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Mang J, Haag J, Liefeldt L, Budde K, Peters R, Hofbauer SL, Schulz M, Weinberger S, Dagnæs-Hansen J, Maxeiner A, Ralla B, Friedersdorff F. Transplant nephrectomy: indication, surgical approach and complications-experiences from a single transplantation center. World J Urol 2024; 42:120. [PMID: 38446250 PMCID: PMC10917844 DOI: 10.1007/s00345-024-04884-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Accepted: 02/12/2024] [Indexed: 03/07/2024] Open
Abstract
PURPOSE Management of a failed kidney allograft, and the question whether it should be removed is a challenging task for clinicians. The reported risks for transplant nephrectomy (TN) vary, and there is no clear recommendation on indications or surgical approach that should be used. This study gives an overview of indications, compares surgical techniques, and identifies risk factors for higher morbidity. METHODS Retrospective analysis was conducted on all transplant nephrectomies performed between 2005 and 2020 at Charité Hospital Berlin, Department of Urology. Patient demographics, laboratory parameters, graft survival data, indication for TN, and surgical complications were extracted from medical reports. RESULTS A total of 195 TN were performed, with graft intolerance syndrome being the most common indication in 52 patients (26.7%), acute rejection in 36 (18.5%), acute infection in 30 (15.4%), and other reasons to stop immunosuppression in 26 patients (13.3%). Rare indications were vascular complications in 16 (8.2%) and malignancies in the allograft in six (3.1%) cases. Extracapsular surgical approach was significantly more often used in cases of vascular complications and earlier allograft removal, but there was no difference in complication rates between extra- and intracapsular approach. Acute infection was identified as an independent risk factor for a complication grade IIIb or higher according to Clavien-Dindo classification, with a HR of 12.3 (CI 2.2-67.7; p = 0.004). CONCLUSION Transplant nephrectomy should only be performed when there is a good indication, and non-elective surgery should be avoided, when possible, as it increases morbidity.
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Affiliation(s)
- Josef Mang
- Department of Urology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
| | - Josephine Haag
- Department of Urology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
| | - Lutz Liefeldt
- Department of Nephrology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Klemens Budde
- Department of Nephrology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Robert Peters
- Department of Urology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
| | - Sebastian L Hofbauer
- Department of Urology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
| | - Matthias Schulz
- Department of Urology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
| | - Sarah Weinberger
- Department of Urology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
| | - Julia Dagnæs-Hansen
- Urologic Research Unit, Department of Urology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Andreas Maxeiner
- Department of Urology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
| | - Bernhard Ralla
- Department of Urology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
| | - Frank Friedersdorff
- Department of Urology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany.
- Department of Urology, Evangelisches Krankenhaus Königin Elisabeth Herzberge, Berlin, Germany.
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2
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Budhiraja P, Nguyen M, Heilman R, Kaplan B. The Role of Allograft Nephrectomy in the Failing Kidney Transplant. Transplantation 2023; 107:2486-2496. [PMID: 37122077 DOI: 10.1097/tp.0000000000004625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
Patients with failed renal allografts have associated increased morbidity and mortality. The individualization of immunosuppression taper is the key element in managing these patients to avoid graft intolerance and sensitization while balancing the risk of continued immunosuppression. Most patients with uncomplicated chronic allograft failure do not require allograft nephrectomy (AN), and there is no clear evidence that it improves outcomes. The AN procedure is associated with variable morbidity and mortality. It is reserved mainly for early technical graft failure or in symptomatic cases associated with allograft infection, malignancy, or graft intolerance syndrome. It may also be considered in those who cannot tolerate immunosuppression and are at high risk for graft intolerance. AN has been associated with an increased risk of sensitization due to inflammatory response from surgery, immunosuppression withdrawal with allograft failure, and retained endovascular tissue. Although it is presumed that for-cause AN after transplant failure is associated with sensitization, it remains unclear whether elective AN in patients who remain on immunotherapy may prevent sensitization. The current practice of immunosuppression taper has not been shown to prevent sensitization or increase infection risk, but current literature is limited by selection bias and the absence of medication adherence data. We discuss the management of failed allografts based on retransplant candidacy, wait times, risk of graft intolerance syndrome, and immunosuppression side effects. Many unanswered questions remain, and future prospective randomized trials are needed to help guide evidence-based management.
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Affiliation(s)
| | | | | | - Bruce Kaplan
- Department of Medicine, Colorado Center for Transplantation Care, Research and Education (CCTCARE), University of Colorado, Aurora, CO
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3
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Gunawardena T, Ridgway D. Transplant Nephrectomy: Current Concepts. SAUDI JOURNAL OF KIDNEY DISEASES AND TRANSPLANTATION 2022; 33:716-725. [PMID: 37955463 DOI: 10.4103/1319-2442.389431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023] Open
Abstract
Kidney transplantation is the gold standard treatment option for patients with endstage kidney disease. As the number of waitlisted patients increases, the gap between supply and demand for suitable donor kidneys keeps widening. The adoption of novel strategies that expand the donor pool has attenuated this issue to a certain degree, and this has led to a progressive increase in the number of annual transplants performed. As transplanted kidneys have a finite lifespan, there is a reciprocal rise in the number of patients who return to dialysis once their allograft fails. The clinicians involved in the management of such patients are left with the problem of managing the nonfunctioning allograft. The decision to undertake transplant nephrectomy (TN) in these patients is not straightforward. Allograft nephrectomy is a procedure that is associated with significant morbidity and mortality. It will have implications for the outcomes of the subsequent transplant. In this review, we aimed to compressively discuss the indications, techniques, and outcomes of TN, which is an integral component of the management of a failing allograft.
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Affiliation(s)
- Thilina Gunawardena
- Department of Renal Transplant, Royal Liverpool University Hospital, Liverpool, United Kingdom
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4
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Aikpokpo NV, Sharma A, Halawa A. Management of the Failing Kidney Transplant: Challenges and Solutions. EXP CLIN TRANSPLANT 2021; 20:443-455. [PMID: 34763628 DOI: 10.6002/ect.2021.0229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The kidneys are the most transplanted organs, and the number of failed kidney transplants that require reinstitution of renal replacement therapy in patients is on the increase. Increased mortality has been noted in patients with failed grafts compared with transplant- naïve patients with chronic kidney disease who are treated with dialysis. Issues such as management of immunosuppression, the need for transplant nephrectomy, addressing the increased risk of cardiovascular events, malignancies, and infections are debatable and often based on individual or hospital practices. The optimal timing and modality of renal replacement therapy to be reinitiated are sometimes blurred, with considerable variations among physician practices. Guidelines are therefore needed to appropriately manage this special population of patients with the aim of improving outcomes. Here, our objective was to review the current practices in managing patients with failing kidney transplants so that recommendations can be made based on the available evidence.
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Affiliation(s)
- Ngozi Virginia Aikpokpo
- From the Institute of Health and Life Sciences, University of Liverpool, Liverpool, United Kingdom.,the Department of Internal Medicine, Babcock university Teaching Hospital, Ilisan, Ogun State, Nigeria
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Abdul-Muhsin HM, McAdams SB, Syal A, Nuñez-Nateras R, Navaratnam A, Moss AA, Hewitt WR, Singer AL, Jadlowiec CC, Harbell JW, Mathur AK, Reddy KS, Castle EP. Robot Assisted Renal Allograft Nephrectomy: Initial Case Series and Description of Technique. Urology 2020; 146:118-124. [PMID: 33091385 DOI: 10.1016/j.urology.2020.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 09/27/2020] [Accepted: 10/06/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate the outcomes and perioperative complication rates following robot- assisted transplant nephrectomy ((RATN). METHODS All patients who underwent RATN at our institution were included. No exclusion criteria were applied. Clinical records were retrospectively reviewed and reported. This included preoperative, intraoperative, and postoperative outcomes. Complications were reported utilizing the Clavien-Dindo classification system. Descriptive statistics were reported using frequencies and percentages for categorical variables, means and standard deviation for continuous variables. RESULTS Between July 2014 and April 2018, 15 patients underwent RATN. Most patients had the transplant in the right iliac fossa (13/15). Ten patients underwent a concomitant procedure. The total operative time for the entire cohort was 336 (±102) minutes (including cases who had concomitant procedures) and 259 (±46 minutes) when cases with concomitant procedures were excluded. Mean estimated blood loss was 383 (±444) mL. Postoperatively, 3 patients required blood transfusion. Average hospital stay was 4 (±2.7) days. Most patients had finding consistent with graft rejection on final pathology. There were 5 complications; 3 of which were minor (grade 2 = 2 and grade 3 = 1); one patient had a wound infection requiring dressing (3A) and one patient died due to pulmonary embolism following discharge. Limitations include small series and retrospective nature of the study. CONCLUSION This case series demonstrate that RATN is technically feasible. With continued experience and larger case series, the robotic approach may provide a minimally invasive alternative to open allograft nephrectomy.
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Affiliation(s)
| | | | - Amit Syal
- Mayo Clinic Arizona, Department of Urology, Phoenix, AZ
| | | | | | - Adyr A Moss
- Mayo Clinic Arizona, Department of Transplantation, Phoenix, AZ
| | | | - Andrew L Singer
- Mayo Clinic Arizona, Department of Transplantation, Phoenix, AZ
| | | | - Jack W Harbell
- Mayo Clinic Arizona, Department of Transplantation, Phoenix, AZ
| | - Amit K Mathur
- Mayo Clinic Arizona, Department of Transplantation, Phoenix, AZ
| | - Kunam S Reddy
- Mayo Clinic Arizona, Department of Transplantation, Phoenix, AZ
| | - Erik P Castle
- Mayo Clinic Arizona, Department of Urology, Phoenix, AZ
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Chowaniec Y, Luyckx F, Karam G, Glemain P, Dantal J, Rigaud J, Branchereau J. Transplant nephrectomy after graft failure: is it so risky? Impact on morbidity, mortality and alloimmunization. Int Urol Nephrol 2018; 50:1787-1793. [PMID: 30120679 DOI: 10.1007/s11255-018-1960-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 08/09/2018] [Indexed: 01/09/2023]
Abstract
PURPOSE To determine the impact of transplant nephrectomy on morbidity and mortality and HLA immunization. METHODS All patients who underwent transplant nephrectomy in our centre between 2000 and 2016 were included in this study. A total of 2822 renal transplantations and 180 transplant nephrectomies were performed during this period. RESULTS The indications for transplant nephrectomy were graft intolerance syndrome: 47.2%, sepsis: 22.2%, vascular thrombosis: 15.5%, tumour: 8.3% and other 6.8%. Transplant nephrectomies were performed via an intracapsular approach in 61.7% of cases. The blood transfusion rate was 50%, the morbidity rate was 38% and the mortality rate was 3%. Transplant nephrectomies more than 12 months after renal transplant failure were associated with more complications (p = 0.006). Transfusions in the context of transplant nephrectomy had no significant impact on alloimmunization. CONCLUSION The risk of bleeding, and therefore of transfusion, constitutes the major challenge of this surgery in patients eligible for retransplantation. Even if transfusions in this context of transplant nephrectomy had no significant impact on alloimmunization, this high-risk surgery, whenever possible, must be performed electively in a well-prepared patient.
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Affiliation(s)
- Y Chowaniec
- Institut of Transplantation, Urology and Nephrology (ITUN), CHU Nantes, 30 Bd Jean Monnet, 44035, Nantes, France
| | - F Luyckx
- Service d'Urologie, Hôpital de la Roche sur Yon, La Roche sur Yon, France
| | - G Karam
- Institut of Transplantation, Urology and Nephrology (ITUN), CHU Nantes, 30 Bd Jean Monnet, 44035, Nantes, France
| | - P Glemain
- Institut of Transplantation, Urology and Nephrology (ITUN), CHU Nantes, 30 Bd Jean Monnet, 44035, Nantes, France
| | - J Dantal
- Institut of Transplantation, Urology and Nephrology (ITUN), CHU Nantes, 30 Bd Jean Monnet, 44035, Nantes, France
| | - J Rigaud
- Institut of Transplantation, Urology and Nephrology (ITUN), CHU Nantes, 30 Bd Jean Monnet, 44035, Nantes, France
| | - J Branchereau
- Centre de Recherche en Transplantation et Immunologie UMR 1064, INSERM, Université de Nantes, Nantes, France. .,Institut of Transplantation, Urology and Nephrology (ITUN), CHU Nantes, 30 Bd Jean Monnet, 44035, Nantes, France.
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7
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Li B, Kirshenbaum EJ, Patel P, Gorbonos A. Pushing Boundaries: Robotic Nephrectomy of an Auto-transplanted Kidney for Recurrent Renal Cell Carcinoma. Cureus 2018; 10:e2280. [PMID: 29736363 PMCID: PMC5935431 DOI: 10.7759/cureus.2280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Advances in robotic technology continue to expand the boundaries of minimally invasive approaches in transplant surgery. A single report has previously described the use of the robotic approach in transplant nephrectomy for a failed allograft. Our objective is to describe our technique and experience for the first reported robotic nephrectomy of an auto-transplanted solitary kidney for a recurrence of renal cell carcinoma (RCC). We highlight technical considerations during allograft mobilization and hilum dissection with the additional demands of a previously operated auto-transplant kidney.
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Affiliation(s)
- Belinda Li
- Urology, Loyola University Chicago, Stritch School of Medicine, Maywood, Illinois
| | - Eric J Kirshenbaum
- Urology, Loyola University Chicago, Stritch School of Medicine, Maywood, Illinois
| | - Parth Patel
- Urology, Loyola University Chicago, Stritch School of Medicine, Maywood, Illinois
| | - Alex Gorbonos
- Urology, Loyola University Chicago, Stritch School of Medicine, Maywood, Illinois
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8
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Stiegler P, Schemmer P. Robot-Assisted Transplant Surgery - Vision or Reality? A Comprehensive Review. Visc Med 2018; 34:24-30. [PMID: 29594166 DOI: 10.1159/000485686] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Minimally invasive surgery is standard procedure for many operations. Further refinements include the introduction of robotic surgery which is still an emerging field especially in laparoscopic surgery. Since the successful introduction of the da Vinci Robotic Surgical System, the robotic approach in organ transplantation has become of great interest in both the live donor organ retrieval and the recipient operation. Robotic surgery for kidney, liver, and pancreas transplantation is feasible. Over 700 donor nephrectomies and 100 kidney transplantations have been performed already, and robotic surgery is standard in a small number of pioneer centers; however, larger series and most importantly randomized controlled trials for the highest evidence are needed. Longer warm ischemia time and higher costs limit these procedures at the moment.
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Affiliation(s)
- Philipp Stiegler
- Division of Transplant Surgery, Department of Surgery, Medical University of Graz, Graz, Austria.,Transplant Center Graz, Medical University of Graz, Graz, Austria
| | - Peter Schemmer
- Division of Transplant Surgery, Department of Surgery, Medical University of Graz, Graz, Austria.,Transplant Center Graz, Medical University of Graz, Graz, Austria
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9
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Levi Sandri GB, de Werra E, Mascianà G, Guerra F, Spoletini G, Lai Q. The use of robotic surgery in abdominal organ transplantation: A literature review. Clin Transplant 2016; 31. [PMID: 27726195 DOI: 10.1111/ctr.12856] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2016] [Indexed: 12/13/2022]
Affiliation(s)
- Giovanni B. Levi Sandri
- Division of General Surgery and Liver Transplantation; San Camillo Hospital; Rome Italy
- Department of Surgical Sciences; Sapienza University of Rome; Rome Italy
| | - Edoardo de Werra
- Division of General Surgery and Liver Transplantation; San Camillo Hospital; Rome Italy
| | - Gianluca Mascianà
- Division of General Surgery and Liver Transplantation; San Camillo Hospital; Rome Italy
| | - Francesco Guerra
- Division of Oncological and Robotic General Surgery; Careggi University Hospital; Florence Italy
| | - Gabriele Spoletini
- Department of HPB and Liver Transplant Surgery; Royal Free Hospital; London UK
| | - Quirino Lai
- Transplant Unit; Department of Surgery; University of L'Aquila; San Salvatore Hospital; L'Aquila Italy
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