The Renal Transplant with Multiple Renal Arteries Graft

To the Editor,

The arterial vascularization of the kidneys is quite variable. Except the main renal artery, one or more additional renal arteries are the commonest arterial anatomical variation of the kidneys, and the influence of multiple renal arteries (MRA) in the renal transplant is not well established. Contradictory results have been reported if the use of kidney allografts with MRA adversely affects posttransplant graft and patient outcomes or increases the incidence of vascular and urologic complications compared with the use of grafts with a single renal artery (SRA). In the meta-analysis of Zorgdrager, analyzing a total of 18,289 patients, the recipients of an MRA graft showed a significantly higher incidence of vascular complications compared to those who received an SRA graft; the incidence of urological complications was also higher in patients who received an MRA graft, 5.5% vs. 5% in SRA grafts; no significant differences were observed in the 5-year graft survival and 1- and 5-year patient survival rates. The authors concluded that MRA grafts were associated with a higher risk of complication and delayed graft function but had comparable long-term outcomes for graft and patient survival.^[1] Bessede et al, reviewing 3189 renal transplants performed in France in the period of 1971–2010, identifies the presence of MRA graft as a risk factor of arterial thrombosis.^[2] Ghods, among 689 renal transplants in Iran, found the presence of MRA as a predictor of delayed graft function.^[3] Ashraf, in 33 live-related kidney transplants with MRA performed from 2006 to 2010 in Pakistan, did not find a significant difference in the warm ischemia with 72 grafts with SRA. He concluded that kidney transplantation using grafts with MRA is equally safe as using grafts with SRA regarding vascular, urological complications, and patient and graft survival.^[4] Fitzpatrick among 106 renal transplants with MRA in the period of 2004–2014 in the UK, reported comparable complication rates with SRA grafts.^[5] MRA presents a technical challenge. Various techniques for arterial reconstruction in cases of MRA grafts were reported. In the bench reconstruction of MRA, it should be used the technique that best fits a particular situation and that the individual transplant surgeon feels most comfortable. In our experience (Figure 1), the presence of MRA with or without multiple anastomoses does not increase the risk of vascular or urological complications. According to current literature, we believe that renal transplant with MRA grafts is a safe procedure with no difference in long-term outcomes with SRA grafts.

Figure 1: Renal transplant from deceased donor, with 3 multiple renal arteries (main artery and 2 smaller ones) supplying the graft. In this experience 2 aortic patches (1 for main artery and 1 for the smaller ones) were used without any vascular or urological complication. (white arrow: main artery, green arrows: smaller arteries).

Conflict of interest:

None declared.