Dual Kidney Transplantation: Single-Center Experience

BackgroundDual and en bloc kidney transplantation are strategies used to mitigate the disparity between a reduced organ pool and an ever-increasing need for organ procurement. En bloc refers to the implantation of 2 kidneys from a pediatric donor, compensating for small renal mass, whereas dual expanded criteria donor (DECD) transplantation refers to older donors with grafts otherwise rejected for single transplant, including expanded. This study describes one center's experience with dual and en bloc transplantation.MethodsA retrospective cohort study of dual kidney transplants (en bloc and DECD) from 1990 through 2021. The analysis included demographic, clinical, and survival analysis.ResultsOf 46 patients who underwent dual kidney transplantation, 17 (37 %) received en-bloc transplantation. The overall mean recipient age was 49.4 ± 13.9 years old, younger in the en-bloc subgroup (39.2 vs 59.8 years old, P < .01). The mean time on dialysis was 37 ± 25 months. Delayed graft function was present in 17.4 % and primary nonfunction in 6.4 %, all from the DECD group. The estimated glomerular filtration rates at 1 and 5 years were 76.7 ± 28.7 and 80.4 ± 24.8 mL/min/1.73 m², lower in the DECD group (65.9 vs 88.7 mL/min/1.73 m², P = 0.02). Eleven recipients lost their graft during the study period: 63.6% from death with a functioning graft, 27.3% due to chronic graft dysfunction (a mean of 76.3 months after transplantation), and 9.1% due to vascular complications. Subgroup comparison found no differences regarding cold ischemia time or length of hospitalization. Kaplan-Meier estimates, censored for death with a functioning graft, resulted in a mean graft survival of 21.3 ± 1.3 years, with survival rates of 93.5, 90.5, and 84.1% at 1, 5, and 10 years, respectively, without significant differences between subgroups.ConclusionsBoth DECD and en bloc strategies provide safe and effective options to further expand the use of otherwise rejected kidneys. Neither of the 2 techniques was superior to the other.     

Kidney Transplantation at Annunziata Hospital of Cosenza: Report of 10 Years Experience

Objective

Kidney transplantation represents the gold standard for treatment of patients with end-stage renal disease. Herein we sought to report our 10-year experience with cadaveric kidney transplantations.

Patients and Methods

From February 1995 to September 2008, we performed 115 kidney transplantations. Patients were followed for an average of 4.9 years (range, 2.2-10.6 years). The cold ischemia time (CIT) averaged 13 ± 3 hours, while the mean warm ischemic time was 25 ± 10 minutes. The ureteral-bladder anastomosis was performed using Bracci catheters in the first series of 72 transplants, and double-J stents in the other 41 cases. The average waiting time was 122 ± 21 months. The immunological regimens were prescribed according to the American Society of Nephrology (K/DOQI) with reference to comorbidity and concomitant risk factors and reported drug toxicity events. We transplanted kidneys with anatomic variations, ie, multiple arteries and double veins, and one double transplant of marginal organs.

Results

Our overall complication rate was 9.18%. The 10-year patient and graft survival rates were 89% and 84%, respectively. The percentage of biopsy-proven acute rejection episodes was 22.16%, while chronic allograft nephropathy (CAN) accounted for 15.3% at 5 years. The incidence of delayed graft function (DGF) was 14.05%. Finally, we noted 3 cases of cardiovascular death.

Conclusion

Our experience showed excellent patient outcomes compared with other Italian and European data.     

Laparoscopic Kidney Transplantation: An Initial Experience

Laparoscopic donor nephrectomy has the advantages of less pain, early ambulation and shorter hospitalization compared to open donor nephrectomy. Kidney recipient surgery is, however, traditionally performed by open surgery. Our aim was to study feasibility and safety of laparoscopic kidney transplantation (LKT). After permission from Internal Review Board, LKT was performed in four patients. All kidneys were procured from deceased donors. Left kidney was used for LKT and transplanted in left iliac fossa while right kidney was used for standard open kidney transplantation (OKT). All transplantation procedures were performed successfully. Cold ischemia time varied between 4 h and 14 h. For LKT, mean time for anas tomosis was 65 (range 62–72) min, mean operative time was 3.97 (range 3.5–5) h, mean blood loss was 131.25 mL (range 45–350) mL. Mean wound length was 7 cm in LKT group and 18.4 cm in OKT group. Delayed graft function was observed in one patient in each group. One patient was lost in OKT group due to posttransplant bacterial meningitis. At 6 months, both groups have comparable value of serum creatinine. In conclusion, LKT is technically feasible and safe. Long term outcome needs to be evaluated in a larger study.     

Pregnancy After Kidney Transplantation: Two Transplantation Centers—Vicenza-Udine Experience

Background

Pregnancy after kidney transplant has become possible thanks to the recent surgical and pharmacological breakthrough.

Materials and Methods

We performed a restrospective study including all childbearing women transplanted in our centers after 1997. The following variables were analyzed: type of nephropathy, patient age when dialysis started, age at transplantation, time between dialysis and transplantation and between transplantation and baby birth. We also considered immunosuppressive therapy, type of delivery, baby weight, Apgar score, and mother and baby follow-up.

Results

We followed up 13 pregnancies in 12 patients who were diagnosed with chronic pyelonephritys (n = 4), postpartum cortical necrosis (n = 1), immunoglobulin A GN (n = 4), diabetic nephropathy (n = 1), unknown nephropathy (n = 2). All patients received a cadaveric donor kidney. They were treated with calcium antagonists and alfamethyldopa for their high blood pressure. We observed 9 mother complications: nonnephrotic proteinuria (n = 1), urinary tract Infection (n = 1), pre-eclampsia (n = 4), internal placenta detachment (n = 1) and spontaneous abortions (n = 2); 4 fetal complications: IUGR (n = 2), acute distress respiaratory syndrome (n = 1), Klinefelter syndrome (n = 1) and preterm births (n = 4). In 2 cases the child weight was lower when compared to the gestational age, and 5 babies were admitted to the neonatal intensive care unit. The mother's follow-up showed no acute rejection episodes. Breastfeeding was discouraged due to the transmission of immunosuppressive medications into breast milk. We did not observe significant disease upon child follow-up.

Conclusion

Our data were in agreement with the literature confirming that pregnancy after kidney transplant though possible carries elevated risks. Patients therefore are referred to highly specialized centers where obstetricians, nephrologists, intensivists, and neonatologists provide surveillance and treatment.     

Single-Center Experience in Double Kidney Transplantation

Use of organs from marginal donors for transplantation is a current strategy to expand the organ donor pool. Its efficacy is universally accepted among data from multicenter studies. Herein, we have reviewed outcomes of double kidney transplantation (DKT) over an 9-year experience in our center. The aim of this study was to evaluate possible important differences between a monocenter versus multicenter studies. Between 1999 and 2008, we performed 59 DKT. Recipient mean age was 63 ± 5 years. Mean HLA-A, -B, and -DR mismatches were 3.69 ± 0.922. Donor mean age was 69 ± 7 years and mean creatinine clearance was 69.8 ± 30.8 mL/min. Proteinuria was detected in three donors (5%). Mean cold ischemia and warm ischemia times were 1130 ± 216 and 48 ± 11 minutes, respectively. The right and left kidney scores were 4.18 ± 2 and 4.21 ± 2, respectively. Thirty patients (51%) displayed good postoperative renal function; 22 (37%), acute tubular necrosis with postoperative dialysis; 3 (5%), acute rejection episodes; 4 (7%), single-graft transplantectomy due to vascular thrombosis; 1 (2%), a retransplantation; 5 (8%), a lymphocele; 3 (5%) vescicoureteral reflux or stenosis requiring surgical correction. Cytomegalovirus infection was detected in five patients (8%). In three patients (5%) displayed de novo neoplasia. Three patients showed chronic rejection (5%), whereas we observed a cyclosporine-related toxicity in 7 (12%). Nine patients (15%) developed iatrogenic diabetes. Patient and graft survivals after 3 years from DKT were 93% and 86.3%, respectively. In this study, we applied successfully a widespread score to allocate organs to single kidney transplantation or DKT. In our experience, the score is suitable for the organ allocation but it may be overprotective, excluding potentially suitable organs for a single transplantation.     

Kidney Transplantation in Elderly Recipients: A Single-Center Experience

In this retrospective single-center study we evaluated the outcome after kidney transplant in recipients older than 65 years in terms of patient and graft survival and causes of death.

Dual Kidney Transplantation: A Single-Center Experience in Thailand

Background

Dual kidney transplants (DKTs) from expanded criteria donors (ECDs) have been performed in our hospital since 2014. We needed to review our clinical outcome and update criteria to selected ECDs for DKTs.

Outcome Comparison of ABO-Incompatible Kidney Transplantation With Low-Dose Rituximab and ABO-Compatible Kidney Transplantation: A Single-Center Experience

Background

The development of immunosuppressive techniques has helped overcome the ABO incompatibility barrier. However, the outcomes of ABO-incompatible (ABOi) kidney transplantation remain a controversial issue with the advent of the anti-CD20 chimeric antibody rituximab. Herein, we report the outcomes of ABOi kidney transplantation with low-dose rituximab.

Patients and Methods

Between June 2006 and April 2013, 42 patients underwent living-related kidney transplantation at our hospital. The patients were divided into 2 groups: ABO-compatible (ABOc; n = 29) and ABOi kidney transplants using low-dose rituximab (100 mg/m²) without splenectomy (n = 13). The basic immunosuppression regimen (calcineurin inhibitor [CNI], mycophenolate mofetil [MMF], and steroids) was the same for both groups, except for the use of rituximab and therapeutic apheresis in the ABOi group. We compared post-transplantation renal function, incidents of virus infection, episodes of rejection, and graft survival between the 2 groups.

Results

In our hospital, 30% of recipients received ABOi kidney transplants. The estimated glomerular filtration rate (eGFR) did not differ between the groups. Rejection episodes confirmed by biopsy in the ABOc and ABOi groups were 8 (28%) and 4 (31%) patients (P = .833), acute antibody-mediated rejection was observed in 1 (3.5%) and 2 (15%) patients (P = .165), and virus infection was observed in 14 (48%) and 3 (23%) patients (P = .252), respectively. The 5-year patient survival rate was 100% in both groups, and the 5-year graft survival rates were 95% for ABOc and 100% for ABOi transplants (P = .527).

Conclusions

These results suggest that the outcomes of ABOi kidney transplantation with low-dose rituximab are similar to those of ABOc kidney transplantation. Further study is necessary to address the efficacy and safety of ABOi kidney transplantation.     

Autosomal-Dominant Polycystic Kidney Disease and Kidney Transplantation: Experience of a Single Center

Background

Autosomal dominant polycystic kidney disease (ADPKD) is a hereditary disease that frequently leads to end-stage renal disease and is a common indication for kidney transplantation. We sought to evaluate the demographic characteristics, graft and patient survival, and some posttransplantation complications among ADPKD recipients.

Methods

This retrospective study included 445 renal transplant recipients, among whom 48 had ADPKD. We excluded patients with pretransplantation diabetes mellitus. We evaluated patient and graft survivals as well as posttransplantation complications.

Results

There was no difference between the 2 groups with respect to demographic or transplant characteristics, except for older age among the ADPKD group (51.2 ± 8.6 years vs 44 ± 13.1 years; P < .001). We also observed no significant difference with regard to immediate graft function, immunological graft, or patient survival. Although not significant, there was a lower incidence of proteinuria and a greater number of acute rejections among ADPKD patients. As for posttransplantation complications, there was no difference regarding the prevalence of hypertension, but there was more erythrocytosis among the ADPKD group. The incidence of posttransplantation diabetes mellitus was significantly greater in ADPKD patients (33.3% vs 17.1%; P = .009), and remained significant after adjusting for confounding variables by multivariate analysis with an adjusted odds ratio of 2.3 (95% confidence interval, 1.008-5.136; P = .048).

Conclusion

Our results suggested that ADPKD patients display a greater incidence of diabetes mellitus posttransplantation; ADPKD emerged as an independent predictor for this complication.     

A Novel Experience in Living Donor Renal Transplantation: Voluntary Exchange Kidney Transplantation

Organ supply is an important problem worldwide with an ever-increasing number of patients on the waiting lists. Various strategies are implemented in the centers to increase the number of transplantations. Paired kidney exchange or nondirected organ donation to an exchange list is being performed for a while. However, the number of renal transplantations has failed to achieve the targeted levels. The present study aimed to provide information regarding 1-year outcomes of voluntary exchange kidney transplantation, which is performed in our center, and to raise awareness about the method. Compatible donor–recipient pairs and ABO-mismatched donor–recipient pairs were invited to participate in the model of voluntary exchange kidney transplantation. Of 42 donor–recipient pairs fulfilling the criteria, 22 (52.4%) accepted to participate in the model. In 4 of these 22 donor–recipient pairs, patients received a kidney transplant from their own donor due to the lack of another suitable donor on the waiting list. Thus, the remaining 18 donor–recipient pairs were included in the model of voluntary exchange kidney transplantation. Sixteen two-way, 1 three-way, and 1 four-way exchange kidney transplantations were performed. Thus, this provided 21 more patients an opportunity to have a renal transplant. Accordingly, the number of living donor transplantations performed in our center increased by 6.1% using this method. We anticipate that the number of patients on the waiting lists for transplantation would be decreased by the widespread use of voluntary exchange kidney transplantation.     

Combined Heart and Kidney Transplantation: A 23-Year Experience

Background

We report clinical experience with combined heart and kidney transplantation (HKTx) over a 23-year time period.

Kidney Transplantation Using Elderly Non-Heart-Beating Donors: A Single-Center Experience

Although acceptable outcomes have been reported in both non-heart-beating (NHB) and elderly donors individually, the large pool of elderly NHB donors has not yet been fully utilized. In 1994, we expanded our transplant protocol to include NHB donors aged over 65 years and this study compares the clinical outcomes with regular NHB transplantations. Up to June 2005, 24 patients were transplanted at our center with kidneys from NHB donors aged 65 years or more, whereas 176 patients received grafts from conventional NHB donors during the same period. Grafts from older donors were associated with inferior glomerular filtration rates (29 vs. 44 mL/min after 1 year, p = 0.01) and graft survival (52% vs. 68% after 5 years, p = 0.19) compared to younger NHB donor grafts, although the difference in graft survival was not statistically significant. Exclusion of older NHB donor kidneys with severe vascular pathology resulted in similar graft survival of older and younger NHB donor kidneys. We conclude that the use of elderly NHB donors in order to expand the donor pool was associated with unacceptable clinical outcomes and cannot be justified without further refinement in their selection, for example, by histological assessment of pretransplant biopsies.     

Outcomes of Paired-Exchange Live-Donor Kidney Transplantation: A Single-Center Experience

IntroductionPaired-exchange kidney transplantation (PEKT) enables recipients with willing but incompatible donors to find potential matches from a larger pool of donors. It involves transportation of donor kidneys to the intended recipient with a consequent increase in the cold ischemia time (CIT).Patients and MethodsOur single-center study compared the outcomes of PEKT versus traditional in-center live-donor kidney transplants (ICKT). Retrospective chart review of adult patients who underwent PEKT and ICKT from January 2009 to February 2012 at our institution was performed. Delayed graft function, acute rejection rates, incidence of proteinuria, trends in serum creatinine, and graft and patient survival rates were compared between groups.ResultsBaseline demographic data were similar between the PEKT group (n = 15) and the ICKT group (n = 30) except that CIT (13.1 vs 3.8 hours; P < .001) and panel reactive antibody titers (12.6% ± 22.9% vs 0.9% ± 4.9%; P = .01) were significantly higher in the PEKT group. No patient developed delayed graft function. At a median follow-up of 12.4 months (range: 2–27.5 months), graft and patient survival rates were 100% in both groups. Serial creatinine levels were similar between the groups. There were no significant differences between groups in acute rejection rates (3 of 15 vs 3 of 30) and development of proteinuria posttransplantation (8 of 15 vs 22 of 30).ConclusionsOur study found similar outcomes between the PEKT and ICKT groups despite longer CIT and higher panel reactive antibody titers in the PEKT group. These findings support the current practice of PEKT with transporting of donor kidneys, with the resultant increase in the chances of living-donor kidney transplantation.     

Kidney Transplantation From Circulatory Death Donors: Monocentric Experience

BackgroundDonation after circulatory death (DCD) is an accepted strategy to widen organ procurement worldwide. Authorized centers in Italy are spreading, increasing kidney transplantation (KTX) from DCD donors (40 in 2017 vs 24 in 2016). In this study, we describe DCD KTX activity at the University of Modena and Reggio Emilia (Modena, Italy) since its beginning in November 2017.MethodsWe retrospectively studied DCD KTX performed in our center from November 2017 to June 2018. We considered donor characteristics (age, sex, cause of death) and recipient clinical data (length of hospital stay, serum creatinine, estimated glomerular filtration rate, delayed graft function [DGF]), primary nonfunction [PNF], HLA match). All the grafts underwent in situ normothermic (ExtraCorporeal Membrane Oxygenation-ECMO) and ex situ hypothermic oxygenated perfusion (HOPE) with Kidney Assist machines. We monitored ex situ perfusion solution biochemical (lactate dehydrogenase [LDH] and lactate) and dynamic (resistance and flow) parameters. A kidney biopsy was performed for allocation strategy according to Karpinski score.ResultsWe performed 6 kidney transplants (3 single and 3 double); the mean recipient (57.5 ± 4.9) and donor age (57.3 ± 7.5) were similar. Mean ECMO duration was 3 h 27 ± 57 min, HOPE was 4 h 47 min ± 119 min, lactate sample values (collected every 15 minutes from the beginning of perfusion) were always lower than1.6 mmol/L, and LDH maximum value was 400 UI/L. Median cold ischemia time was 11 h 18 min. Mean Karpinski score was 3.6; mean HLA match 1.7.We experienced 1 DGF (16.6%), no PNF, with a mean hospital stay of 14.6 days, mean creatinine at hospital discharge 2 ± 1.04 mg/dL), and mean eGFR 53.8 ±27.3 mL/min); at 1 month, mean creatinine and eGFR were 2 ± 1.34 mg/dL and 59.8 ± 24.5 mL/min, respectively.ConclusionsDCD is a promising resource for increasing organ donation. The Emilia Romagna regional organization allowed short ischemia times, with solid KTX outcomes, supporting further development of this program.     

Late Ureteral Stenosis After Kidney Transplantation: A Single-Center Experience

In a retrospective study, we analyzed 1419 consecutive kidney transplantation procedures performed at a single center to identify potential predictive factors of ureteral stenosis. Only stenosis observed after the first month posttransplantation was considered. The Cox proportional hazard regression model was used to analyze donor age and serum creatinine concentration before procurement, recipient age, cold ischemia time, delayed graft function, number of renal arteries, and presence of a double-J stent. Follow-up evaluation included number and timing of acute rejection episodes, cytomegalovirus infection, acute pyelonephritis, renal function, and patient death. Ureteral stenosis developed in 45 patients (3.17%), and was correlated with donor age older than 65 years (P = .001), kidneys with more than 2 arteries (P = .009), and delayed graft function (P = .02). The data suggest a potential protective role of donor age, number of renal arteries, and delayed graft function in development of ureteral stenosis after kidney transplantation.