Donor kidney microthrombi and outcomes of kidney transplant: a single‐center experience

The kidney wait list has outgrown the supply of available organs every year. Efforts are being made to minimize discard rate of organs. One such area is the use of kidneys with glomerular microthrombi (MT). We retrospectively examined graft/patient outcomes in 28 cases with MT in pre‐implantation biopsies. All patients had follow‐up of at least 36 months, or until graft loss or death. In total, 17 of the 18 patients who underwent follow‐up biopsy within 90 days of transplantation had cleared all MT. Most patients had excellent long‐term graft function. On a closer review of the biopsies included in our study, we found that even in the organs with the most widespread thrombosis, the median percentage of glomeruli with more than 50 percentage of the capillary loops occluded was 8% (range 0–17%). The current practice of mentioning the % of glomeruli with thrombi cannot adequately capture the extent of donor organ pathology, as the actual % glomerular area involved can vary greatly from case to case. Future studies should attempt to quantify donor thrombi by a more robust method and revisit the issue of using clinico‐pathologic parameters to predict allograft function in the setting of MT.     

Long-term outcomes of dual kidney transplantation—a single center experience

Abstract:  The shortage of kidney donors has led to broadening of the acceptance criteria for deceased donor organs beyond the traditional use of young donors. We determined long-term post-transplant outcomes in recipients of dual expanded criteria donor kidneys (dECD, n = 44) and compared them to recipients of standard criteria donor kidneys (SCD, n = 194) and single expanded criteria donor kidneys (sECD, n = 62). We retrospectively reviewed these 300 deceased donor kidney transplants without primary non-function (PNF) or death in the first two wk, at our center from 1996 to 2003. The three groups were similar in baseline characteristics. Kidney allograft survival and patient survival (nine yr) were similar in the three respective donor groups, SCD, sECD and dECD (60% vs. 59% vs. 64% and 82% vs. 73% vs. 73%). Acute rejection in the first three months was 23.2%, 16.1%, and 22.7% in SCD, sECD and dECD, respectively (p = 0.49) and delayed graft function was 25.2%, 31.9% and 17.1% in the three groups, respectively (p = 0.28). When PNF and death within the first two wk was included, there was no significant difference in graft survival between the three groups. In our population, recipients of dECD transplants have acceptable patient and graft survival with kidneys that would have usually been discarded.     

Safety of dual kidney transplantation compared to single kidney transplantation from expanded criteria donors: a single center cohort study of 39 recipients

Our objective was to compare the outcomes of dual kidney transplanataion (DKT) to single kidney transplantation (SKT) performed with grafts from expanded criteria donors (ECD) in recipients ≥65 years, focusing on surgical complications. All kidney transplantations (KT) performed between 2006 and 2014 in our institution were analysed. DKT was indicated according to the criteria of the French national Agence de la Biomedecine. Thirty‐nine DKT and 155 SKT were included, with a median follow‐up of 36 and 26.5 months, respectively. The rate of early surgical revisions was not significantly higher after DKT (23.1% vs 15.5% (P = 0.2593)) but more venous graft thromboses (12.8% vs 3.2% (P = 0.02)) were reported. The glomerular filtration rate (GFR) 24 months after KT was significantly higher after DKT (45.0 ± 16.3 vs 39.8 ± 13.8 ml/min/1.73m²; P = 0.04) and allowed shorter waiting time without a significant increased risk of surgical revision, excepted for venous graft thrombosis, more frequent after DKT. Graft survivals were not significantly different and GFR was higher after DKT. DKT seems to remain an appropriate strategy to address the growing graft shortage in elderly patients.     

Malignancies after kidney transplantation: a 40‐year single‐center experience in Korea

Cancer is a well‐recognized complication of kidney transplantation (KT), but nearly almost all data have come from Western countries. The aim of this study was to determine the incidence, type, and risk factors of malignancy after KT in Korea. The 1695 patients who underwent KT between 1969 and 2009 were studied retrospectively. Results were compared with a cohort of patients without cancer from the same center. During the follow‐up period, 136 of 1695 patients developed 141 post‐transplant malignancies (PTM). The cumulative incidence of cancer at 1, 5, 10, 20, and 30 years was 0.64%, 2.42%, 7.89%, 21.49%, and 66.35% respectively. Stomach cancer was the most common PTM. Risk of Kaposi sarcoma, malignant lymphoma, skin cancer, cervical cancer, and renal cell carcinoma was more than 10‐times higher in KT recipients. Multivariate logistic regression analysis showed that cancers were clearly associated with recipients’ age, recipients’ gender, duration of graft function and follow‐up period. Our data suggest that most malignancies develop more frequently after KT, but the incidence of individual cancer is different from Western countries. A more vigorous cancer surveillance program should be adapted to risk associated with transplant recipients, especially older, female or long‐term follow‐up recipients or those with functioning grafts.     

New surgical technique for pediatric en‐bloc kidney and pancreas transplantation: the pancreas piggy‐back

Combined pancreas and kidney transplantation is the therapy of choice for type I diabetes patients with associated end‐stage renal disease. To counterbalance increasing waiting lists, there is a clear need to extend the organ donor pool. Although results following simultaneous pancreas and kidney transplantation (SPK) using pediatric organs are encouraging, there is still reluctance in accepting them. This reflects the fear of graft thrombosis and graft failure because of small vessels and little absolute islet cell mass. Simpler transplant techniques for pediatric SPK might lower this threshold. In this article, a novel technique using a “piggy‐back” implantation of the pancreas onto the conduits of en‐bloc grafted kidneys, performed in two consecutive cases, is presented. This technique is associated with less vascular manipulation, requiring only one arterial anastomosis onto the frequently arteriosclerotic arteries of the recipient for all three organs. One‐year follow‐up (14 and 12 months) proved excellent graft function of kidneys and pancreas.     

Single‐center experience with third and fourth kidney transplants

Kidney retransplantation is often associated with a higher immunological risk than is primary renal transplantation. Faced with increasing organ shortage and growing waiting lists, results of kidney retransplantation are of particular interest. Fifty‐six third and fourth kidney transplants were analyzed retrospectively. Parameters included patient and donor demographics, operative details, incidence of surgical, immunological and infectious complications and patient and graft survival. Patients receiving third kidney grafts had 1‐ and 5‐year patient/graft survival rates of 97.4%/72.9% and 88.9%/53.6%, respectively. Episodes of acute rejection and delayed graft function were observed in 44% and 49% of these patients. Fourth kidney transplantation was associated with 1‐ and 2‐year patient/graft survival rates of 84.8%/68.5% and 63.6%/47%, respectively. Acute rejection and delayed graft function occurred in 33% and in 60% of cases. Acceptable patient and graft survival may be achieved after third and fourth kidney transplantation. Graft losses in this sensitized population are mainly because of rejection. Profound immunosuppression may lead to major infectious problems.     

Retroperitoneoscopic live‐donor nephrectomy: 5‐year single‐center experience in China

Objective: To evaluate the efficacy and the learning‐curve period of our modified retroperitoneoscopic live‐donor nephrectomy. Methods: From December 2003 to May 2009, 138 consecutive retroperitoneoscopic live‐donor nephrectomies were carried out at our institution. Donors were separated into four groups in consecutive sequence in order to determine the learning‐curve period. Groups 1–3 included forty consecutive cases each, whereas group 4 included the last eighteen cases. The renal artery and vein were controlled with two plastic locking clips at proximal ends without any clips on the kidney side. The kidney was manually retrieved through lumbar incision. Results: Mean operative times were 160.5, 116.9, 101.4 and 109.2 min in groups 1–4, respectively (group 1 vs group 2, 3 or 4, P < 0.01). Mean warm ischemic time was 3.5 min. Mean estimated blood loss was 88.8, 73.0, 69.3 and 43.9 mL in groups 1–4, respectively (group 1 vs group 4, P < 0.01). No blood transfusion or open conversion was required. Mean hospital stay was 7.8, 6.9, 6.6 and 5.8 days in groups 1–4, respectively (group 1 vs group 4, P < 0.05). Eight donors and seven grafts suffered from complications. Complication rates were 22.5%, 7.5%, 5.0% and 6.0% in groups 1–4, respectively (group 1 vs group 3, P < 0.05). Conclusion: Our modified retroperitoneoscopic live‐donor nephrectomy can be carried out safely with a learning‐curve period of about 40 cases.     

Vascular reconstruction in monolateral dual kidney transplantation with multiple arteries

We report the results of monolateral dual kidney transplantation with grafts with multiple arteries. Among the 42 monolateral DKT performed in a seven-yr period, 12 (28.5%) patients received renal grafts with multiple arteries. In six patients, the accessory arteries were anastomosed end-to-side or side-to-side on the aortic patch. In six patients, with three or more accessory arteries, a vascular reconstruction with an inferior vena cava patch was performed, before implanting the kidney. There were no intraoperative complications in the entire series, and there were no immediate vascular complications. Vascular reconstruction of kidneys with multiple arteries may be performed safely even in monolateral dual kidney transplantation. Inferior vena cava may be an attractive alternative in vascular reconstruction for kidneys with multiple arteries.     

Phase I study of single‐dose pharmacokinetics and pharmacodynamics of belatacept in adolescent kidney transplant recipients

Belatacept is an intravenously infused selective T cell costimulation blocker approved for preventing organ rejection in renal transplant recipients aged ≥18 years. This phase I trial examined the pharmacokinetics and pharmacodynamics (percentage CD86 receptor occupancy [%CD86RO]) of a single dose of belatacept (7.5 mg/kg) administered to kidney transplant recipients aged 12‐17 years receiving a stable calcineurin inhibitor–based immunosuppressive regimen. Nine adolescents (mean age 15.1 years) who were seropositive for Epstein‐Barr virus were enrolled; all completed the 6‐month study. Pharmacokinetics suggested relatively low variability of exposure (coefficients of variation for maximum observed serum concentration [C_max] and area under the serum concentration‐time curve from time zero extrapolated to infinity [AUC_0‐INF] were 20% and 25%, respectively). Mean half‐life (T_1/2) occurred 7.2 days postinfusion. Belatacept total body clearance was 0.48 mL/h/kg, and volume of distribution at steady‐state (V_ss) was low at 0.09 L/kg. Compared with historical data from healthy adult volunteers administered a single dose of belatacept 10 mg/kg and adult kidney transplant recipients administered multiple doses of belatacept 5 mg/kg, pharmacokinetic values for adolescents were similar, indicating consistency across adolescent and adult populations. Mean %CD86RO increased with increasing belatacept concentration, indicating a direct relationship between pharmacokinetics and pharmacodynamics. Four patients reported 7 serious adverse events; none was considered related to belatacept. These data will inform belatacept dose selection in future studies of adolescent kidney transplant recipients.     

Monolateral placement of both kidneys in dual kidney transplantation: low surgical complication rate and short operating time.

Dual kidney transplantation (DKT) from marginal donors is increasingly used at many centers to help cope with the organ shortage problem. The disadvantages of DKT consist in longer operating times and the risk of surgical complications. DKT can be performed in two ways, i.e. using monolateral or bilateral procedures. From October 1999 to June 2005, 58 DKTs were performed at our unit. In 29 cases (group I), the kidneys were extraperitoneally placed bilaterally in the iliac fossae via two separate incisions; as of June 2003, monolateral kidney placement was preferred in 29 cases, whenever compatible with the recipient's morphological status (group II). After a mean follow-up of 51 +/- 19 months for group I and 15 +/- 7 months for group II, all patients are alive with 1-year graft survival rates of 93% and 96%, respectively. Mean operating times were 351 +/- 76 min in group I and 261 +/- 31 min in group II (P = 0.0001). The mean S-creatinine levels in groups I and II were 132 +/- 47 and 119 +/- 36 mumol/l, respectively, at 1 year. We observed eight surgical complications in group I and seven in group II. Both techniques proved safe, with no differences in surgical complication rates. The monolateral procedure has the advantage of a shorter operating time and the contralateral iliac fossa remains available for further retransplantation procedures.     

Nontraditional sites for vascular anastomoses to enable kidney transplantation in patients with major systemic venous thromboses

Successful renal transplantation requires low‐pressure venous drainage to permit adequate outflow from the allograft. We report here a series of three patients in whom the inferior vena cava as well as bilateral iliac veins were thrombosed, making it necessary to explore less traditional vessels for venous drainage of the renal allograft. We utilized the splanchnic vasculature in two cases and the native left renal vein in another. The resulting atypical intra‐abdominal locations of these allografts also presented difficulties for arterial anastomoses and for urinary drainage. Arterial conduits were utilized in two cases to facilitate anastomosis to the common iliac artery or the aorta, and in the third case, the splenic artery was used for arterial inflow. A traditional ureterocystostomy was technically feasible for only one patient. In another, ureteroureterostomy to the native ureter was performed, and in the third case, the creation of an ileal conduit was necessary. All three patients had antibodies to human leukocyte antigens and two required desensitization. All three kidneys had immediate graft function and continued to function at 1 year post‐transplant. With a combination of planning, creativity, and persistence, patients with IVC thrombosis can enjoy the benefits of renal transplantation.     

Association of donor hypertension and recipient renal function in living donor kidney transplantation: A single‐center retrospective study

Transplant centers now accept living donors with well‐controlled hypertension. Little is known whether hypertension in living donors affects recipient's kidney function. We aimed to examine potential differences in kidneys from hypertensive donors compared to normotensive donors with respect to renal function over 36 months and histologic findings at transplantation (T0) and 12 months after transplantation (T1). Retrospective single‐center analysis of 174 living donor‐recipient pairs (age > 18; transplantation date 1/2008‐3/2016). Hypertension in donors was defined as being on antihypertensive medication. All biopsies were assessed by the same blinded, experienced renal pathologist. Biopsies were scored for glomerulosclerosis, IFTA, and arteriosclerosis. Regression models were used to examine the relationship of donor hypertension with renal function and histologic changes. Hypertensive donors were significantly older than normotensive donors. Chronic changes such as tubular atrophy and atherosclerosis were more evident in kidneys from hypertensive donors at T0 as well as T1. Donor hypertension was independently associated with histologic changes at T0 and T1 but not with renal function over the follow period. Despite more pronounced histologic changes in kidneys from hypertensive living donors, these grafts exhibited a similar functional outcome. However, they subsequently might be at a greater risk and warrant thorough follow‐up care.     

Panniculectomy at the time of living donor renal transplantation: An 8‐year experience

Panniculectomy can be performed as a prophylactic procedure preceding transplantation to enable obese patients to meet criteria for renal transplantation. No literature exists on combined renal transplant and panniculectomy surgery (LRT‐PAN). We describe our 8‐year experience performing LRT‐PAN. A retrospective chart review of all patients who had undergone LRT‐PAN from 2010 to 2018 was conducted. Data were collected on patient demographics, allograft survival and function, and postoperative course. Fifty‐eight patients underwent LRT‐PAN. All grafts survived, with acceptable function at 1 year. Median length of stay was 4 days with a mean operative duration of 363 minutes. The wound complication rate was 24%. Ninety‐day readmission rate was 52%, with medical causes as the most common reason for readmission (45%), followed by wound (32%) and graft‐related complications (23%). Body mass index, diabetes status, and previous immunosuppression did not influence wound complication rate or readmission (P = .7720, P = .0818, and P = .4830, respectively). Combining living donor renal transplant and panniculectomy using a multidisciplinary team may improve access to transplantation, particularly for the obese and postobese population. This combined approach yielded shorter‐than‐expected hospital stays and similar wound complication rates, and thus should be considered for patients in whom transplantation might otherwise be withheld on the basis of obesity.     

The Stockholm experience with ABO-incompatible kidney transplantations without splenectomy

BACKGROUND: ABO-incompatible kidney transplantations have previously only been performed after several pre-operative sessions of plasmapheresis followed by splenectomy, and with the conventional triple-drug immunosuppressive protocol being reinforced with anti-lymphocyte globulin and B-cell-specific drugs. We have designed a protocol without splenectomy, based on antigen-specific immunoadsorption, rituximab and a conventional triple-drug immunosuppressive protocol. METHODS: The protocol called for a 1-month pre-transplantation conditioning period, starting with one dosage of rituximab and followed by full-dose tacrolimus, mycophenolate mofetil and prednisolone. Antigen-specific immunoadsorption was performed on pre-transplantation days -6, -5, -2 and -1. After the last session, 0.5 g/kg of intravenous immunoglobulin (IVIG) was administered. Postoperatively, three more apheresis sessions were given every third day. RESULTS: Twenty-one patients have received transplants with this protocol. The ABO-antibodies (Abs) were readily removed by the antigen-specific immunoadsorption and were kept at a low level post-transplantation by further adsorptions. There were no side effects, and all but one patient have normal renal transplant function. CONCLUSIONS: We conclude that after one infusion each of rituximab and IVIG, and antigen-specific immunoadsorption, blood-group incompatible renal transplantations can be performed with standard immunosuppression and without splenectomy, and with excellent short- and long-term results.     

Robotic kidney transplantation in the obese patient: 10‐year experience from a single center

Despite increasing obesity rates in the dialysis population, obese kidney transplant candidates are still denied transplantation by many centers. We performed a single‐center retrospective analysis of a robotic‐assisted kidney transplant (RAKT) cohort from January 2009 to December 2018. A total of 239 patients were included in this analysis. The median BMI was 41.4 kg/m², with the majority (53.1%) of patients being African American and 69.4% of organs sourced from living donors. The median surgery duration and warm ischemia times were 4.8 hours and 45 minutes respectively. Wound complications (mostly seromas and hematomas) occurred in 3.8% of patients, with 1 patient developing a surgical site infection (SSI). Seventeen (7.1%) graft failures, mostly due to acute rejection, were reported during follow‐up. Patient survival was 98% and 95%, whereas graft survival was 98% and 93%, at 1 and 3 years respectively. Similar survival statistics were obtained from patients undergoing open transplant over the same time period from the UNOS database. In conclusion, RAKT can be safely performed in obese patients with minimal SSI risk, excellent graft function, and patient outcomes comparable to national data. RAKT could improve access to kidney transplantation in obese patients due to the low surgical complication rate.     

The results of 1009 kidney transplantations performed in Hungary

Kidney transplantation is a widely used method throughout the world for the treatment of end-stage renal disease. Following the pioneering work of Szeged Medical University Hospital and Miskolc District General Hospital, the first successful kidney transplantation in Hungary was performed at the Department of Transplantation and Surgery at Semmelweis Medical University on November 16, 1973. This patient is still alive with a functioning kidney graft after 21 years. We report herein our review of the global results of Hungarian kidney transplantation. Hungary is a medium-developed country with a population of over 10 million where the gross national product is about 4000 U.S. dollars per person per year. In Hungary there are 49 dialysis centers, 4 immunological laboratories, and 4 transplantation centers.