Use of the Splenic Vessels for an ABO Incompatible Renal Transplant in a Patient with Thrombosis of the Vena Cava (2005)

To the Editor: We report the case of an 18‐year‐old African American female who underwent kidney transplantation (KT) from an ABO incompatible living donor, using the splenic vessels for vascular anastomosis. The patient has suffered from renal failure due to lupus nephritis. She had complete thrombosis of the inferior vena cava, bilateral iliac veins, superior vena cava and subclavian veins due to lupus‐related anti‐phospholipid antibody syndrome. She also had a skin graft placed directly over small bowel as a consequence of several surgical procedures for tubo‐ovarian abscesses and wound dehiscences. She needed urgent KT due to the impending lack of suitable central veins for hemodialysis and the only suitable living donor was her brother, to whom she was ABO incompatible (group B donor for A recipient). The baseline titer of anti‐B antibodies of the recipient was 1:8 for both IgM and IgG, and the flow‐cytometry cross‐match was positive for both T and B cells. The patient underwent four treatments of plasmapheresis before transplantation, received IVIG 100 mg/kg administered after each plasmapheresis and one dose of 500 mg of Rituximab 2 days before transplant. The donor operation consisted in a standard laparoscopic, robotic‐assisted, left nephrectomy (1Horgan S Benedetti E Moser F Robotically assisted donor nephrectomy for kidney transplantation.Am J Surg. 2004; 188: 45S-51SAbstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar). In the recipient, after left subcostal incision, a standard splenectomy was performed. The vein and the artery of the kidney graft were then anastomosed end‐to‐end to the splenic vessels. The left native ureter was then divided just distal to the pelvis and anastomosed in an end‐to‐end fashion to the transplant ureter, over a long double J stent (Figure 1). The immunosuppressive therapy included five doses of thymoglobulin, tacrolimus, mycophenolate mofetil and prednisone; plasmapheresis and IVIG were continued every other day for 10 days after transplant. Currently the patient is doing well 6 months after the transplant, with a serum creatinine level of 1.5 mg/dL. In the presence of infra‐renal IVC thrombosis, KT can be performed anastomosing the renal vein to a patent infra‐hepatic IVC stump or using a patent iliac vein; moreover in the setting of complete iliac and caval thrombosis, the renal graft can be drained into the portal vein, into the superior mesenteric vein, or into the inferior mesenteric vein (2Rosental JL Loo RK Portal venous drainage for cadaveric renal transplantation.J Urol. 1990; 144: 969Crossref Scopus (19) Google Scholar); Gil‐Vernet et al. performed routinely KT using the splenic artery as an inflow and the renal vein for venous anastomosis (3Gil‐Vernet JM Gil‐Vernet A Caralps A et al.Orthotopic renal transplant and results in 139 consecutive cases.J Urol. 1989; 142: 248-252Crossref PubMed Scopus (59) Google Scholar). Although recent reports suggest the feasibility of KT from ABO incompatible donors without the need for spleen removal, most reported series use splenectomy routinely (4Takahashi K Saito K Takahara S Okuyama A Tanabe K Toma H et al.Excellent long‐term outcome of ABO‐incompatible living donor kidney transplantation in Japan.Am J Transplant. 2004; 4: 1089-1096Abstract Full Text Full Text PDF PubMed Scopus (293) Google Scholar); the presence of concomitant cross‐match is not a contraindication to proceed, as shown by Kayler et al. (5Kayler LK Colombe B Farber JL Lacava D Dafoe DC Burke JF et al.Successful living donor renal transplantation despite ABO incompatibility and a positive cross‐match.Clin Transplant. 2004; 18: 737-742Crossref PubMed Scopus (10) Google Scholar). In our case the choice of using the splenic vessels seemed the most logical due to the need of splenectomy in presence of an ABO incompatible donor and lack of access to suitable systemic or mesenteric venous drainage due to thrombosis and previous surgery. Moreover, the subcostal approach away from the large abdominal hernia with skin graft over bowel, allowed us easy access to our target vessels and the left ureter. In summary, our case confirms that the splenic vessels are perfectly suitable inflow and outflow for a kidney transplant graft.