By Cale Li, MD
Key Takeaways:
- Kidney autotransplantation offers a solution for specific conditions such as renal artery aneurysms, loin pain hematuria syndrome, and Nutcracker syndrome, where traditional treatments may risk significant kidney damage.
- A dedicated autotransplant team provides a unique and specialized approach. Programs like Columbia’s combine urologic testing, vascular surgery expertise, and transplant procedures to address intricate kidney anatomy issues.
- Ongoing developments in robotic surgery for kidney transplantation present a promising therapy option with minimal postoperative discomfort, and because the transplant is on oneself, no risk of organ rejection.
Bloody urine. Sharp back pain. The culprit is typically kidney stones. For a number of people, however, these symptoms are the result of a rare, anatomical disorder of the kidney that requires surgery. This is where kidney autotransplantation comes in.
“There are a number of conditions in which the best solution is to take the kidney out, work on it outside of the human body, and then put it back in,” said Lloyd E. Ratner, MD, Director of Renal and Pancreatic Transplantation at NewYork-Presbyterian/Columbia University Irving Medical Center.
“Transplant” refers to the kidney being removed from the body to be repaired; “auto” refers to the kidney being taken from and returned to the same patient.
These conditions generally fall under three categories: renal artery aneurysms (a bulge in the wall of an artery to the kidney), syndromes that cause debilitating pain, and venous obstructions.
“Renal artery aneurysms, depending on where they occur, in a branch point or the trunk of the artery or if they’re multiple or big, if you try to fix them any other way, you wind up bumping off a significant portion of the kidney,” said Dr. Ratner. “Sometimes the safest thing to do is fix the aneurysm outside the patient.”
“Another example is a condition called loin pain hematuria syndrome, which is not that well understood, but as it implies, people get renal colic, pain like when you have a kidney stone. It's a terrible pain that's really debilitating. They also get hematuria, blood in the urine. It usually follows someone having kidney stones, having a urinary tract infection, or infection in the kidney,” said Dr. Ratner.
“We realized that it's not so much the kidney that's the problem in loin pain hematuria syndrome, but the ureter, the tube that connects the kidney to the bladder and pushes the urine down its lane. The ureter is dyskinetic. In other words, the muscle contractions aren't coordinated and they wind up causing pain,” said Dr. Ratner. “If you only take out and move the kidney but you don't operate on the whole ureter, then this pain actually persists.”
A similar condition that also leads to an autotransplant is called the Nutcracker syndrome, when the veins of the left kidney become obstructed.
Dr. Ratner believes there are significant benefits in having a dedicated team for autotransplantation, particularly in dealing with these complex conditions that involve multiple parts of the kidney anatomy.
“A lot of these patients don't even know where to go, because, particularly for the Nutcracker Syndrome and loin pain hematuria syndrome, most physicians aren't familiar with the syndromes and they are tough to pin down,” said Dr. Ratner. “We have Nick Morrisey from vascular surgery, Ojas Shah from urology, and myself. We have all bases covered.”
The autotransplant team can provide what is needed in a comprehensive way—urologic testing, through labs and imaging, to confirm their diagnosis. Then, if seeking treatment for a renal aneurysm, meet with the vascular surgeon to discuss transplant and non-transplant alternatives.
Because these conditions often involve multiple areas of the kidney anatomy, collaboration between surgeons highly skilled in their expertise – vascular, urology, transplantation – is key to achieving successful treatment.
“There really isn't another program like this in the New York Metropolitan Area. It takes real specialized care because a vascular surgeon may be able to fix the vessel, but they don't know how to transplant the kidneys and take care of them. Same thing with urologists,” said Dr. Ratner. “It's not something that really could be done at a non-transplant center or a center that doesn't have transplant surgeries.”
Due to the complicated nature of autotransplantation, the procedure is a lengthy one, each case more akin to three.
“They're big cases. They're long cases. For renal artery aneurysm, it's really three cases because we're taking the kidney out, we're doing the repair of the aneurysm, and then we're putting it back in. They take a long time, they require a lot of care, but the surgery offers hope for some of these patients that would have either lost the kidney or continue to go on suffering,” said Dr. Ratner.
With advances in laparoscopic surgery, kidney autotransplant is also seeing some changes in how the procedure is performed.
“We remove the kidney laparoscopically, and we're starting to develop a robotic program where we're transplanting kidneys robotically, so it could be done minimally invasively. We're hoping to get to the point where we could do it all robotically, but right now, it's only half of it.”
One of the benefits of minimally invasive surgery is swift recovery time.
“Patients usually spend three to five days in the hospital, and recover in about a month,” said Dr. Ratner. “The transplant incision is not terribly painful relative to having a kidney taken out. Patients bounce back pretty fast.”
And because the kidney belongs to the same patient in autotransplantation, there is no risk of organ rejection.
“No immunosuppression, no rejection. It's just like any other surgical procedure in that respect,” said Dr. Ratner. “For the right patients, it's a great therapy option.”
One of the main challenges facing patients today is access to surgeons experienced in kidney autotransplantation.
“There are a couple of other centers in the country that have dedicated auto transplant programs, but short of that, few others,” said Dr. Ratner. “We're it in the New York metropolitan area.”
Further Reading:
- Unbreakable Bonds: The First Robotic Kidney Transplant Is a Testament to Lifelong Friendship
- Predatory Artery Treatment for PAD: A Vascular Surgeon Weighs In
- Alive at 65: Three-time Transplant Recipient Jerry Cahill Appreciates Every Day