Use of preoperative embolization prior to Transplant nephrectomy

Abstract

Introduction After a failed transplant, management of a non-functional graft with pain or recurrent infections can be challenging. Transplant nephrectomy (TN) can be a morbid procedure with the potential for significant blood loss. Embolization of the renal artery alone has been proposed as a method of reducing complications from an in vivo failed kidney transplant. While this does yield less morbidity, it may not address an infected graft or refractory hematuria or rejection. We elected to begin preoperative embolization to assess if this would help decrease the blood loss and transfusion rate associated with TN. Materials and Methods We performed a retrospective analysis of all patients who underwent non-emergent TN at our institution. Patients who had functioning grafts that later failed were included in analysis. TN was performed for recurrent infections, pain or hematuria. We evaluated for blood loss (EBL) during TN, transfusion rate and length of hospital stay. Results A total of 16 patients were identified. Nine had preoperative embolization or no blood flow to the graft prior to TN. The remaining 7 did not have preoperative embolization. The shortest time from transplant to TN was 8 months and the longest 18 years with an average of 6.3 years. Average EBL for the embolized patients (ETN) was 143.9cc compared to 621.4cc in the non-embolized (NETN) group (p=0.041). Average number of units of blood transfused was 0.44 in the ETN with only 3/9 patients requiring transfusion. The NETN patients had average of 1.29 units transfused with 5/7 requiring transfusion. The length of stay was longer for the ETN (5.4 days) compared to 3.9 in the NETN. No intraoperative complications were seen in either group and only one patient had a postoperative ileus in the NETN. Conclusion Embolization prior to TN significantly decreases the EBL but does not significantly decrease transfusion rate. However, patients do require a significantly longer hospitalization with embolization due to the time needed for embolization. Larger studies are needed to determine if embolization before transplant nephrectomy reduces the transfusion rates and overall complications.

Graft Intolerance Syndrome in Children Treated with Kidney Embolization: A Case Report

“…Other indications for kidney embolization in pediatric nephrology are arterial aneurysms and arteriovenous malformations, functional exclusion and polycystic kidney disease before transplantation, angiomyolipoma (mainly in the context of tuberous sclerosis), and autosomal dominant polycystic kidney disease (ADPKD) before kidney transplantation [9] [10].…”

Nephrotransplantectomy Using Radiosurgical Techniques

“…Независимо от техники выделение трансплантата сопряжено со значительными техническими трудностями из-за выраженного фиброзно-воспалительного процесса в забрюшинном пространстве, отечности из-за отторжения (воспаления) или инфекции, что ухудшает визуализацию, способствует высокой вариабельности степени интраоперационной кровопотери, риску повреждению сосудов, летальности. В связи с осложнениями и летальностью рядом авторов описываются современные методики ведения и удаления нефротрансплантата, выполняемые после изоляции его артериального русла [22][23][24].…”

“…(англ. A. Panarese, et al; 2021), которые также отметили значительно меньшую кровопотерю у пациентов, подвергшихся эмболизации [23,38]. Дополнение НТЭ превентивной ЭЭАТ позволяло работать в «сухом» операционном поле, интраоперационно выбирать наиболее безопасную методику удаления, при необходимости сочетать суб-и экстракапсулярную техники, минимизировать риск повреждения сосудов, послеоперационных осложнений.…”

Pearls and Pitfalls in Pediatric Kidney Transplantation After 5 Decades

“…However, the risk on necrotic pyelonephritis and post-embolization syndrome are increased after RAE and RAE as monotherapy is not widely used (200). However, using RAE as neo-adjuvant intervention before GN was shown to reduce both blood loss and operating time (201)(202)(203).…”