Original article
Renal transplantation using vascular conduit reconstruction in deceased kidneys with multiple renal arteries and short renal veins
Trasplante renal mediante reconstrucción de conducto vascular en riñones de donantes fallecidos con arterias renales múltiples y venas renales cortas
A. Alexandera,c,f, G. Serenaa,c,d, J. Gonzáleze, W. DeFariaa,c, G. Ciancioa,b,c,
Corresponding author
a Department of Surgery, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL, United States
b Urology, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL, United States
c Miami Transplant Institute, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL, United States
d Department of Surgery, Nassau University Medical Center, East Meadow, NY, United States
e Department of Urology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
f St. George's University School of Medicine, Grenada
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"apellidos" => "Ciancio" "email" => array:1 [ 0 => "gciancio@med.miami.edu" ] "referencia" => array:4 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] 3 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:6 [ 0 => array:3 [ "entidad" => "Department of Surgery, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL, United States" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Urology, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL, United States" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Miami Transplant Institute, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL, United States" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Department of Surgery, Nassau University Medical Center, East Meadow, NY, United States" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Department of Urology, Hospital General Universitario Gregorio Marañón, Madrid, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "St. George's University School of Medicine, Grenada" "etiqueta" => "f" "identificador" => "aff0030" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Trasplante renal mediante reconstrucción de conducto vascular en riñones de donantes fallecidos con arterias renales múltiples y venas renales cortas" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1876 "Ancho" => 1339 "Tamanyo" => 285191 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Right kidney allograft available containing 5 renal arteries (three renal arteries originated from the upper pole and two from the lower pole) and 3 renal veins. All 5 arteries were anastomosed to a segment of donor aorta, creating a single vascular conduit.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Kidney transplantation remains the treatment of choice for end-stage renal disease (ESRD), as it leads to prolonged survival, decreased costs for medical expenses, and improved quality of life when compared to standard dialysis.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">1,2</span></a> Nevertheless, many patients with ESRD requiring transplant must remain on the waiting list due to limited donor organ availability. In fact, according to the Organ Procurement and Transplantation Network (OPTN) annual report for 2017, nearly 95,000 patients continued on dialysis whilst awaiting renal transplantation.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The shortage of organs is a fact easily attributable to the improved medical overall care that carries a parallel increase of older patients (usually in worse conditions) in the waiting list. In the past, these patients would otherwise have died before the kidney transplant was attempted. However, a more worrisome fact emerges when is figured out that currently thousands of renal donations (3534 potential kidney grafts meaning a 18.9% of all kidney donations in 2017) are discarded every year.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">3</span></a> The decision to discard potential kidney allografts from deceased donors considers (among others) the donor age and comorbid conditions (i.e., acute kidney injury, diabetes, hypertension, infectious diseases, and cancer), specimen biopsy findings, and vascular anatomical variants (i.e., multiple renal arteries and veins).<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">4,5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Donor kidneys with vascular anatomical variants, particularly multiple renal arteries (MRA), represents a common finding.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">6</span></a> It has been estimated that approximately 33% of all deceased kidney donors harbor such a condition; being bilateral in up to 10% of the cases.<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">7,8</span></a> Despite the frequency of MRA in renal donors, these kidney allografts go frequently unused assuming in advance an unaffordable rate of vascular complications including renal artery stenosis, thrombosis, or expanding hematoma with hilum patency compromise, leading to increased warm ischemia times(WITs), delayed graft function(DGF) rates, and thus a certain variability of success after transplantation.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">2,9</span></a> In opposition to the higher postoperative complication rates observed by some authors with the use of MRA kidney grafts, recent studies have reported comparable outcomes in terms of viability and graft survival between recipients receiving either a MRA or single artery allografts<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">9,10</span></a>; meaning that if postoperative complications would be avoided in the short-term, MRA allografts would represent an excellent way to expand the kidney graft pool for transplantation, and thus to overcome the existing mismatch between organ availability and potential recipients.</p><p id="par0020" class="elsevierStylePara elsevierViewall">With this aim, we decided to reconstruct the vascular initial configuration of three kidney allografts harboring anatomical vascular variants (that otherwise would be a priori discarded for this reason) by creating a single conduit that uses a variable segment of previously harvested same deceased donor aorta, inferior vena cava, or common iliac artery grafts in order to simplify the vascular anastomoses in the recipient during transplantation surgery. By using this strategy, the risk of postoperative vascular complications would be decreased, thus favoring the routine use of reconstructed MRA kidney allografts in clinical practice. A detailed description of our surgical approach in these cases, along with their functional outcomes in the follow-up are reported in this paper.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Patients and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Preoperative issues</span><p id="par0025" class="elsevierStylePara elsevierViewall">Three patients with ESRD on dialysis underwent renal transplantation using kidney allografts that required bench vascular reconstruction (arterial and/or venous) in the form of a conduit due to the presence of anatomical variants (multiple renal arteries and/or short renal veins) to simplify and facilitate the vascular anastomoses during the transplantation procedure. Before attempting the transplantation, a thorough preoperative evaluation was performed in each of the candidates according to our standard protocol.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Ethical issues</span><p id="par0030" class="elsevierStylePara elsevierViewall">Possible and expected complications (i.e., including particularly detailed information on vascular and urological mishaps) associated with the procedure while using kidneys with anatomical vascular variants were discussed with all the patients involved, and written informed consent was obtained prior to surgery in all cases. In addition, Institutional Review Board approval was obtained for the retrospective review of the medical records of all the patients included.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Cases and vascular reconstructions</span><p id="par0035" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Case 1</span>: 48-year-old male with ESRD secondary to congenital bilateral kidney hypoplasia who started hemodialysis in 2007. After a 4-year period on the waiting list, a horseshoe kidney allograft became available from a 39-year-old deceased donor. The graft was fused at the lower pole and contained a total of 11 renal arteries (4 to the right side, 4 to the left side, and 3 to the isthmus) and 5 renal veins (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The kidney was considered unsplittable due to the location of the artery toward the isthmus after dividing the main left renal vein from the inferior vena cava (IVC). Therefore, a decision was made to transplant the kidney en bloc, and hence the main left renal vein was reanastomosed again to the IVC on its native location. The donor IVC distal end was anastomosed in an end-to-side fashion to the recipient IVC, while the donor abdominal aorta distal end was anastomosed in an end-to-side manner to the recipient aorta just above the common iliac arteries bifurcation.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Case 2</span>: 51-year-old female with ESRD of unknown etiology who had a previous renal transplantation in 1986, which finally failed in 2001 beginning hemodialysis shortly after. In 2012, the patient was re-evaluated to undergo a new deceased kidney transplantation. Multiple doses of intravenous immunoglobulins were required to face a 99% panel of reactive antibodies(PRA) present in this patient before transplantation. Surprisingly, T- and B-lymphocyte cross-matches resulted negative after immunoglobulin administration, despite the high PRA levels. The right kidney allograft available for this patient contained 5 renal arteries (three renal arteries originated from the upper pole and two from the lower pole) and 3 renal veins. All 5 arteries were anastomosed to a segment of donor aorta, creating a single vascular conduit (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>), while two small renal veins were sacrificed to obtain a single venous cuff which was adequately lengthened using a segment of donor IVC in a form of a single longer venous conduit. The donor aortic conduit and IVC distal end were anastomosed in an end-to-side fashion to the recipient external iliac artery and vein, respectively.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Case 3</span>: 26-year-old male with ESRD due to multicystic dysplastic kidney who began on dialysis in 2009. Seven years later, a right-sided split horseshoe kidney graft became available, and the patient was accordingly evaluated to undergo a deceased kidney transplantation. The allograft contained 3 renal arteries (1 main renal artery at the hilum and two smaller branches originated from the right common iliac artery) and a single renal vein sensibly shorter than the arteries (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). A Carrel patch was harvested along with the main renal artery, while the take-off of both lower pole branches was preserved into a donor common iliac artery conduit that was properly sewn closed in its proximal end. A segment of donor IVC was used to lengthen the venous cuff and anastomosed in an end-to-end fashion with the main renal vein in its proximal side. The vascular anastomoses in the recipient were made in an end-to-side manner as follows: two separated arterial anastomosis (for the Carrel patch and the donor common iliac artery distal end) to the recipient external iliac artery, and a single venous anastomosis (for the distal end of the donor IVC conduit) to the recipient external iliac vein.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Technical details</span><p id="par0050" class="elsevierStylePara elsevierViewall">After bench surgery completion, all the three allografts were connected to the LifePort® renal preservation machine using KPS-1® preservation solution until the time for transplantation. Renal resistance data for the cases included is shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. Vascular anastomoses were performed using a double-180° 6–0 (artery) or 5–0 (vein) Prolene® running sutures. Arterial anastomoses were completed first in every case, and Evicel® was thereafter spread out at the vascular anastomotic sites to avoid residual bleeding after reperfusion. After completing all vascular anastomoses, the clamps were finally released, and the anastomotic sites checked for bleeding. Residual bleeding control was not necessary in any case, and no intraoperative complications either noted.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">All the allografts perfused homogeneously soon after clamp release, and clear urine output observed in each case before attempting the ureteric reconstruction. Ureteroneocystostomies were performed according to a modified Lich-Gregoir technique. No drainage was deemed necessary, nor subsequently placed at the end of the procedure. Surgical time did not exceed 270<span class="elsevierStyleHsp" style=""></span>min (range: 200–270<span class="elsevierStyleHsp" style=""></span>min), and estimated blood loss recorded was maintained below 150<span class="elsevierStyleHsp" style=""></span>cc (range: 50–150<span class="elsevierStyleHsp" style=""></span>cc) in all cases. Recorded WITs were 40, 34, and 35<span class="elsevierStyleHsp" style=""></span>min for cases #1–#3, respectively.</p><p id="par0060" class="elsevierStylePara elsevierViewall">The main features of the allografts transplanted, operative details regarding reconstruction and anastomoses, and functional outcomes after transplantation are summarized in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Results</span><p id="par0065" class="elsevierStylePara elsevierViewall">All the patients included tolerated the procedure well, and their postoperative course was uneventful. The renal function was fully recovered before discharge (creatinine serum levels 1–1.5<span class="elsevierStyleHsp" style=""></span>mg/dL) in all cases, and no DGF was noted. Postoperative complications were neither recorded during the first 90 days after transplantation, nor later in the follow-up. Creatinine serum levels at 6, 12, and 24 months are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Discussion</span><p id="par0070" class="elsevierStylePara elsevierViewall">Transplantation of kidneys harboring anatomical vascular variants (i.e., MRA) often requires complex and time-consuming bench vascular reconstructions. Sometimes, spare vascular grafts harvested during the procurement of renal allografts may deemed helpful for this purpose according to different previous experiences reported in the literature.<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">6,11</span></a> In fact, Bachul et al.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">6</span></a> performed the successful transplantation of a kidney allograft containing 5 renal arteries using a same donor aorta graft to create a single arterial conduit that was further anastomosed in the external iliac artery of the recipient. Similar outcomes were reported by Hefty et al.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">11</span></a> in transplanting en bloc an unsplittable horseshoe kidney using a donor common iliac artery conduit to extend the distal aorta in the allograft, thus facilitating the arterial anastomosis.</p><p id="par0075" class="elsevierStylePara elsevierViewall">In line with previous experiences, we also used this kind of vascular grafts for reconstruction in all the cases included in this initial series. With no exception, they all regained a normal renal function after renal transplantation. Therefore, the post-transplantation functional outcomes achieved in all these patients proves again the usefulness of donor arterial (aorta and common iliac artery) and venous (IVC) spare grafts to be used for conduit-type vascular reconstructions in kidneys from deceased donors harboring anatomical vascular variants (i.e., MRA and/or short renal veins).</p><p id="par0080" class="elsevierStylePara elsevierViewall">The use of renal allografts harboring vascular anatomical variations has been typically associated with higher perioperative complication rates. In this regard, Alarcón et al.,<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">10</span></a> reported a comparison of long-term outcomes in a series of deceased kidney allografts harboring MRA to those containing single renal arteries, observing no statistically significant differences. Comparable results were also reported by Rump et al.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">12</span></a> and Benedetti et al.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">13</span></a> in the living donation setting, and the short-term follow-up, respectively. In addition, a systematic review and meta-analysis conducted by Zorgdrager et al.,<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">9</span></a> demonstrated that MRA grafts were more prone to short-term complications than single artery grafts, but conversely comparable long-term outcomes and patient survival rates at 1- and 5-year follow-up were showed in this study.</p><p id="par0085" class="elsevierStylePara elsevierViewall">We did not experienced complications in the short or long-term follow-up period. WITs remained comparable to those observed for single artery allografts, and no cases of DGF were recorded. Hence, in spite of our still limited experience, we believe that the results obtained greatly support the use of same deceased donor vascular grafts for those kidney allografts requiring complex vascular reconstructions in order to avoid postoperative complications that may arise during or after the procedure. Strict adherence to a systematic and meticulous technique is considered by the authors of outmost importance to achieve the herein reported outcomes. In our opinion, the surgical approach described here would also represent an efficacious way to expand the organ pool for renal transplantation, by facilitating the recovery of deceased donor renal allografts harboring vascular variants, that otherwise would be discarded for this reason.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conclusions</span><p id="par0090" class="elsevierStylePara elsevierViewall">Despite the technical difficulty entailed, vascular reconstruction using arterial and venous grafts harvested from the same deceased donor may result a helpful tool to simplify the vascular anastomoses during transplantation surgery in those allografts harboring vascular variants. This strategy may increase their use, minimize perioperative complications, and enable normal graft function rates in the short and long-term follow-up. The successful outcome obtained by using this approach would help to expand the donor criteria for the inclusion of organs containing vascular anatomical variants.</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflict of interest</span><p id="par0095" class="elsevierStylePara elsevierViewall">The authors of this manuscript have no conflict of interest to disclose.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres1414853" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Patients and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1294920" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1414852" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Antecedentes" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Pacientes y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1294921" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Patients and methods" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Preoperative issues" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Ethical issues" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Cases and vascular reconstructions" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Technical details" ] ] ] 6 => array:2 [ "identificador" => "sec0035" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0040" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0045" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0050" "titulo" => "Conflict of interest" ] 10 => array:2 [ "identificador" => "xack492858" "titulo" => "Acknowledgments" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-01-09" "fechaAceptado" => "2020-01-24" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1294920" "palabras" => array:4 [ 0 => "Kidney transplantation" 1 => "Multiple arteries" 2 => "Reconstruction" 3 => "Vascular conduit" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1294921" "palabras" => array:4 [ 0 => "Trasplante renal" 1 => "Arterias múltiples" 2 => "Reconstrucción" 3 => "Conducto vascular" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Transplantation of kidneys with vascular anatomical variants remains a challenge. Due to its varying success in regard to graft function after transplantation, these organs have been frequently discarded assuming in advance an unaffordable rate of vascular complications.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Patients and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We performed three kidney transplants using organs from deceased donors harboring vascular variants (multiple arteries and short veins), including an unsplittable horseshoe kidney. Different grafts harvested from the same donor aorta, common iliac artery, and inferior vena cava, were used to reconstruct the initial vascular configuration by creating single arterial and venous conduits aimed to simplify the vascular anastomoses in the recipient.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">No post-operative complications were recorded. Warm ischemia times remained comparable to single artery renal allografts. No delayed graft function was noted in any case, and every patient regained normal renal function after transplantation.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Vascular reconstruction using arterial and venous grafts harvested from the same deceased donor may result a helpful tool to simplify vascular anastomoses during transplantation surgery, thus avoiding their discard in advance, minimizing perioperative complications, and enabling normal graft function rates in the long-term follow-up. The successful outcome obtained by using this approach would help to expand the donor criteria for the inclusion of organs containing vascular anatomical variants.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Patients and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Antecedentes</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">El trasplante renal con variantes anatómicas vasculares sigue siendo un desafío. Debido a su éxito variable en lo que respecta a la función del injerto después del trasplante, estos órganos se descartan frecuentemente, asumiendo de antemano una tasa inasequible de complicaciones vasculares.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Pacientes y métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Realizamos 3 trasplantes de riñón utilizando órganos de donantes fallecidos que presentaban variantes vasculares (arterias múltiples y venas cortas), incluyendo un riñón en herradura indivisible. Se utilizaron diferentes injertos extraídos de la aorta, la arteria ilíaca común y la vena cava inferior del mismo donante para reconstruir la configuración vascular inicial mediante la creación de conductos arteriales y venosos individuales, con el fin de simplificar la anastomosis vascular en el receptor.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">No se registraron complicaciones postoperatorias. Los tiempos de isquemia caliente fueron comparables con los de aloinjertos renales de una sola arteria. En ningún caso se observó un retraso en la función del injerto y todos los pacientes recuperaron la función renal normal después del trasplante.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La reconstrucción vascular mediante injertos arteriales y venosos del mismo donante fallecido puede ser un recurso útil para simplificar la anastomosis vascular durante la cirugía de trasplante, evitando así su descarte de antemano, reduciendo al mínimo las complicaciones perioperatorias y permitiendo tasas normales de función de los injertos en el seguimiento a largo plazo. El resultado satisfactorio obtenido mediante la utilización de este enfoque ayudaría a ampliar los criterios de donantes para incluir órganos que presentan variantes anatómicas vasculares.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Antecedentes" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Pacientes y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "⋆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Alexander A, Serena G, González J, DeFaria W, Ciancio G. Trasplante renal mediante reconstrucción de conducto vascular en riñones de donantes fallecidos con arterias renales múltiples y venas renales cortas. Actas Urol Esp. 2020;44:623–629.</p>" ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 805 "Ancho" => 2067 "Tamanyo" => 248698 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Horseshoe kidney graft fused at the lower pole containing a total of 11 renal arteries (4 to the right side, 4 to the left side, and 3 to the isthmus) and 5 renal veins.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1876 "Ancho" => 1339 "Tamanyo" => 285191 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Right kidney allograft available containing 5 renal arteries (three renal arteries originated from the upper pole and two from the lower pole) and 3 renal veins. All 5 arteries were anastomosed to a segment of donor aorta, creating a single vascular conduit.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 2596 "Ancho" => 1534 "Tamanyo" => 554004 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Kidney allograft containing 3 renal arteries (1 main renal artery at the hilum and two smaller branches originated from the right common iliac artery), and a single renal vein (sensibly shorter than the arteries). A Carrel patch was harvested along with the main renal artery, while the take-off of both lower pole branches was preserved into a donor common iliac artery conduit that was properly sewn closed in its proximal end. A segment of donor IVC was used to lengthen the venous cuff and anastomosed in an end-to-end fashion with the main renal vein in its proximal side.</p>" ] ] 3 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">(**) Four of the arteries were right-sided, 4 were left-sided, and 3 provided vascular supply to the isthmus. Due to this initial vascular configuration the horseshoe kidney was considered unsplittable and transplanted in bloc.</p><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">(***) To enlengthen the venous cuff an end-to-end venous anastomosis was used between the graft main renal vein and the donor IVC conduit, while the IVC conduit was anastomosed in the counter side to the recipient right EIV in an end-to-side fashion.</p><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">d: donor; r: recipient; IVC: inferior vena cava; EIA: external iliac artery; CIA: common iliac artery; REIV: right external iliac vein; RRV: right renal vein; LEIV: left external iliac vein RR: renal resistance; WIT: warm ischemia time; DGF: delayed graft function; min: minutes; mo: months.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="\n \t\t\t\t\ttable-head\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col">Case number \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col">Type of kidney allograft \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Initial graft vascular configuration</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col">Machine perfusion RR (mmHg/mL/min) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Vascular reconstruction performed</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Vascular anastomoses</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col">WIT (min) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col">DGF \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="3" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Serum creatinine level (mg/dL)</th></tr><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Number of arteries \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Number of veins \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Arterial \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Venous \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Arterial (type/d-r) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Venous (type/d-r) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">6 mo \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">12 mo \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">24 mo \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t"># 1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Unsplittable horseshoe kidney (fused at the lower pole) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11(**) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Single conduit using donor aorta graft \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Single conduit using donor IVC graft \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">End-to-side/Aorta-aorta \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">End-to-side IVC-IVC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">40 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t"># 2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Conventional \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Single conduit using donor aorta graft \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Single conduit sacrificing two small renal veins \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">End-to-side/Aorta-EIA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">End-to-side/RRV to LEIV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">34 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t"># 3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Right-sided split horseshoe kidney \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Double arterial cuffMain renal artery: Carrel patch;2 lower pole arteries: conduit with donor CIA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Single conduit using donor IVC to increase the length of the right renal vein \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Double anastomosis:End-to-side/main renal artery-EIA and End-to-side/CIA-EIA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">End-to-side/IVC-REIV(***) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">35 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2427768.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Operative variable and recipient outcomes after transplantation.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:13 [ 0 => array:3 [ "identificador" => "bib0070" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "2018 USRDS annual data report: epidemiology of kidney disease in the United States" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "United States Renal Data System" ] ] ] 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Husain" 5 => """ D.J.\n <et l=""></et> Carpenter """ ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.kint" "Revista" => array:6 [ "tituloSerie" => "Kidney Int" "fecha" => "2018" "volumen" => "94" "paginaInicial" => "187" "paginaFinal" => "198" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29735310" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0095" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Crossing anatomic barriers—transplantation of a kidney with 5 arteries duplication of the pyelocalyceal system, and double ureter" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "P.J. Bachul" 1 => "C. Osuch" 2 => "E.S. Chang" 3 => "A. Bętkowska-Prokop" 4 => "A. Pasternak" 5 => "M. 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