Kidney autotransplantation, where a person’s own kidney is removed from its original location and then reimplanted back into the same person, is a rare but useful last resort to preserve renal function in carefully selected patients, a review of cases at Westmead public and private hospitals has shown.
Despite a moderately high complication rate and the risk of graft loss, there were no cases requiring subsequent dialysis and no deaths, supporting the procedure as a viable option where alternative treatments have failed or were unfeasible.
The review, published in the ANZ Journal of Surgery [link here], comprised 10 patients who underwent 11 kidney autotransplants between 2014 and 2023. Four out of the 10 patients had a solitary kidney.
Indications for the elective procedures included renal artery aneurysms, ureteral strictures, complex renal cell carcinomas, loin pain haematuria syndrome and nutcracker syndrome.
One patient required an emergency procedure following iatrogenic renal artery injury during elective laparoscopic left radical nephrectomy for a non-functional kidney with xanthogranulomatous pyelonephritis.
Seven procedures were performed via an open approach and four used a robotic technique. The mean times for the open and robotic procedures, from nephrectomy to back table surgery and implantation of the autograft, were 433 and 360 minutes respectively.
In perioperative outcomes, one robotic procedure required conversion to an open procedure due to inadequate arterial flow following renal reperfusion. Day 2 imaging showed no flow and graft nephrectomy was performed in this patient.
A second patient also required graft nephrectomy on day 4 due to renal vein thrombosis.
Both patients were fortunate to have a healthy contralateral kidney and maintained normal renal function during follow-up.
The review reported an overall complication rate of 54.5%. There were no mortalities and no patients required dialysis during the median follow-up of 74.8 months.
Median eGFR was 90 mL/min/1.73 m2 at 3 months and 82.5 mL/min/1.73 m2 at 12 months. The lowest eGFR at 12 months was 57 mL/min/1.73 m2 in the patient who required the emergency procedure and would otherwise have been left anephric.
In the two patients who underwent ex vivo partial nephrectomy and autotransplantation for renal tumours in solitary kidneys, both had clear histopathological margins and did not experience recurrence during follow-up out to 63.3 months.
“Both renal cell carcinomas treated with kidney autotransplantation were located in solitary kidneys, and an in situ partial nephrectomy would have posed a significant risk of resulting in nephrectomy due to the tumour’s complexity, which would have ultimately rendered these patients dialysis dependent,” the review said.
The investigators, including urologist Professor Howard Lau, said other patients with aneurysms or ureteral injuries were either considered unsuitable for endovascular repair due to anatomical complexity or had undergone unsuccessful endovascular treatment.
They said split function testing is now performed routinely during the workup for all patients with two kidneys considering kidney autotransplantation.
“We typically recommend nephrectomy if split renal function testing shows less than 20% function on the affected side.”
The investigators said patients are routinely followed with regular 6–12 months graft ultrasound and serum creatinine surveillance.
They concluded that kidney autotransplantation allows the treatment of life-limiting/threatening conditions in patients who would otherwise be considered inoperable or alternately be left anephric and dialysis dependent.
“Robotic-assisted kidney autotransplantation is a feasible approach to reduce the morbidity associated with the procedure; however, further research, including studies that directly compare open KAT and RAKAT, is needed to determine the exact benefits, indications, and limitations of this approach,” they said.