*2.8.2.1. Acceptance of grafts with anatomic anomalies*

The number of donations can be increased by accepting donors with anatomic anomalies (multiples arteries, multiple veins, moderate dysfunction of the UPJ, renal cyst, complete duplicate ureteral system, solitary stone) which can be corrected in bench surgery.

Anatomical anomalies of the kidney have been considered for a long time as an absolute contraindication for living donation. Even now, many nephrological centers are including in their exclusion criteria for live related or unrelated donation items like urological abnormalities in donors or history or presence of any kidney stones.

But in our days, the majority of transplant centers with experience in the field, due to the shortage of the living donors pool, are considering the contraindication for using grafts with anatomical anomalies just a relative contraindication. Occasionally, the donor has minor unilateral abnormalities such as a renal cyst, ureteropelvic junction obstruction, solitary stones, duplex ureteral system, etc. If the related donor with a good immunological correspondence with the recipient has an abnormal kidney and is the only one available and the evolution of the recipient on hemodialysis is unacceptable, it is advisable to transplant the abnormal kidney, living the donor with the best one.

#### *2.8.2.2. Acceptance of donors with multiple arteries and veins*

The management of multiple renal arteries (MRA) are considered technically demanding in renal transplantation programs with kidneys from related or unrelated living donors. Some programs consider the use of multiple arteries and veins as a relative contraindication, because of increased risk of vascular and urological complications.

In addition, the rapidly increasing laparoscopic kidney donation has been accompanied by a significant shift in surgical practice [50,51]. Many centers which are performing laparoscopic harvesting restrict it to the left kidney [52-54]. The limitation to the left kidney leads to a higher utilization rate of kidneys with multiple arteries; in the literature, incidence of unilateral multiple renal arteries is between 18% and 30%, unless one limits laparoscopic nephrectomy only to the kidney with normal anatomy which is precluding 30% of all donors.

By accepting grafts with multiple renal arteries, one may theoretically accept an adverse effect on the outcome of those grafts. Previous authors [55,56], stated that MRA in their reconstruc‐ tion were associated with several post-transplant complications. This is the motivation why such anatomy was considered to be a transplant contraindication. The most frequent vascular complications which were encountered in reconstruction of multiple arteries were graft thrombosis, stenosis of the renal artery, and an increased risk of reno-vascular hypertension [55-57]. The most frequently ureteral complication encountered [58] were ureteral necrosis and pelvi-caliceal fistulas.

Utilizing living donors may decrease the pressure for renal transplantation. Moreover, implementing of different types of kidney exchange could give further solutions to increase the transplantation rates. Combining different approaches to kidney exchange may create complex and versatile solutions to the incompatibility issue, even finding a better match for

The number of donations can be increased by accepting donors with anatomic anomalies (multiples arteries, multiple veins, moderate dysfunction of the UPJ, renal cyst, complete

Anatomical anomalies of the kidney have been considered for a long time as an absolute contraindication for living donation. Even now, many nephrological centers are including in their exclusion criteria for live related or unrelated donation items like urological abnormalities

But in our days, the majority of transplant centers with experience in the field, due to the shortage of the living donors pool, are considering the contraindication for using grafts with anatomical anomalies just a relative contraindication. Occasionally, the donor has minor unilateral abnormalities such as a renal cyst, ureteropelvic junction obstruction, solitary stones, duplex ureteral system, etc. If the related donor with a good immunological correspondence with the recipient has an abnormal kidney and is the only one available and the evolution of the recipient on hemodialysis is unacceptable, it is advisable to transplant the abnormal kidney,

The management of multiple renal arteries (MRA) are considered technically demanding in renal transplantation programs with kidneys from related or unrelated living donors. Some programs consider the use of multiple arteries and veins as a relative contraindication, because

In addition, the rapidly increasing laparoscopic kidney donation has been accompanied by a significant shift in surgical practice [50,51]. Many centers which are performing laparoscopic harvesting restrict it to the left kidney [52-54]. The limitation to the left kidney leads to a higher utilization rate of kidneys with multiple arteries; in the literature, incidence of unilateral multiple renal arteries is between 18% and 30%, unless one limits laparoscopic nephrectomy

By accepting grafts with multiple renal arteries, one may theoretically accept an adverse effect on the outcome of those grafts. Previous authors [55,56], stated that MRA in their reconstruc‐ tion were associated with several post-transplant complications. This is the motivation why such anatomy was considered to be a transplant contraindication. The most frequent vascular

only to the kidney with normal anatomy which is precluding 30% of all donors.

duplicate ureteral system, solitary stone) which can be corrected in bench surgery.

*2.8.2. Medical methods to increase the number of living donation*

*2.8.2.1. Acceptance of grafts with anatomic anomalies*

146 Current Issues and Future Direction in Kidney Transplantation

in donors or history or presence of any kidney stones.

*2.8.2.2. Acceptance of donors with multiple arteries and veins*

of increased risk of vascular and urological complications.

living the donor with the best one.

compatible pairs.

Smaller arteries are more prone to develop premature atherosclerotic occlusion. If that happens with a small accessory lower pole artery it would lead to ischemic distal ureteral stricture.

Any way, recent data collected from the centers and program of renal transplantation with experience in the field, display above any doubt that procurement of kidneys with multiple renal arteries can be accomplished safely and not impose additional medical, social, econom‐ ical or postoperative clinical evolution burden, on the donor and the recipient.

Overall intraoperative and early postoperative complications of the recipients are not signifi‐ cantly different from the evolution of the recipients who received grafts with single arteries. A low rate of vascular complications is achieved using standard microvascular reconstruction technique with or without autologous vein patches [59-61] or extension graft. More than that, early graft function assessed by urine output and serum creatinine measurements were not significantly different among grafts with single arteries or grafts with multiple reconstructed arteries. In addition, long term quality of function, rejection, graft loss rates and graft survival were also similar. More than that, overall graft survival rates of this patients is exceeding 90% at 3 years.

In summary, the introduction of laparoscopic donor nephrectomy has significantly increased the number of grafts with multiple renal artery. Utilization of this donors, increase the rate of donation with 30% in specific centers. Modern techniques based on microsurgery have reduced dramatically incidence of above mentioned complications. From a patient outcome based perspective, this change in practice showed to be safe for both donors and recipients.
