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Abstract

During pediatric kidney transplant, surgical challenges occasionally occur. In particular, vascular anastomosis should be considered for children with small body weight < 12 kg, multiple renal arteries, vascular anomaly, and inferior vena cava occlusion. In pediatric patients, a living-donor renal graft is usually donated from a parent. Therefore, the renal artery and vein are too large to be anastomosed with the recipient's internal iliac artery and external iliac vein. In children who are > 12 kg, the renal artery and vein could be anastomosed with the external iliac artery and the external iliac vein. In children who are < 10 kg, the renal artery and vein should be anastomosed directly with the aorta and inferior vena cava. A pediatric transplant surgeon should consider arterial and venous anastomosis sites before transplant surgery. In small children with partial or total inferior vena cava occlusion, the venous anastomosis site should be evaluated. If the graft is placed on the left side, a venous graft must be used as a bridge between the renal vein and inferior vena cava. In 13 kidney transplants in children with inferior vena cava occlusion, 7 were on the left and 6 were on the right side. A patent segment of the inferior vena cava, the left original renal vein, an ascending lumbar vein, an azygos vein, the first graft renal vein, and a portal vein were used for venous anastomosis in 6, 2, 2, 1, 1 and 1 recipient, respectively. One child had graft loss due to renal vein thrombosis and one died of hemorrhage immediately posttransplant. Three had grafts with relatively long-term function, but these were lost due to chronic allograft nephropathy 100, 122, and 137 months posttransplant. However, the other 8 recipients have so far maintained graft function from 6 to 138 months since transplant. Key words: Living-donor renal transplant, Small body weight, Vascular anastomosis IntroductionFor kidney transplant, young children usually receive a living-related transplant from a parent donor. However, this adult renal allograft is transplanted in a small space in young children. In small children who are less than 10 kg body weight, we usually make a paramedian incision and the intraperitoneal approach is preferred, although recently the extraperitoneal approach has been also used in children who are less than 10 kg body weight. 1 When a renal allograft has double arteries, a conjoined and end-to-side anastomoses to one orifice are performed. Procedure times for multiple anastomoses are lengthy, leading to long ischemic time in the lower extremities and pelvic organs. In addition, a multiple arterial anastomosis to a direct aorta increases the risk of massive bleeding.In children with a thrombosed inferior vena cava (IVC), a pretransplant evaluation with three-dimensional computed tomographic (3D-CT) venography is important. [2][3][4] This procedure can allow clear discussion of the venous anastomosis site [5][6][7][8][9][10][11][12][13][14] and the necessity of a venous graft 5-12,13 before transplant sur...