En Bloc Liver Kidney Transplantation Using Donor Splenic Artery as Inflow to the Kidney: Report of Two Cases

Abstract

The number of simultaneous liver-kidney transplants has been increasing. This surgery is associated with an increased risk of complications, longer duration of surgery and longer ischemia time for the renal allograft. Two patients listed for liver-kidney transplant at our center underwent en bloc combined liver-kidney transplantation using donor splenic artery as inflow. Patient 1 previously underwent cardiac catheterization that was complicated by a bleeding pseudoaneurysm of the right external iliac artery that required endovascular stenting of the external iliac artery and embolization of the inferior epigastric artery. Patient 2 was on vasopressor support and continuous renal replacement therapy at the time of transplant. In this paper, we described a novel technique of en bloc liver-kidney transplant with simultaneous reperfusion of both allografts using the donor splenic artery for renal inflow. This technique is useful for decreasing cold ischemia time and total operative time by simultaneous reperfusion of both allografts. It is a useful technical variant that can be used in patients with severe disease of the iliac arteries.

Outcomes of en bloc simultaneous liver-kidney transplantation compared to the traditional technique

“…An additional concern is the potential risk to both grafts if the common arterial inflow is compromised via stenosis or thrombosis. 4 Although we did not experience this complication involving both organs in our cohort, there was one patient who had kinking of the splenic artery supply to the kidney, which may have contributed to the loss of the graft, although the same pa- Another limitation of the en bloc technique is the inability to perform a delayed kidney graft implantation, which has been increasingly utilized in patients with significant hemodynamic instability, vasopressor requirements, or coagulopathy during liver implantation. 15 For candidates who are at higher risk of hemodynamic instability, perhaps those who are already on vasopressors, are coagulopathic preoperatively, or have a difficult hepatectomy secondary to prior upper abdominal surgery or portal vein thrombosis, the traditional SLKT technique allowing for delayed implantation of the kidney should be considered.…”

“…Caution may be required when considering the use of en bloc SLKT for donors with aberrant renal or hepatic arterial anatomy. An additional concern is the potential risk to both grafts if the common arterial inflow is compromised via stenosis or thrombosis . Although we did not experience this complication involving both organs in our cohort, there was one patient who had kinking of the splenic artery supply to the kidney, which may have contributed to the loss of the graft, although the same patient also experienced antibody‐mediated rejection.…”

“…Previous literature on the en bloc SLKT technique has been limited to a few case reports, typically for recipients with significant iliac artery disease, liver‐double kidney transplant, or multivisceral transplant . In addition to these indications, there are several other potential advantages to utilizing the en bloc SLKT technique compared to the traditional method.…”

“…The traditional method of SLKT is performed with separate implantations of the liver followed by the kidney. An alternative approach to the traditional method is the en bloc technique . In this approach, the liver and kidney are recovered en bloc, with the donor renal artery anastomosed to the donor splenic artery, resulting in simultaneous reperfusion of both organs after implantation.…”

En bloc liver-kidney transplantation with renal artery variation using donor splenic artery and left gastric artery as inflow to the kidney: Case report

“…Gunabushanam et al reported two successful case reports of en bloc liver-kidney transplants using the splenic artery as inflow to the kidney allograft. In these cases, the renal artery was positioned posterior to the portal vein and bile duct, but anterior to the donor IVC [ 9 ]. In our case, the renal artery was positioned posterior to the portal vein and donor IVC.…”