regarding his experience regarding this kind of operation and also regarding potential recipients their good space and anastomosis site for both vascular and ureteric tree.
If he has the confidence to deal with such a challenge and the potential recipient has enough space so, I will accept.
Usually, the isthmus is only fibrous tissue, and no communicating system in the collecting system of both kidneys but if the thickness of the isthmus is significant and communicating system is suspected so the decision of en bloc should be made and good aortic and caval stamp should be left for easy anastomosis the other hand if the isthmus is not prominent and separation was decided so, urine leakage should be checked by injecting a colored fluid such as methylene blue in one ureter and check if there is a leak from the crossing area or not, if yes, both separated kidney will be discarded if no so, each kidney can be transplanted now for 2 potential recipients
Reported cases of urine leak and sepsis post-transplantation.
Ureteric complications after renal transplantation are often difficult to manage
if the thickness of the isthmus is significant and communicating system is suspected so the decision of en bloc should be made and good aortic and caval stamp should be left for easy anastomosis.
on the other hand, if the isthmus is not prominent and separation was decided so, urine leakage should be checked by injecting a colored fluid such as methylene blue in one ureter and checking if there is a leak from the crossing area or not, if yes, both separated kidneys will be discarded if no so, each kidney can be transplanted now for 2 potential recipients
What are the risks associated with these kidneys?
Reference:
NEMES B, KANYÁRI Z, ZÁDORI G, ZSOM L, BERHÉS M, HAMAR M, et al. Horseshoe kidney transplantation. Interventional Medicine & Applied Science. 2015;7(2):85–89
** Please comment on the picture above
Case of horseshoe kidney with double ureters . Kidneys are connecting at lower lobes
** Would you accept this donor?
DCD donor 54 year old with DM so he is ECD and has a horseshoe kidney with good renal function
As horseshoe kidney has complex vascular anatomy and Ureteral and collecting system abnormalities are also common.
Horseshoe kidneys can be transplanted en bloc or separated
So I need MDT with vascular surgeon and urologist to make desision
** If yes, what is your advice to the retrieval team?
arterial perfusion cannula should be placed in the common or the external iliac artery to avoid injury of accessorial arteries
And harvesting horseshoe kidney en bloc with long segments of aorta, vena cava, and iliac vessels
If yes, how do you plan for transplantation?
If Kidneys have a thick isthmus and a wide parenchymal bridge I prefeered transplantation en bloc
If there are no collecting system in the isthmus it may transplant separately
** What are the risks associated with these kidneys?
Complications are : urinary leak , vascular complication , infections , bleeding in split transplant
A horseshoe kidney showed fusion in the lower poles with 2 separate ureters
yes I will accept the donor
He is an ECD (age > 50 + DM ) with anatomical and structural abnormalities (Horseshoe kidney ) + has an excellent baseline creatinine and good urine output
as Utilizing marginal donors or donors with vascular or urinary anomalies, which provide surgical challenges, is occasionally necessary due to the chronic organ shortage and rising number of patients awaiting a transplant
Transplant en bloc as As isthmusectomy might have caused ischemia damage to at least one kidney’s lower pole due to its shared vascularity with more risk for ischemia and urine leaks.
This idea of the en bloc transplantation of the horseshoe kidneys is further supported by the increased number of discarded kidneys (18% of the collected series) lost during renal splitting due to damage to the complicated vascular and excretory systems that were unrepairable.
It has been demonstrated that using a single long ureteral stent left in for a short period of time may effectively protect dual-kidney transplant patients from urinary problems and lower leakage rates.
Cannulation of the common iliac arteries was advised by Tan et al. in order to protect the lower polar vessels and guarantee sufficient cold perfusion via them.
To guarantee adequate perfusion of this large-sized graft, choose a recipient with a large abdomen, excellent cardiac output, no coagulopathy, and the ability to maintain appropriate blood pressure.
To rule out the development of intra-abdominal compartment syndrome, intra-abdominal pressure must be monitored.
· What are the risks associated with these kidneys?
Urinary leakage is the most often reported problem and is probably caused by the urinary pelvis’ anterior position
The DGF e was most likely caused by acute tubular necrosis, possibly as a result of the prolonged total ischemia time brought on by the requirement for additional arterial anastomoses during the surgery
The complicated vascular supply and abnormal collecting system of the horseshoe kidney make transplantation difficult especially if isthmusectomy is planned for SKT .
Risk of horseshoe kidney itself ( liability for infection and stone formation )
References
Nghiem, D.D. En bloc transplantation of kidneys from donors under 15 kg into adult recipients. J. Urol. 1991, 145, 14–16.
Tan H. P., Samaniego M. D., Montgomery R. A., et al. Donor horseshoe kidneys for transplantation. Transplantation. 2001;72(5):869–873.
Glenn J. F. Analysis of 51 patients with horseshoe kidney. New England Journal of Medicine. 1959;261(14):684–687.
Horseshoe kidney connected in the lower pole of the kidneys with ureter in each kidney .
regarding DM is mild and no proteinuria and regarding the horseshoe kidney needs discussion and evaluation by the surgical team regarding how many artery ,also about colleting urinary system and the risk of the surgery, if low risk and there is suitable anatomy we may consider this donor if not avoid it.
some group of recipient benefit from this donation such as those who have no suitable donor ,long waiting time and poor compatibility.
anatomical assessment included vasculature and urinary collecting system.
and this kidney can be offer to single recipient.
this kidney can be transplant to one recipient or two by separate the isthmus the ureter close to bladder.
immunosuppression therapy 20 mg i.v basiliximab in day 0 and 4
methylprednisolone 2 mg/kg /day for 3 days and cyclosporin 3 mg /kg /day and MMF 1gm bid.
surgical complication such as bleeding, infection ,urinary leak
medical complication such as rejection ,DGF
References1. Hau H.M., Morgul H.M., Uhlmann D., Thelen A., Fellmer P., Benckert C. Horseshoe kidney for transplantation: technical considerations. Scand. J. Urol. 2013;47:76–79. [PubMed] [Google Scholar]
2. Sezer T.O., Solak I., Sozbilen M., Firat O., Yilmaz M., Toz H. A horseshoe kidney from a live donor as a renal transplant: case report. Exp. Clin. Transplant. 2013;11:454–457. [PubMed] [Google Scholar]
Please comment on the picture above
It is horseshoe kidney connected at lower lobe with double ureters
Would you accept this donor?how do you plan for transplantation.
I will accept this donor as horseshoe kidney not contraindicated
It is surgically challenge rather than medical issue
Better to evaluate vascular and collecting system
If yes, what is your advice to the retrieval team?
Better to assess the vascular and collecting system to decide separation
Horseshoe kidney can be transplanted separated or en bloc
If the isthmus is thick and wide parenchymal bridge better to transplant as en bloc
What are the risks associated with these kidneys?
Ureteric complications
Urine leakage
Urolithiasis
Vascular complications
The picture shows 2 horseshoe kidneys with 2 separate ureters.
Yes ,I can accept that donor for organ shortage and long waiting.
Vascular anatomy is usually complex. with common ureteral and collecting system abnormalities.
Evaluation with contrast of collecting system anatomy, isthmus thickness and also vascular assessment evaluation.
En bloc approach with long segments of the aorta, vena cava, and iliac vessels in case of :
. Thick isthmus with wide parenchymal bridge more than 2 cm.
. collecting system crossing isthmus
. Abnormal vasculature
Otherwise, split approach could be adopted with contrast study.
A stapler is used for safely sealing surface of divided isthmus.
Division of the ureter at bladder junction to give possible maximal length.
Extra vessels to be packed with the kidney for possible needed vascular reconstruction.
Associated risks:
– Bleeding in case of splitting.
– Urinary complications: urine leakage, fistula, necrotized graft ureter.
– Vascular complications.
References:
– Transplantation. 2007 Mar 27;83(6):828-9. doi: 10.1097/01.tp.0000257957.71912.2a. PMID: 17414722.
– Nemes B, Kanyári Z, Zádori G, Zsom L, Berhés M, Hamar M, Kóbor K, Péter A. Horseshoe kidney transplantation. Interv Med Appl Sci. 2015 Jun;7(2):85-9. doi: 10.1556/1646.7.2015.2.7. Epub 2015 Jun 11. PMID: 26120481; PMCID: PMC4464770.
Please comment on the picture above
The picture shows a horseshoe kidney with central isthmus , anterior lying pelvis with ureters and blood vessels. There is possibility of cysts bilaterally
Would you accept this donor?
Yes I would accept it for donation. The donor is diet controlled diabetic with no obvious end organ damage. (Preferably as a dual renal transplant)
If yes, what is your advice to the retrieval team?
Better to retrieve en block and offer to one centre and a single recepient. Care should be taken about altered complex vascular anatomy
If yes, how do you plan for transplantation?
Preferably can be done as dual renal transplant. However can be separated at the isthmus carefully to do single transplant in two donors. Careful inspection should be done at division point to check any leak. Divide the Ureter close to bladder. Two ueters can be reimplanted separately.
What are the risks associated with these kidneys?
These kidney can have complex arterial supply. There can be element of PUJ obstruction. There is higher risk of infections and stone formation, urine leak. abdominal closure can be challenging and a help from Plastic surgeon may be needed.
Reference
Nemes B, Kanyári Z, Zádori G, Zsom L, Berhés M, Hamar M, Kóbor K, Péter A. Horseshoe kidney transplantation. Interv Med Appl Sci. 2015 Jun;7(2):85-9.
Studies showed that the transplantation of a HSK, either en bloc or separated,
produced the same results compared with the transplantation of a regular kidney.
Yes I will accept this kidney.
I would advise the retrieval team to do:
Dynamic renal perfusion scintigraphy provide a good estimate for the functions of individual kidneys or a descending urography to show the caliceal systems,
There are two possible surgical techniques in HSK transplantation, either en bloc or after splitting the kidney.
Splitting Kidney
Important due to the scarcity of the organs required for transplantation.
Depending on factors like:
There might be a high risk of technical failure.
Most concerning complications after splitting a HSK include bleeding and urinary fistula from the cut edges. We can assume that the thicker the isthmus is, the greater risk.
Kidneys with a thick isthmus and a wide parenchymal bridge are recommended for transplantation en bloc.
I would advise the transplant team to look for urinary leak and bleeding.
Risks associated with these kidneys are infection,delayed graft function, leak if injured ureter during anastomosis and Pelvi-ureteric junction(PUJ) obstruction.
Stroosma OB, Smits JM, Schurink GW, et al. Horseshoe kidney transplantation within
the Eurotransplant region: a case control study. Transplantation. 2001;72:1930–1933.
https://doi.org/10.1097/00007890-200112270-00011.
this picture is for horseshoe kidneys with two ureters
This kidneys hold higher risk of infections AND STONE FORMATION ,and ABMR.
we are going to accept this kidney with DKT approach
this type of kidneys have problems related to the urology with high PVR AND STONE FORMATION
Better to continue following this patient for wills tumor and to keep them on CNI free regime
Please comment on the picture above
Gross appearance of hoarseshoe kidney with two ureters
Would you accept this donor?
Yes; I would accept this donor, extended criteria donor > 50 with mild diet controlled DM.
If yes, what is your advice to the retrieval team?
I will ask them to separate the two parts of kidney by cone like excision of isthmus after identifying the vascular anatomy of two parts, before taking them out. Trying un-injuring the vessels and urinary collecting system, by en bloc extraction including the aorta and the inferior vena cava can be performed.
The horseshoe kidneys have the potential for anatomical variation, careful inspection, imaging, and knowing the exact anatomy of the kidney could lead to successful transplantation.
If yes, how do you plan for transplantation?
I will transplant the two parts to the same recipient, ATG induction, CIN free maintenance immunosuppression- better m-TOR based.
What are the risks associated with these kidneys?
Risks of the horseshoe kidney is urinary tract infection, vesicoureteral reflux, hydronephrosis, urine stasis, and nephrolithiasis. Comorbidities associated with transplant of hoarseshoe kidney is ectopic ureterocele, UPJ obstruction, and polycystic kidney disease can occur, as well as ureteric stones, the incidence of Wilm’s tumor in people who have the horseshoe kidneys is twice as high as in the general population, more at isthmus, requiring frequent follow up.
References:
[1] Yun S, Woo HD, Doo SW, Kwon SH, Noh H, Song D. Transplantation of a horseshoe kidney found during harvest operation of a cadaveric donor: a case report. J Korean Med Sci. 2014 Aug;29(8):1166-9. doi: 10.3346/jkms.2014.29.8.1166. Epub 2014 Jul 30. PMID: 25120330; PMCID: PMC4129212.
[2] Vernadakis S, Moris D, Kaiser G, Kykalos S, Sotiropoulos GC. Horseshoe kidney transplantation. Am Surg. 2013 Sep;79(9):e298-9. PMID: 24069967.
Please comment on the picture above
1. This is a viable horseshoe kidney; the kidneys are joined together with an isthmus at the lower pole.
2. Horseshoe kidneys are the most common fusion defect of the kidneys occurring in approximately 1:500 individuals.
3. They are characterized by abnormalities in the position, rotation, and vascular supply of the kidney.
4. Although largely benign, they are associated with urological sequelae due largely to the associated ureteric obstruction and impaired urinary drainage.
Would you accept this donor?
I would accept this donor
1. Horseshoe kidney is not a contraindication to donation. A horseshoe kidney as a renal allograft after a detailed preoperative evaluation may help expand the donor pool1.
2. Most surgeons thought that the results of horseshoe kidney transplantation were equal to those of normal kidneys2.
If yes, what is your advice to the retrieval team?
1. To avoid division of the horseshoe kidney as may result in rendering one of the kidneys nonusable due to these injuries.
2. In deceased donors, the transection of the isthmus, if considered, should be done in the back table.
3. The cold perfusion cannula to be placed in the right common iliac artery to ensure good flow in the abnormal lower polar branch supplying the lower poles and isthmus.
If yes, how do you plan for transplantation?
1. en bloc horseshoe kidney transplantation3. or can be transplanted separately to two different recipients after isthmusectomy provided they have suitable anatomy of the vascular and collecting systems3.
2. Considering the complexity of the transplant and size of the allograft, the selected recipient should be with the followings;
a) should have a spacious abdomen.
b) Having good cardiac output.
c) Not coagulopathic.
d) Should maintain a satisfactory blood pressure to ensure good perfusion to this large-sized graft.
3. Postoperative US to confirm adequate vascularity of the graft.
4. Monitoring of the intra-abdominal pressure to rule out the development of intra-abdominal and renal allograft compartment syndrome.
What are the risks associated with these kidneys?
1. Pelvi-ureteric junction(PUJ) obstruction.
2. Hydronephrosis.
3. Urinary leak.
4. Bleeding.
5. Infection.
6. Renal stones.
7. Susceptibility to trauma and compartment syndrome.
Reference
1. Sezer TO, Solak I, Sozbilen M, Firat O, Yilmaz M, Toz H, Sarsik B, Isayev C, Harman M, Hoscoskun C. A horseshoe kidney from a live donor as a renal transplant: case report. Exp Clin Transplant. 2013 Oct;11(5):454-7. doi: 10.6002/ect.2012.0214. Epub 2013 Feb 22. PMID: 23431980.
2. Stroosma OB, Schurink H, Kootstra G. Current opinions in horseshoe kidney transplantation. Transpl Int. 2002 Apr;15(4):196-9. doi: 10.1007/s00147-002-0388-y. Epub 2002 Mar 21. PMID: 11976742.
3. Bodhisatwa Sengupta, Iftikhar Khan, Akram Saiaghi, Ethar A. Gaw, Mansour Tawfeeq, Mohammed S. AlQahtani, Mahmoud Obeid, “En Bloc Transplantation of Horseshoe Kidney from Deceased Donor: An Unusual Transplantation Utilizing Kidneys with Congenital Fusion Abnormality”, Case Reports in Transplantation, vol. 2021, Article ID 2286831, 4 pages, 2021. https://doi.org/10.1155/2021/2286831
References ;
Transplantation of Horseshoe Kidney from Living, Genetically Unrelated Donor
1 , * Zsolt Kanyári, 1 Gergely Zádori, 1 Lajos Zsom, 1 Mariann Berhés, 2 Mátyás Hamar, 3 Krisztina Kóbor, 4 and Antal Péter 3
Kazuro Kikkawa
,1Takahito Wakamiya,1Hiroki Kusumoto,1Nagahide Matsumura,1Yasuo Kohjimoto,1and Isao Hara
1
Horseshoe kidney transplantationBalázs Nemes
Please comment on the picture above
Horseshoe kidney with ureters, the kidneys are connected at the lower pole.
Would you accept this donor?
This case is more surgically challenging than medical. Need to evaluate the vascular and collecting system to decide whether accept it or not.
If yes, what is your advice to the retrieval team?
Kidneys with a thick isthmus and a wide parenchymal bridge, then en bloc.
If yes, how do you plan for transplantation?
Challenge is surgical, space if en block; vascular and collecting system anatomy is also crucial. Harvesting horseshoe kidney en bloc with long segments of the aorta, vena cava, and iliac vessels can be done.
What are the risks associated with these kidneys?
– Surgical complication
– Vascular complication
– Urine leak
– Standard medical complications
THat is a great reply, dear Dr Ansary, but without any evidence to support your arguments.
horseshoe kidney with double ureters, the kidneys are connected at the lower pole.
The vascular anatomy of a horseshoe kidney is usually complex.
Ureteral and collecting system abnormalities are also common.
Due to common vascular and ureteral variations, transplantation of a horseshoe kidney presents a technical challenge.
So I need to evaluate the vascular and collecting system of this kidney to decide.
Horseshoe kidneys can be transplanted en bloc or separated, and this is dependent on the thickness of the isthmus. Kidneys with a thick isthmus and a wide parenchymal bridge are recommended for transplantation en bloc.
The collecting system rarely crosses the isthmus. It is more common to find the isthmus to contain only fibrous tissue.
In cases of a thick isthmus, one study recommends evaluating the collecting system with contrast to ascertain anatomy and implanting it en bloc in case the collecting system crosses the isthmus.
Reported cases of urine leak and sepsis post-transplantation.
Ureteric complications after renal transplantation are often difficult to manage
After being sure that there are no collecting system tissues in the isthmus, it can be transplanted separately.
Transplanting a horseshoe kidney demands technical expertise because an average, normal vascular anatomy occurs only in 33% of these cases. Caution is needed during organ harvesting.
In cadaveric donors, an arterial perfusion cannula should be placed in the common or the external iliac artery to avoid injury to accessorial arteries.
A study recommends harvesting horseshoe kidney en bloc with long segments of the aorta, vena cava, and iliac vessels.
Reference:
NEMES B, KANYÁRI Z, ZÁDORI G, ZSOM L, BERHÉS M, HAMAR M, et al. Horseshoe kidney transplantation. Interventional Medicine & Applied Science. 2015;7(2):85–89.
THat is a great reply, dear Dr Huda.
thank you prof
-This is a picture of horse shoe kidney ,the 2 kidneys are connected by an isthmus consisting of parenchyma or fibrous tissue, located at the lower pole and 2 separate ureters.
-This donor is an ECD and can be considered controlled DCD (Maastricht Category 4) with serum creatinine 1 mg/dl with acceptable urinary output, controlled DM.
Due to vascular and ureteral variations, transplantation with a horseshoe kidney presents a technical challenge.
But KDPI scoring can be done and he can be accepted as donor.
-Horseshoe kidneys can be transplanted en bloc or separated first and then transplanted separately.
Kidneys need to be harvested cautiously. Arterial perfusion cannula can be placed in the common or the external iliac artery to avoid injury of accessorial arteries.
H.P. Tan et al. recommend harvesting horseshoe kidney en bloc with long segments of aorta, vena cava, and iliac vessels.
When broad, multiple veins are present branching from the vena cava ,It is adviced to close the proximal end of donor vena cava with a running suture and anastomosed the other end in an end-to-side way to the common iliac vein.
Kidneys with a thick isthmus and a wide parenchymal bridge are recommended for transplantation en bloc.
Stroosma et al recommended using a stapler in order to safely seal the surface of the divided isthmus. The collecting system rarely crosses the isthmus. It is more common to find the isthmus to contain only fibrous tissue. In cases of a thick isthmus, one study recommended evaluating the collecting system with contrast to ascertain anatomy and implanting it en bloc in case the collecting system crosses the isthmus.
Also in case of a complex vasculature, and a wide (more than 2 cm) isthmus, the en bloc implantation is suggested
In case of separation, a ureterography is recommended: if the two pyelons are separated, the surgical division is to be chosen. They also recommend the intraabdominal implantation due to the extreme importance of positioning the graft properly.
– This kidney can be transplanted as en block DKT
– The rate of primary nonfunction (PNF) did not change significantly after transplanting horseshoe kidney compared with transplanting normal kidneys. Surgical complications as bleeding from the surface of divided isthmus were only seen in the split group. One-year graft survival did not differ between the normal and horseshoe kidney groups.
Complications can occur as urinary leakage and necrotized graft ureter after kidney transplantation.
Reference
-Nemes B, Kanyári Z, Zádori G, Zsom L, Berhés M, Hamar M, Kóbor K, Péter A. Horseshoe kidney transplantation. Interv Med Appl Sci. 2015 Jun;7(2):85-9.
-Pontinen T, Khanmoradi K, Kumar A, Kudsi H, Cheng Kung S, Chewaproug D, Zaki R, Ortiz J. Horseshoe kidneys: an underutilized resource in kidney transplant. Exp Clin Transplant. 2010;8:74–78.
– Tan HP, Samaniego MD, Montgomery RA, Burdick JF, Maley WR, Kraus ES, Ratner LE. Donor horseshoe kidneys for transplantation. Transplantation. 2001;72:869–873.
-Stroosma OB, Schurink GW, Smits JM, Kootstra G. Transplanting horseshoe kidneys: a worldwide survey. J Urol. 2001;166:2039–2042.
Dear Dr Doaa,
I like the scientific contents of your reply. Please type headings and subheadings in bold or underline so that it is easier to read.
Please comment on the picture above
This picture shows deceased donor with horseshoe kidney with lower poles fused and two separate ureters.
Would you accept this donor?
Yes, I would accept this donor
If yes, what is your advice to the retrieval team?
If yes, how do you plan for transplantation?
What are the risks associated with these kidneys?
From the various case reports available, if the above care is taken during explantation, the outcome of horse-shoe kidneys should be good.
The problems with this kidneys are :
Stroosma OB, Scheltinga MR, Stubenitsky BM, Kootstra G. Horseshoe kidney transplantation: an overview. Clinical transplantation. 2000 Dec;14(6):515-9.
Corcoran AT, Shapiro R, Kayler LK. Transplantation of a horseshoe kidney. Transplantation. 2007 Mar 27;83(6):828-9.
Nemes B, Kanyári Z, Zádori G, Zsom L, Berhés M, Hamar M, Kóbor K, Péter A. Horseshoe kidney transplantation. Interv Med Appl Sci. 2015 Jun;7(2):85-9. doi: 10.1556/1646.7.2015.2.7. Epub 2015 Jun 11. PMID: 26120481; PMCID: PMC4464770.
Butler-Peres K, Scalea JR. Horseshoe kidney in a deceased organ donor: a rare glimpse at an uncommon finding. The Lancet. 2018 May 19;391(10134):2028.
Sengupta, B., Khan, I., Saiaghi, A., Gaw, E.A., Tawfeeq, M., AlQahtani, M.S. and Obeid, M., 2021. En Bloc Transplantation of Horseshoe Kidney from Deceased Donor: An Unusual Transplantation Utilizing Kidneys with Congenital Fusion Abnormality. Case Reports in Transplantation, 2021.
THat is a great reply, dear Dr Patil.
Please comment on the picture above
Would you accept this donor?
If yes, what is your advice to the retrieval team?
If yes, how do you plan for transplantation?
What are the risks associated with these kidneys?
Thankyou also multiple vascular anamolies, or connected urinary tracts.
Please comment on the picture above
Horse show kidneys, communicating from lower pole.
Would you accept this donor?
Sure , will accept for donation which is only indicated here with deceased donation and sure absolute contraindication with living.
If yes, what is your advice to the retrieval team?
Retrieval en-block, and offered to one center.
If yes, how do you plan for transplantation?
We transplant it single after division but we should keep in mind one important issue the there is no communication between excretory system of both kidneys before division which is done by injecting colored fluid such as (methylene blue or propofol in ureter and check if there is leak from the crossing area or not.
What are the risks associated with these kidneys?
keep in mind that usually this case has multiple arterial supply.
References:
1. Stroosma OB, Schurink GW, Smits JM, Kootstra G. Transplanting horseshoe kidneys: a worldwide survey. J Urol. 2001;166:2039–2042.
2. Interesting case scenario lecture, Professor. Ahemd Halwa, Consultant Transplant Surgeon Associate Professor, University of Liverpool – UK.
Well done
Horse shoe kidney with lower pole fusion, multlobulation,
Yes
– My advice that no need for splitting of both kidneys as I would prefer to go for DKT
As the patient has h/o DM, DCD
And it will be faster operation to reduce the cold ischemic time
The horseshoe kidney can be implanted retroperitoneally, in the left side, with en bloc technique
– Check for vascular or ureteric anomalies
– Stone formation
– Surgical complications; bleeding, urinary leakage
– More liable to develop graft dysfunction
Kaabak, M. M., Babenko, N. N., Zokoev, A. K., Khovrin, V. V., & Galyan, T. N. (2016). Renal Transplantation From a Living Donor With a Horseshoe Kidney. Transplantation Direct, 2(1). https://doi.org/10.1097/TXD.0000000000000564
Pablos-Rodríguez, P. D., Suárez, J. F., Canals, L. R., Sanz-Serra, P., & Vigués, F. (2021). Horseshoe kidney splitting technique for transplantation. Urology Case Reports, 37. https://doi.org/10.1016/j.eucr.2021.101604
Well done
· horseshoe kidney fused at the lower pole
each kidney have separate ureter
Yes,I will accept this kidney
The shortage of donors has led to an expansion of the criteria for the acceptability of deceased-donor organs, including the use of horseshoe kidneys (HSK). The HSK is one of the most common anatomical varia- tions of the kidney resulting from anomalous fusion at the lower poles (95% cases).
Vascular and urinary tract abnormalities that usually accompany these kidneys have always been a concern for primary non- function based on technical failure.
According to Eurotransplant data, more than one-third of HSKs from deceased donors were discarded because of their complex vascular anatomy and urinary collecting system injury
There are two possible surgical techniques in HSK transplantation, either en bloc or after splitting the kidney.
Previous studies showed that the transplantation of a HSK, either en bloc or separated, produced the same results compared with the transplantation of a regular kidney.
Split technique transplantation is important due to the scarcity of the organs required for transplantation. However, depending on factors like the number or position of the vessels or the urinary system’s anatomical characteristics, there might be a high risk of technical failure.
Most concerning complications after splitting a HSK include bleeding and urinary fistula from the cut edges. We can assume that the thicker the isthmus is, the greater risk we take.
Running sutures in one or more layers is the most common technique used
however, excessive tightening could tear the renal parenchyma apart. Other devices, such as a stapler or a harmonic scalpel have also been used for this purpose.
selectively sutured vessels exposed after isthmus incision and performed simple stitches with hemolocks on each side to bring the edges together.
Applying this technique, we could achieve good tension of the suture minimizing the risk of lacerating the parenchyma.
It is equivalent to the renorraphy performed after partial nephrectomies, where it is not uncommon to see large parenchymal defects that frequently include urinary collecting system.
Once transplantation of a HSK has been decided and the feasibility to divide it has been assessed, it is imperative to obtain properly sealed edges. We believe that this technique represents a cheap, safe, and effective horseshoe kidney division method.
The horseshoe kidney is one of the most common congenital anomalies. The incidence has been reported to range from 1 per 600–800 . The vascular anatomy in the horseshoe kidney is complex, and ureteral abnormalities also may be present.
Therefore, urinary tract infection, vesicoureteral reflux, nephrolithiasis, and hydronephrosis are frequent complications in patients with horseshoe kidneys.
The rate of primary nonfunction (PNF) did not alter significantly after transplanting horseshoe kidney compared with transplanting normal kidneys. One-year graft survival did not differ between the normal and horseshoe kidney groups
Surgical complications (bleeding from the surface of divided isthmus) were only seen in the split group.
After the transplantation, urine leakage may occur on 7th postoperative day after the transplantation of a divided horseshoe kidney which later led to sepsis. Therefore, graftectomy could not be avoided. Ureteric complications after renal transplantation are often difficult to manage. Occasionally, challenging surgery procedures are necessary to solve the problem.
Reference
1-Horseshoe kidney splitting technique for transplantation
Pedro De Pablos-Rodríguez *, Jos ́e Francisco Sua ́rez, Lluis Riera Canals, Pol Sanz-Serra, Francisco Vigu ́es
Hospital Universitari de Bellvitge, Carrer de la Feixa Llarga, 08907, L’Hospitalet de Llobregat, Barcelona, Spain
Urology Case Reports 37 (2021) 101604
2- Transplantation of Horseshoe Kidney from Living, Genetically Unrelated DonorKazuro Kikkawa,1Takahito Wakamiya,1Hiroki Kusumoto,1Nagahide Matsumura,1Yasuo Kohjimoto,1and Isao Hara1
Case Report | Open Access
Volume 2015 | Article ID 390381 | https://doi.org/10.1155/2015/390381
3- Horseshoe kidney transplantation
BALÁZS NEMES1,*, ZSOLT KANYÁRI1, GERGELY ZÁDORI1, LAJOS ZSOM1, MARIANN BERHÉS2, MÁTYÁS HAMAR3, KRISZTINA KÓBOR4, ANTAL PÉTER3
Interventional Medicine & Applied Science, Vol. 7 (2), pp. 85–89 (2015)
Excellent
Because of the continuing organ shortage, kidneys with atypical anatomy are frequently considered for transplantation. The most common anatomic variation of the kidney is the horseshoe kidney, with an incidence of 1 in 800. These kidneys are frequently accompanied by vascular and urinary tract abnormalities and there has always been a concern for primary nonfunction based on technical failure
Horseshoe kidney is the most common urinary congenital abnormality. When it is found at the time of operation in a deceased donor, it can be divided and transplanted into two different recipients or as a unit in a single receptor; depending on the vascular and urinary anatomy
Discard of potentially usable horseshoe kidneys can occur because of vascular anatomic limitations or injuries. According to a recent report of horseshoe kidneys that were donated within the Eurotransplant region, 27% were discarded immediately and 9.6% were discarded after division. The reason was the complex vascular anatomy in at least 53.8% and 60%, respectively .
Please comment on the picture above:
Horseshoe kidney with fusion at lower pole (isthmus)with two different collecting system.
Would you accept this donor?
Yes , in order to expand the donor pool, I will accept this ECD with congenital malformation.
If yes, what is your advice to the retrieval team?
It’s better that the surgeon understand the anatomical consideration of this fused kidneys in regard to vascular and collecting system abnormalities.and to transplant it either en blok or after separate the isthmus.use of perfusion cannula should be placed in the common iliac artery.
If yes, how do you plan for transplantation?
There is a lot of challenges regarding this complex vascular and collecting system anomaly.
it can be divided and transplanted into two different recipients or as a unit in a single receipt
En blok is preferred with good selection of the recipients.
What are the risks associated with these kidneys?
Technical issues
Bleeding
Long CIT
Ischemia,
urinary leak
and DGF.
Reference:
Transplantation of a Horseshoe Kidney
Corcoran, Anthony T.; Shapiro, Ron; Kayler, Liise K.
Thankyou well done
The picture shows a horseshoe kidney, with fusion of the 2 kidneys at the lower pole and two separate ureters.
The index donor is an extended criteria donor (age 50-60 year with death resulting from a cerebrovascular accident) with donation after cardiac death (DCD). In addition, she is having history of mild diabetes mellitus. Her urine output is excellent, and the terminal serum creatinine is 78 µmol/L. The issue with this donor is anatomical abnormality in form of a horseshoe kidney.
DCD donors have increased risk of DGF (2).
I will accept this donor as the outcomes of ECD transplant are better than remaining on wait-list (3).
As there is anatomical abnormality in form of horseshoe kidney, dual kidney transplant in form of en-block transplant should be performed. The ureters should be severed as close to the urinary bladder as possible (4). Arterial perfusion cannula should be placed in common iliac artery.
En block transplant is preferred. The ureters should be severed as close to the urinary bladder as possible (4). Careful and close inspection of the vasculature and collecting system should be done at the backtable. The preferred recipient in this scenario would be someone with a spacious abdomen (due to increased size of the en block transplant kidney), without coagulopathy, and with good cardiac output (1).
Transplanting such kidneys is technically challenging, with increased cold ischemia time and resultant increased risk of vascular thrombosis and primary non-function (4). Splitting the 2 kidneys by isthmusectomy may lead to injury to lower pole and has been shown to be associated with bleeding and ischemia, urinary leak and urinary fistula from the cut edges (5). Hence it is better to perform en block transplant unless the vasculature and the collecting system are delineated separately. The outcomes of a transplant using horseshoe kidney is similar to that with a non-horseshoe kidney (6,7).
References:
1) Sengupta B, Khan I, Saiaghi A, Gaw EA, Tawfeeq M, AlQahtani MS, Obeid M. En Bloc Transplantation of Horseshoe Kidney from Deceased Donor: An Unusual Transplantation Utilizing Kidneys with Congenital Fusion Abnormality. Case Rep Transplant. 2021 Aug 11;2021:2286831. doi: 10.1155/2021/2286831. PMID: 34422430; PMCID: PMC8373511.
2) Donation after Circulatory Death. British Transplant Society. Available at: http://www.bts.org.uk/Documents/Guidelines. Accessed October 17, 2022.
3) Audard V, Matignon M, Dahan K, Lang P, Grimbert P. Renal transplantation from extended criteria cadaveric donors: problems and perspectives overview. Transpl Int. 2008 Jan;21(1):11-7. doi: 10.1111/j.1432-2277.2007.00543.x. Epub 2007 Sep 10. PMID: 17850235.
4) Stroosma OB, Scheltinga MR, Stubenitsky BM, Kootstra G. Horseshoe kidney transplantation: an overview. Clin Transplant. 2000 Dec;14(6):515-9. doi: 10.1034/j.1399-0012.2000.140601.x. PMID: 11127302.
5) De Pablos-Rodríguez P, Suárez JF, Riera Canals L, Sanz-Serra P, Vigués F. Horseshoe kidney splitting technique for transplantation. Urol Case Rep. 2021 Feb 12;37:101604. doi: 10.1016/j.eucr.2021.101604. PMID: 33665125; PMCID: PMC7905440.
6) Butler-Peres K, Scalea JR. Horseshoe kidney in a deceased organ donor: a rare glimpse at an uncommon finding. Lancet. 2018 May 19;391(10134):2028. doi: 10.1016/S0140-6736(18)30759-1. Epub 2018 May 17. PMID: 29864019.
7) Pontinen T, Khanmoradi K, Kumar A, Kudsi H, Cheng Kung S, Chewaproug D, Zaki R, Ortiz J. Horseshoe kidneys: an underutilized resource in kidney transplant. Exp Clin Transplant. 2010 Mar;8(1):74-8. PMID: 20199375.
Well done
Please comment on the picture above
Fusion of the kidneys in lower pole→ horseshoe kidney
Would you accept this donor?
Yes ,I would accept this kidney.
If yes, what is your advice to the retrieval team?
I advice them to use cold perfusion cannula in the right common iliac artery to ensure good flow in the abnormal lower polar branch supplying the lower poles and isthmus. The horse-shoe kidneys procure en bloc with the intact aorta and inferior vena cava .
If yes, how do you plan for transplantation?
-Transplantation of horseshoe kidney is challenging due to the complexity of the vascular supply and anomalous collecting system . Tansplant it as en bloc .
– Select a recipient who had aspacious abdomen, had good cardiac output, was not coagu-lopathic, and could maintain satisfactory blood pressure to ensure good perfusion to this large-sized graft.
What are the risks associated with these kidneys?
intra-abdominal and renal allograft compartment syndrome.
Reference:
Bodhisatwa Sengupta et al. En Bloc Transplantation of Horseshoe Kidney from DeceasedDonor: An Unusual Transplantation Utilizing Kidneys withCongenital Fusion Abnormalit. Hindawi Case Reports in TransplantationVolume 2021, Article ID 2286831, 4 pageshttps://doi.org/10.1155/2021/2286831.
Thankyou well done the last comment is also good but you chose the suitable size recipient.
Hoarse shoe kidney connected by isthmus at lower pole.
Yes I will accept this donor.
A preoperative CTA may provide the retrieval surgeon relevant information in case of anomalous anatomy and he can make appropriate preparations leading to successful transplantation of such organs.
Transplantation of horseshoe kidney is challenging due to the complexity of the vascular supply and anomalous collecting system . These kidneys can be transplanted either en bloc or can be transplanted separately to two different recipients after isthmusectomy provided they have suitable anatomy of the vascular and collecting systems.
Considering the complexity of the transplant and size of the allograft, a recipient who had a spacious abdomen, had good cardiac output, was not coagulopathic, and could maintain satisfactory blood pressure to ensure good perfusion to this large-sized graft might select as a recipient.
There have been reports of the development of ischemia and urinary leak in the transplanted kidneys after isthmusectomy. As a result, division of the horseshoe kidney can result in rendering one of the kidneys nonusable due to these injuries.
Ref:
En Bloc Transplantation of Horseshoe Kidney from Deceased Donor: An Unusual Transplantation Utilizing Kidneys with Congenital Fusion Abnormality.Bodhisatwa Sengupta,1Iftikhar Khan,1Akram Saiaghi,1Ethar A. Gaw,1Mansour Tawfeeq,1Mohammed S. AlQahtani,1and Mahmoud Obeid1.Volume 2021 | Article ID 2286831 | https://doi.org/10.1155/2021/2286831
Well done
From the picture above one can see that the patient has a horseshoe kidney. Horseshoes kidneys are an abnormal fusion of the kidneys and occur in about 1:400-600 individuals. It is fused at the lower pole. It is found more in males than females and may have challenges to use as transplantation due to abnormal anatomies and structures like vascular variation, ureteral variations, etc.
The kidneys can be used as a donation but there will be challenges in both surgical techniques and anatomy or structural challenges. The kidneys are having good functions and with mild DM but controlled.
The retrieval team should be made aware that it is a kidney malformation and there could be surgical techniques difficulties and the kidneys will have abnormal structures.
The kidneys may be transplanted in two ways either in bloc form or separate the two kidneys.
The recipient must be aware of the procedure and the possible complications. It would be ideal that the recipient never had any previous transplantation, has normal blood pressure, or any cardiovascular issues, and must be aware that there may be DRF and other complications like necrosis and rejections.
The possible risk is:
1) There is an increased risk for complications in both surgical and kidney function
2) There is a higher risk of rejection
3) Higher risk of infections
4) Greater risk of necrosis of the tissues like ureters
5) Greater risk of forming kidney stones
6) Greater chance of having urinoma etc.
7) Higher risk of cancers.
According to International medicine and applied science, it suggests that horseshoe kidneys can be transplanted successfully but there can be complications like sepsis, acute humoral rejection, and as such kidney failure.
Nemes, B., et al, International medicine and applied science (2015). Horseshoe kidney transplantation. DOI: 10.1556/1646.7.2015.2.7
Please Marius
I disagree with your comment regarding the higher risk of rejection, infection, and stone formation.
Please review and get back to us
Thank you sir for the comment.
I have read various articles on the topic of horseshoe kidneys and transplantation and I may have interpreted the reports incorrectly. Still, many have been saying there the recipient is at risk of infections especially urinoma that get infected can lead to infection and as such infection and possible graft rejection. The article survival Intervention medicine and applied Science (2015) suggested that the graft was significantly worse but misunderstood that the recipient had pre-existing donor-specific HLA antibodies and AMR on the graft which caused the graft rejection(1). As such, I misinterpreted the article. Another article suggested that some complications that can arise from horseshoe transplantations are likely to be hydronephrosis, infection, and stones which can occur in up to 40%of patients(2). That is why I have suggested that it is of higher risk. As I continue analyzing the articles I concluded that it is not a higher risk but if the complications are not detected timely the recipient can present them but just to be aware that it can happen and as with other normal kidneys.
References:
1. Nemes B, Kanyari Z, Zadori G, Zsom L, Berhes M, Hamar M, et al. Horseshoe kidney transplantation. Interv Med Appl Sci. 2015 Jun 1;7(2):85–9.
2. Sengupta B, Khan I, Saiaghi A, Gaw EA, Tawfeeq M, Alqahtani MS, et al. Case Report En Bloc Transplantation of Horseshoe Kidney from Deceased Donor: An Unusual Transplantation Utilizing Kidneys with Congenital Fusion Abnormality. 2021; Available from: https://doi.org/10.1155/2021/2286831
1- This patient has a Horseshoe kidney with Fusion at the inferior pole.
2- Yes.
Horseshoe kidney is the most common urinary congenital abnormality. When it is found at the time of operation in a deceased donor, it can be divided and transplanted into two different recipients or as a unit in a single receptor; depending on the vascular and urinary anatomy. 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.
3- There are three abnormalities that can be found in a horseshoe kidney: ectopia, malrotation and vascular changes. three types of arteries in a horseshoe kidney were defined: in type 1, there are single arteries in each side; in type 2, lower arteries arise from the aorta and in type 3, middle and lower arteries arise from the aorta. Type 3 arteries probably pose an increased surgical risk in the donor because of the technical difficulties during separation and implantation. A shared urinary pelvis is another factor that precludes the excision in a living donor. When this anatomic feature is found in cadaveric kidneys it must be transplanted in bloc. Other factors which influence the decision to split the kidney are the number of veins and the nature of the pole fusion, if it is fibrous or parenchymal tissue. Fusion usually occurs in the inferior pole and it can be either fibrous tissue that can be cut without hemorrhagic risk or renal tissue. In both cases separation of the tissue can be made with a suitable hemostatic technique, such as bipolar or harmonic energy, a local hemostatic agent or a linear cutter stapler. A careful exploration of the arterial anatomy is mandatory in order to establish the line of transection.
4- The most common complication reported is urinary leakage, most likely due to the anterior situation of the urinary pelvis. Acute tubular necrosis was the most likely explanation for the DGF seen in this, perhaps due to the clamping of the arteries to limit the place for transection causing warm ischemia, or as a result of the prolonged total ischemia time caused by the need for more arterial anastomoses during back table surgery.
Ref: Justo-Janeiro JM, Orozco EP, Reyes FJ, de la Rosa Paredes R, de Lara Cisneros LG, Espinosa AL, Naylor JM. Transplantation of a horseshoe kidney from a living donor: Case report, long term outcome and donor safety. Int J Surg Case Rep. 2015;15:21-5. doi: 10.1016/j.ijscr.2015.08.008. Epub 2015 Aug 12. PMID: 26299249; PMCID: PMC4601952.
I appreciate your logical approach, Dr Alalawi.