LAUSR

Introduction: Aorto-iliac vascular disease is becoming more common among kidney transplant candidates resulting in technical and ethical concerns due to accompanying cardiovascular disease. We performed a survey among kidney transplant surgeons regarding the management and acceptance of patients with aorto-iliac vascular disease. Methods: A survey was conducted in March 2019 among 939 transplant surgeons. The survey contained 2 parts: one part containing general questions about the policy in their own center and a second part where surgeons were confronted with real-time cases deciding eligibility for transplantation based on CT-imaging. Results: A total number of 148 transplant surgeons completed the survey, mainly from Europe (77%) and working in transplant centers where <100 kidney transplants per year were performed (42.6%). Most respondents had performed between 100-300 kidney transplants (31.1%) in their career and received no vascular specialty training (60.8%). Imaging of the aorto-iliac arteries was usually performed in recipients with risk factors only (37.8%), followed by per protocol above a certain age (17.6%). If needed, most respondents would prefer an endovascular intervention prior to transplantation (94.5%) while no consensus was reached concerning the timing of an open vascular intervention; 64.1% answered preferably prior to transplantation and 30.5% simultaneously. 37.8% of the respondents who answered ‘preferably prior to transplantation’ answered that are no guidelines about the optimal length of time between an open vascular intervention and transplantation. Respondents working in high-volume centers (≥200 transplants/ year) were more likely to consider kidney transplantation after pretransplantation vascular interventions (p<0.001). In the interactive cases, respondents with vascular specialty training were more likely to consider an endovascular/open vascular treatment instead of rejecting the patient (p=0.037). The most important concern when performing a kidney transplantation in patients with aorto-iliac vascular disease was technical problems (75.4%), followed by increased operative risk (17.5%) and as last reason the ethical issue of transplanting a scarce kidney in a patient with lowered life expectancy (7.1%). According to the respondents, kidney transplant candidates should have a median minimal life expectancy of 10 years for a living donor kidney transplantation (IQR 5-10) and 5 years (IQR: 5-8) for a deceased donor kidney transplantation. Conclusion: Major differences exist in the approach towards KTx candidates with aorto-iliac vascular disease. Referral to a high-volume center and vascular specialty training may increase the chance of receiving a transplant for a patient with aorto-iliac vascular disease. A consensus meeting could help to assure optimal standard of care.