Successful living-donor kidney transplantation after vena cava flow obstruction in a small recipient

Abstract

Introduction: Transplantation of an adult-size kidney into a mismatched pediatric recipient reduces transplant waiting time but may lead to potential complications related to vascular anastomoses and graft hypoperfusion. Our aim is to share our experience in the management of an early graft thrombosis due to a complete venous flow obstruction after a living-donor kidney transplantation in a small pediatric recipient, and the long term outcome after the graft recovery. Case report: A three-year-old male with end stage renal disease due to posterior urethral valves received a living-donor kidney transplant from his mother in the right side. Surgery was uneventful, but 2 h post-transplant, oligoanuria, hyperkalaemia and metabolic acidosis appeared. Döppler ultrasound detected increasing arterial resistance with diastolic inversion, and no venous flow into the graft. Exploratory surgery confirmed venous flow obstruction in both the renal vein and cava, due to compression of the graft renal artery. The graft was washed out with cold preservation fluid and the renal artery reanastomosed more distally. After 5 days with acute tubular necrosis, renal function was slowly recovered, reaching Schwartz glomerular filtration rate (GFR) of 77ml/min/1.732 at the fourth month post-transplant. After 5 years, the graft is still functioning with a creatinine of 0.88mg/dl and Schwartz GFR of 52ml/min/1.732. Conclusions: Adult-size kidney transplantation into small recipients requires tailoring of the vascular anastomoses to the anatomical situation. Early diagnosis and prompt surgical exploration and treatment of graft venous thrombosis may lead to graft recovery, with long term graft survival.