Left renal vein ligation during liver transplantation in a recipient with a single kidney

Abstract

TO THE EDITORS:The treatments for a spontaneous splenorenal shunt (SRS) include splenectomy and direct SRS ligation. However, both are major, technically complicated procedures that are associated with significant bleeding risks.1,2 To achieve the same outcome and avoid SRS manipulation in a region with significant collateral circulation, the surgeon may perform left renal vein ligation (LRVL). This procedure restores the appropriate portal flow to the liver graft by reversing the blood flow from the left renal vein to the portal vein through the SRS. 3 We report a case of LRVL that was performed during liver transplantation (LT) for a female recipient with only a single (left) kidney. The patient was a 61-yearold woman with hepatitis B, hepatic cirrhosis, and portal hypertension. She had tense ascites, jaundice (total bilirubin level 5 3.8 mg/dL), and encephalopathy with a Model for End-Stage Liver Disease score of 21 and a Child-Pugh score of 12. Color Doppler ultrasonography indicated a patent portal vein with a hepatofugal, monophasic flow and a diverted flow to the upper mesenteric veins, gastric veins, and splenorenal shunts. During LT, the recipient portal vein flows were low after reperfusion. Dissection and clamping of the left renal vein were followed by a significant increase in the portal vein flow; LRVL was subsequently performed. Postoperative creatinine levels varied between 1.4 and 2.4 mg/dL. There was no damage to renal function attributable to this maneuver, with creatinine levels remaining at 1.4 mg/dL at the 1-year follow-up examination. Post-LT angioresonance indicated left kidney venous drainage through the gonadal vein to the iliac vessels and through the perisplenic veins to the portal vein (Fig. 1). A 2-year follow-up Doppler ultrasound examination showed increased portal vein flow approximately 3 times greater than the normal with a homogeneous echotexture of the hepatic parenchyma.Adequate portal perfusion is essential for a graft's continued viability after LT.3 Portal flow diversion through a SRS occurs in nearly 19% of patients with cirrhosis and results in hepatofugal flow and compromised hepatic graft reperfusion. 4,5 When it is necessary, a SRS can be surgically treated during LT through direct ligation of the splenorenal collateral veins with or without splenectomy. However, these procedures are dangerous because they are associated with a significant bleeding risk and may even result in death. As a simpler alternative to direct SRS ligation, LRVL has been proposed to avoid surgical manipulation in a region comprising innumerable Figure. 1. Post-LT magnetic resonance angiography shows adequate left kidney venous drainage through the gonadal vein to the iliac vessels and through perisplenic veins to the portal vein. Top arrow indicates a SRS and lower arrow a gonadal vein.The study protocol received a priori approval by the institutional review committee.Address reprint requests to

Tips and pitfalls in direct ligation of large spontaneous splenorenal shunt during liver transplantation

“…Several maneuvers have been reported to improve inadequate portal flow to the allograft. Left RV ligation, splenectomy, renoportal anastomosis, ligation at the root of the SV, and selective SRS or splenic radiologic venous embolization or stent graft closure increase portal flow in cases of a large SRS.…”

“…PV thrombectomy is not enough to overcome this situation because of poor portal flow. There are several methods to increase portal flow in cases of large SRSs, including left renal vein (RV) ligation, splenectomy, and renoportal anastomosis . However, direct ligation of a large SRS is not widely used in clinical situations because it can be technically difficult and even dangerous …”

A Case of Left Renal Vein Ligation in a Patient with Solitary Left Kidney Undergoing Liver Transplantation to Control Splenorenal Shunt and Improve Portal Venous Flow

“…From the published literature, left renal vein ligation has been shown to be a safe procedure when the patient had two functioning kidneys. However, in this case, the surgical team performed liver transplantation for a patient with a single left kidney, and the decision to ligate the left renal vein was not easy because only one similar case had been previously reported in the literature [ 8 ].…”