Renal transplantation remains the most desirable form of treatment for patients with renal failure, yet the number of donors falls drastically short of the need. In 2002, there were 53 704 potential renal recipients in the United States and only 11 863 renal donors (see the 2003 Annual Report of the US Scientific Registry of Transplant Recipients and the Organ Procurement and Transplantation Network: Transplant Data 19932002, available at http://www.optn.org/AR2003). In almost 50 years of clinical renal transplantation, the rate-limiting factor has been the availability of a suitable donor. The evolution of the donor pool has paralleled the elucidation of the phenomenon of allograft rejection, beginning with the unsuccessful use of cadaver donors to identical twin, living-related, cadaveric and, eventually, living non-related sources. Although there have been unique donor/recipient transplants in the past, this is believed to be the first reported case of planned incidental nephrectomy for transplantation [1].
Case. A 51-year-old female presented for evaluation of faecal vaginal discharge. Computerized tomography (CT) demonstrated a colovaginal fistula. The patient underwent uneventful sigmoid resection with fistula repair. She was readmitted 5 weeks post-operatively with a retroperitoneal abscess, which was drained percutaneously. Following recovery from adult respiratory distress syndrome, the patient was discharged. She returned 1 week later with increasing output from the abscess drain, which was determined to be urine. Retrograde pyelography demonstrated obstruction of the ureter at the level of the fourth lumbar vertebrae without evidence of extravasation. A drain study revealed a normal proximal ureter. Subsequent CT showed resolution of the abscess.
Options of repair were discussed with the patient, including primary uretero-ureterostomy, Boari flap, transureterostomy, nephrectomy with auto-transplantation, simple nephrectomy or simple nephrectomy with intention to donate the kidney. Because of previous complicated hospitalizations, she desired the route that would lead to the quickest resolution of her problem with the minimum of time and risk involved. She elected simple nephrectomy with intention to donate the kidney for transplantation. The organ transplant team at the University of Wisconsin in Madison was contacted and, after relating the patient's history, it was elected to proceed with donor evaluation. There were no contraindications for donation. She preferred to remain locally under the care of her urologist (J.V.T.) and underwent an uneventful flank nephrectomy. At surgery, the procurement team received the graft and prepared it for transport. A pre-selected recipient was successfully transplanted. The kidney functioned immediately. Both patients have done well post-operatively. The donor has had no further sequelae of the vesicovaginal fistula. The recipient has experienced continued graft function.
Comment. Unique potential donor sources continue to be discovered and should be utilized when appropriate (donors with small benign kidney tumours, sero-positive for hepatitis C and hypertension or stroke) [2]. Although the events with this particular patient were unique, it is likely that a number of similar cases annually could lead to positive outcomes for both donors and recipients.
Conflict of interest statement. None declared.
1 Department of Urology Marshfield Clinic Marshfield2 Department of Surgery Division of Organ Transplantation University of Wisconsin School of Medicine Madison WI, USA Email: thomalla.j.vincent{at}marshfieldclinic.org
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