Fibromuscular dysplasia and living kidney donors: a narrative review

Abstract

To address the shortage of grafts, renal transplant teams actively utilize all available donation options, including those that challenge the conventional criteria for living donors. However, this approach may involve situations requiring careful assessment of specific risks-particularly those that could jeopardize donor safety, expose the recipient or graft to vascular complications associated with certain arterial reconstructions, or threaten graft function in the recipient. Kidney donation in the context of fibromuscular dysplasia represents one such scenario, as this condition encompasses all three of these risks. Transplant centers that do not automatically exclude such donations recommend a selective approach, with decisions to accept these kidneys made on a case-by-case basis through evaluation by multidisciplinary teams comprising nephrologists, angiologists, and transplant surgeons. This narrative review aims to provide an update on (1) the identification and assessment of this arterial lesion during predonation evaluation, (2) the acceptability criteria for kidneys affected by fibromuscular dysplasia, (3) the safety and long-term outcomes for donors following nephrectomy, and (4) technical considerations for transplanting these grafts and their outcomes in recipients.

Keywords: Fibromuscular dysplasia; Informed consent; Kidney transplantation; Living donor; Vascular surgical procedures.

Fig. 1

Predonation computed tomography angiography. (A) Multifocal renal artery fibromuscular dysplasia (FMD). White arrows indicate the extent of the dysplasia, affecting the distal two-thirds of the main renal artery, with the characteristic “string-of-beads” appearance. (B) Concentric arterial narrowing in a young woman, suggestive of monofocal renal artery FMD. ARG, left renal artery.

Fig. 2

Two renal allografts exhibiting multifocal fibromuscular dysplasia of the main renal artery, the most common subtype. White arrows indicate the dysplastic arterial segment following longitudinal arteriotomy performed under cold ischemia on the back table. (A) Overview of a renal graft with the main renal artery (arrow) affected by multifocal fibromuscular dysplasia. (B) Magnified view highlighting the multifocal dysplastic lesions (arrow) affecting the main renal artery of a second allograft.

Fig. 3

Technical considerations and steps following validation of a fibromuscular dysplasia (FMD)-affected kidney donation. (A) The red arrows indicate the downstream boundary between arterial segments appearing healthy and those affected by dysplasia on angiography. (B) The white arrow denotes the length of the healthy portion of the main renal artery branching division, which is too short for direct reimplantation in the recipient. (C) Vascular graft harvested from the ipsilateral hypogastric artery. (D) Excised segment of the dysplastic artery. (B, E) The black arrows highlight the longitudinal section of the dysplastic artery up to the healthy arterial wall.

Fig. 4

Bilateral renal fibromuscular dysplasia. Reproduced from Plouin et al. [30] under the Creative Commons License.

Fig. 5

Close-up view of the final arterial configuration. Arterial reimplantation was performed via interposition of an autologous hypogastric graft harvested from the homolateral side of the transplant. The black arrows indicate the proximal anastomosis, performed under warm ischemia. The yellow arrow denotes the distal anastomosis between the main branch of the renal artery and the hypogastric graft, previously performed under cold ischemia. The white dashed circle highlights the location of the hypogastric artery ostium, previously harvested and used as the vascular extension in this reconstruction.

Fig. 6

Overview of renal graft reimplantation. Arterial reimplantation was performed via interposition of an autologous hypogastric graft harvested from the homolateral side of the transplant. The black arrows indicate the proximal anastomosis, performed under warm ischemia. The yellow arrow denotes the distal arterial anastomosis, previously performed under cold ischemia. The blue arrow indicates the venous anastomosis.

Fig. 7

Arterial reimplantation via interposition of two autologous arterial grafts harvested from the contralateral superficial femoral artery. The yellow arrows indicate the distal prehilar anastomosis, previously constructed and leak-tested under cold ischemia. The black arrows highlight the proximal arterial anastomosis, performed under warm ischemia. The blue arrow indicates the venous anastomosis.