Successful renal transplantation in children in the presence of thrombosis of the inferior vena cava

Abstract

Thrombosis of the inferior vena cava (IVC) has previously been considered to be a contraindication to renal transplantation in children because of the technical difficulties associated with surgery and the increased risk of graft thrombosis. We report three children with previous IVC thrombosis who underwent renal transplantation at our institution over the last 5 years. The pretransplant imaging of these patients included direct venography or magnetic resonance venography to evaluate venous outflow. Two children (19 kg and 36 kg) received deceased donor renal allografts with no surgical complications or delayed graft function. At the latest follow-up 3.0 and 4.6 years posttransplantation, respectively, they were well, with estimated glomerular filtration rates of 52 and 64 ml/min per 1.73 m(2), respectively. The third child underwent a live-related-donor renal transplant at the age of 4.9 years (weight 13.5 kg). There was primary graft nonfunction. Renal vein thrombosis was noted on postoperative day 12, with subsequent graft loss. Children with previous IVC thrombosis can be successfully transplanted with adult-sized kidneys provided detailed evaluation of the venous drainage has been performed. There is substantial risk of graft thrombosis, and detailed counselling regarding the specific risks of the procedure is essential.

Renal transplantation with unusual vasculature

“…These two cases highlight the importance of considering alternative allograft flow circuits in patients with significant history of iliac vessel thrombosis. An increasing body of evidence is surfacing suggesting that appropriate allograft flow can be achieved using the pelvic venous collaterals [1][2][3], the right ovarian vein [4,5], or superior mesenteric vein [6]. The two cases we present here also strengthen the extremely limited evidence in support of the left ovarian and the IMV as additional allograft venous drains.…”

“…Conventionally, thrombosed iliac vessels have been a contraindication for renal transplantation. Recent case reports have highlighted the benefit of alternate venous systems for allograft drainage in patients with thrombosed iliac veins; renal allografts have successfully been anastomosed to: pelvic or presacral venous collaterals draining into the inferior vena cava [1][2][3], the right ovarian vein [4,5], and the superior mesenteric vein [6]. To the best of our knowledge, only a single case has also been described using the left gonadal vein [7], and only two cases have been reported using the inferior mesenteric vein (IMV) [8,9].…”

Renal transplantation in children with thrombosis of the inferior vena cava requires careful assessment and planning

“…This decision is a very difficult one for the pediatric surgery-nephrology team and is well described by Shenoy et al [1]. Important surgical considerations with the use of an ASK also include a good length of ureter when an IVC anastomosis is to be carried out and the consideration of either an ovarian vein or portal vein anastomosis in extreme situations.…”

“…The article in this issue by Shenoy et al [1] describes three cases of renal transplantation in children with pre-existing inferior vena cava (IVC) thrombosis. Children with endstage renal failure and IVC thrombosis are rare, but their condition presents one of the most challenging clinical situations for pediatric kidney transplant teams.…”

“…The articles cited above [1][2][3][4] account for 14 patients receiving kidney transplants and with preexisting IVC thrombosis. One patient that was described in two separate articles was counted as one, while another patient was included that had severe, but not complete, IVC obstruction [3].…”