Combined spinal-epidural anesthesia for renal transplant in a lung transplant recipient: a case report

A 67-year-old lung transplant recipient with severe comorbidities was admitted for renal transplant. As anesthesia technique, combined spinal-epidural at the T11-T12 level was chosen, associated with intravenous sedation. Graft's function initially results altered, bringing to pulmonary fluid overload. Beginning from the postoperative day 5 there was a slow but constant gain-of-function of the graft, proven by an improvement of renal function indexes and by the resolution of the pulmonary edema. Conclusions: Whereas general anesthesia remains the gold standard anesthesia technique for kidney transplant, a locoregional anesthesia, could be a feasible and effective option in patients at high risk of respiratory complications. (www.actabiomedica.it).

Outcomes and surgical complications following living-donor renal transplantation using kidneys retrieved with trans-peritoneal or retro-peritoneal hand-assisted laparoscopic nephrectomy

The best minimally invasive procedure for living-donor kidney retrieval remains debated. Our objective was to assess trans-peritoneal (TP) and retro-peritoneal (RP) hand-assisted laparoscopic donor nephrectomy (HALDN). In this single-center retrospective study, we analyzed results from 317 living-donor renal transplants (RT) performed between 2008 and 2016. Donor and recipient outcomes were compared between TP-HALDN (n = 235) and RP-HALDN (n = 82). Conversion to open nephrectomy (0.4% vs 0%; P = 1.000), intra-operative complications (1.7% vs 1.2%; P = 1.000), and 1-year overall post-operative complications (11.9% vs 17.1%; P = .258) rates were similar in TP-HALDN and RP-HALDN. Overall surgical site infections were higher in RP-HALDN (6.1% vs 1.7%; P = .053), whereas incisional hernias were only recorded following TP-HALDN (3.4% vs 0%; P = .118). The duration of the procedure was 11-minute shorter for TP-HALDN than RP-HALDN (P < .001) but extraction time was equivalent (2, IQR 1.5-2.5 minutes; P = 1.000). RT following TP-HALDN and RP-HALDN showed comparable one-year death-censored allograft survival (97% vs 98.8%; P = .685), primary non-function (0.4% vs 0%; P = .290), delayed graft function (1.3% vs 4.9%; P = .077), and urological complications (2.6% vs 4.9%; P = .290) rates. In our series, donor and recipient outcomes were not substantially affected by the approach used for donor nephrectomy. TP-HALDN and RP-HALDN were both safe and effective.

Aponeurotic-Cutaneous Tract Exeresis in Patients With Persistent Lymphorrhea After Kidney Transplantation: A Valid Approach in a Day Surgery Setting

BACKGROUND

Lymphatic disorders (LDs) are the most common minor complications after kidney transplantation (KT), with an incidence rate between 0.6% and 33.9%, which appears to be related to both surgical and medical factors. LDs mostly resolve spontaneously, but occasionally a surgical approach may be required.

MATERIALS AND METHODS

We report our experience with 7 KT recipients who developed persistent lymphorrhea (>150 mL/24 h) between October 2017 and March 2019. All cases were treated as outpatients with parietal fistulectomy (PF). The fibrotic aponeurotic-cutaneous tract was thoroughly excised, and the residual aponeurotic defect was closed by watertight suturing. Serial abdominal ultrasounds (US) were carried out after the procedure.

RESULTS

A small perirenal graft lymphocele of <2 cm was detected by US in all patients after 48 to 72 hours, without any evidence of either vascular or ureteral compression. During the subsequent scheduled US follow-up, lymphoceles did not increase in size, and additional interventions were not needed. Neither superficial nor deep surgical-site infections were recorded in such patients.

CONCLUSIONS

PF was found to be a safe and effective minimally invasive approach for persistent lymphorrhea after KT. It could be easily performed with local anesthesia in a day surgery setting and did not require patient hospitalization.

Utility and safety of early allograft biopsy in adult deceased donor kidney transplant recipients

INTRODUCTION

Delayed graft function (DGF) is considered a risk factor for rejection after kidney transplantation (KTx). Clinical guidelines recommend weekly allograft biopsy until DGF resolves. However, who may benefit the most from such an aggressive policy and when histology should be evaluated remain debated.

METHODS

We analyzed 223 biopsies in 145 deceased donor KTx treated with basiliximab or anti-thymocyte globulin (rATG) and calcineurin inhibitor-based maintenance. The aim of the study was to assess the utility and safety of biopsies performed within 28 days of transplant. Relationships between transplant characteristics, indication, timing, and biopsy-related outcomes were evaluated.

RESULTS

Main indication for biopsy was DGF (87.8%) followed by lack of improvement in graft function (9.2%), and worsening graft function (3.1%). Acute tubular necrosis was the leading diagnosis (89.8%) whereas rejection was detected in 8.2% specimens. Rejection was more frequent in patients biopsied due to worsening graft function or lack of improvement in graft function than DGF (66.7% vs. 3.5%; P = 0.0075 and 33.3% vs. 3.5%; P = 0.0104, respectively) and in biopsies performed between day 15 and 28 than from day 0 to 14 (31.2% vs. 3.7%; P = 0.0002). Complication rate was 4.1%. Management was affected by the information gained with histology in 12.2% cases (7% considering DGF).

CONCLUSIONS

In low-immunological risk recipients treated with induction and calcineurin inhibitors maintenance, protocol biopsies obtained within 2 weeks of surgery to rule out rejection during DGF do not necessarily offer a favourable balance between risks and benefits. In these patients, a tailored approach may minimize complications thus optimizing results.

Transplant nephrectomy; pathological features of 124 consecutive cases in a single center study over 10 years

Background: Transplant nephrectomy (TN) is not commonly performed but it may be essential for several indications. Objectives: This study details an in-depth evaluation of the histological changes present in TN specimens. Patients and Methods: We identified 124 consecutive TN cases between 2004 and 2014. The indication for TN was divided into four groups: acute graft loss without significant blood flow (AGL group- 47 cases); suspected ongoing rejection or graft intolerance syndrome (Rej/GIS group44 cases); infection (INF group- 24 cases); and miscellaneous reasons (MIS group- 9 cases). We examined the histological changes, including the main renal artery (MRA), intrarenal arteries, the renal vein and the ureter. Results: In AGL group, most cases showed no tubulointerstitial inflammation, interstitial fibrosis and tubular atrophy, but 74.5% had necrosis. All cases in Rej/GIS group showed severe interstitial fibrosis and tubular atrophy, since 40.9% showed severe tubulointerstitial inflammation. Glomerulitis was observed in 52.3% and transplant glomerulopathy (TG) was detected in 75.0%. Arteritis of intrarenal arteries and the MRA were detected in 70.5% and 59.1%. In INF group, 66.7% had tubulitis and 79.2% had interstitial inflammation with lymphocytes, and severe interstitial fibrosis while, tubular atrophy were detected in 66.7%. TG was detected in 62.5%. In MIS group, the histological changes were minor. Conclusions: This study provides a detailed description of the morphological characteristics associated with various indications for TN. TN will occasionally reveal unexpected and significant findings that may require specific forms of treatment to manage the patient appropriately.

Incidence, risk factors, and outcome of BK polyomavirus infection after kidney transplantation

BACKGROUND

Polyomavirus-associated nephropathy is a leading cause of kidney allograft failure. Therapeutic options are limited and prompt reduction of the net state of immunosuppression represents the mainstay of treatment. More recent application of aggressive screening and management protocols for BK-virus infection after renal transplantation has shown encouraging results. Nevertheless, long-term outcome for patients with BK-viremia and nephropathy remains obscure. Risk factors for BK-virus infection are also unclear.

AIM

To investigate incidence, risk factors, and outcome of BK-virus infection after kidney transplantation.

METHODS

This single-centre observational study with a median follow up of 57 (31-80) mo comprises 629 consecutive adult patients who underwent kidney transplantation between 2007 and 2013. Data were prospectively recorded and annually reviewed until 2016. Recipients were periodically screened for BK-virus by plasma quantitative polymerized chain reaction. Patients with BK viral load ≥ 1000 copies/mL were diagnosed BK-viremia and underwent histological assessment to rule out nephropathy. In case of BK-viremia, immunosuppression was minimized according to a prespecified protocol. The following outcomes were evaluated: patient survival, overall graft survival, graft failure considering death as a competing risk, 30-d-event-censored graft failure, response to treatment, rejection, renal function, urologic complications, opportunistic infections, new-onset diabetes after transplantation, and malignancies. We used a multivariable model to analyse risk factors for BK-viremia and nephropathy.

RESULTS

BK-viremia was detected in 9.5% recipients. Initial viral load was high (≥ 10000 copies/mL) in 66.7% and low (< 10000 copies/mL) in 33.3% of these patients. Polyomavirus-associated nephropathy was diagnosed in 6.5% of the study population. Patients with high initial viral load were more likely to experience sustained viremia (95% vs 25%, P < 0.00001), nephropathy (92.5% vs 15%, P < 0.00001), and polyomavirus-related graft loss (27.5% vs 0%, P = 0.0108) than recipients with low initial viral load. Comparison between recipients with or without BK-viremia showed that the proportion of patients with Afro-Caribbean ethnicity (33.3% vs 16.5%, P = 0.0024), panel-reactive antibody ≥ 50% (30% vs 14.6%, P = 0.0047), human leukocyte antigen (HLA) mismatching > 4 (26.7% vs 13.4%, P = 0.0110), and rejection within thirty days of transplant (21.7% vs 9.5%; P = 0.0073) was higher in the viremic group. Five-year patient and overall graft survival rates for patients with or without BK-viremia were similar. However, viremic recipients showed higher 5-year crude cumulative (22.5% vs 12.2%, P = 0.0270) and 30-d-event-censored (22.5% vs 7.1%, P = 0.001) incidences of graft failure than control. In the viremic group we also observed higher proportions of recipients with 5-year estimated glomerular filtration rate < 30 mL/min than the group without viremia: 45% vs 27% (P = 0.0064). Urologic complications were comparable between the two groups. Response to treatment was complete in 55%, partial in 26.7%, and absent in 18.3% patients. The nephropathy group showed higher 5-year crude cumulative and 30-d-event-censored incidences of graft failure than control: 29.1% vs 12.1% (P = 0.008) and 29.1% vs 7.2% (P < 0.001), respectively. Our multivariable model demonstrated that Afro-Caribbean ethnicity, panel-reactive antibody > 50%, HLA mismatching > 4, and rejection were independent risk factors for BK-virus viremia whereas cytomegalovirus prophylaxis was protective.

CONCLUSION

Current treatment of BK-virus infection offers sub-optimal results. Initial viremia is a valuable parameter to detect patients at increased risk of nephropathy. Panel-reactive antibody > 50% and Afro-Caribbean ethnicity are independent predictors of BK-virus infection whereas cytomegalovirus prophylaxis has a protective effect.

Impact of Transplant Nephrectomy for Patient Survival Over the Past 15 Years: A Single-Center Study

OBJECTIVES

How transplant nephrectomy affects patient survival after return to dialysis is unclear. Here, we compared patient survival after graft loss between patients with and without transplant nephrectomy.

MATERIALS AND METHODS

We divided 171 patients who received transplant between 2000 and 2015 and had graft loss into 3 groups: 64 had graft failure left in situ (without nephrectomy), 51 had nephrectomy < 3 months posttransplant (early nephrectomy), and 56 patients had nephrectomy > 3 months posttransplant (late nephrectomy). The primary endpoint was patient survival. Risk factors for patient death were also analyzed. Secondary endpoints included relisting for transplant and immunosuppressive agent status.

RESULTS

Patient survival rates at 1, 3, and 5 years posttransplant in those without nephrectomy, early nephrectomy, and late nephrectomy were 92.1% /90.5%/86.6%, 96.0%/89.7%/80.4%, and 100.0% /97.9%/ 95.6%, respectively. Rates in patients with early nephrectomy differed significantly from those with late nephrectomy (P = .005). On multivariate analysis, patient survival was affected by relisting for transplant (hazard ratio 0.17; 95% confidence interval, 0.06-0.41; P < .001) and graft survival duration (hazard ratio 0.36, 95% confidence interval, 0.13-0.93; P = .036). Relisting for transplant occurred in 46.9% of patients without nephrectomy, 56.9% of patients with early nephrectomy, and 51.8% of patients with late nephrectomy. Those with late nephrectomy took 14.7 months after graft loss to relist for transplant, with 7.8 months for those without nephrectomy (P = .039) and 6.3 months for those with early nephrectomy (P = .051). Only 10.9% of those without nephrectomy were immunosuppressive free, which was in contrast to 94.1% and 78.6% of those with early and late nephrectomy, respectively.

CONCLUSIONS

After graft failure, patients without nephrectomy did not have inferior survival versus patients who received early or late nephrectomy. Graft survival time and relisting for transplant were associated with patient survival regardless of having transplant nephrectomy.

Impact of Donor Age on Clinical Outcomes of Primary Single Kidney Transplantation From Maastricht Category-III Donors After Circulatory Death

BACKGROUND

Standard-criteria donation after circulatory death (DCD) kidney transplants (KTx) have higher primary nonfunction, delayed graft function (DGF), and rejection rates than age-matched donation after brain death (DBD) but similar graft survival. Data on expanded-criteria DCD are conflicting and many centers remain concerned regarding their use.

METHODS

In this single-center observational study with 5-year follow-up, we analyzed data from 112 primary DCD Maastricht category-III single KTx receiving similar organ preservation and maintenance immunosuppression. Patients were sorted as young DCD (donor <60 years, 72 recipients) or old DCD (donor ≥60 years, 40 recipients). Old DCD outcomes were compared with young DCD and to a DBD control group (old DBD, donor ≥60 years, 40 recipients).

RESULTS

After 5 years, old DCD showed lower patient survival (66% vs 85%; P = 0.014), death-censored graft survival (63% vs 83%; P = 0.001), and Modification of Diet in Renal Disease estimated glomerular filtration rate (34, 27.0-42.0 mL/min per 1.73 m2 vs 45.0, 33.0-58.0 mL/min per 1.73 m2; P = 0.021) than young DCD with higher DGF (70% vs 47.2%; P = 0.029) and graft thrombosis (12.5% vs 1.4%; P = 0.021). Comparison between old DCD and old DBD showed similar 5-year patient survival (66% vs 67%; P = 0.394) and death-censored graft survival (63% vs 69%; P = 0.518) but higher DGF (70% vs 37.5%; P = 0.007) and lower estimated glomerular filtration rate (34, 27.0-42.0 mL/min per 1.73 m2 vs 41, 40.0-42.0 mL/min per 1.73 m2; P = 0.029). Multivariate Cox regression analysis showed that donor 60 years or older (hazard ratio, 3.135; 95% confidence interval, 1.716-5.729; P < 0.001) and induction with anti-IL2-receptor-α monoclonal antibody (hazard ratio, 0.503; 95% confidence interval, 0.269-0.940, P = 0.031 in favor of induction with rabbit antithymocyte globulin) are independent predictors of transplant loss.

CONCLUSIONS

Overall, single KTx from DCD Maastricht category-III donors 60 years or older have inferior outcomes than KTx from donors younger than 60 years. Comparison with age-matched DBD showed similar patient and graft survivals. However, the discrepancy in graft function between DCD and DBD deserves further investigation.

Multidisciplinary management of complicated bilateral renal artery aneurysm in a woman of childbearing age

Ruptured renal artery aneurysm (RAA) during pregnancy is a rare condition associated with high mortality rates to both the mother and the foetus. We report on a 41-year-old woman at her second trimester who presented with shock to the emergency department as a result of a ruptured left RAA. While the bleeding was successfully treated with angiographic embolization, a contralateral RAA, also at risk of rupture, was discovered. Due to its position on the artery bifurcation, this lesion was considered not suitable for interventional radiology and was therefore managed by hand-assisted retroperitoneoscopic nephrectomy, ex-vivo repair and autotransplantation. This was done in order to preserve renal mass and give our patient a chance of having future pregnancies without risk of rupture. Three years later, her renal function is normal, there is no evidence of recurrence, and more importantly she had two successful and uncomplicated pregnancies.

Impact of Allograft Nephrectomy on Second Renal Transplant Outcome

OBJECTIVES

The impact of allograft nephrectomy on the outcome of a subsequent renal transplant is unclear. This study was conducted to assess the effects of the first allograft nephrectomy on outcomes of a second transplant.

MATERIALS AND METHODS

This study included 118 patients who received a second transplant between 1994 and 2015. Before the second transplant, 59 patients did not undergo a first allograft nephrectomy (group A). Group B comprised 59 patients who had undergone a first allograft nephrectomy. We compared sensitization, acute rejection, and survival of the second graft between groups. The risk factors of a second graft loss were assessed.

RESULTS

The first graft survival was significantly longer in group A than in group B (100.6 vs 3.7 months; P < .001). Prevalence of preformed donor-specific antibodies before the second allograft was similar between both groups (28.8% vs 39.0% for group A vs group B; P = .243). Numerically higher acute rejection rates occurred in group B than in group A (23.7% vs 15.3%; P = .245). In group A, graft survival rates at 1, 3, and 5 years were 93.0%, 87.0%, and 82.3% and were significantly higher than for group B (76.7%, 69.1%, and 62.5%; P ⟨ .05). On multivariate analysis, survival of the second graft was affected by acute rejection (hazard ratio = 2.24; 95% confidence interval, 1.10-4.45; P = .027) and the interval from first graft loss to second transplant (hazard ratio = 1.11; 95% confidence interval, 1.02-1.19; P = .008).

CONCLUSIONS

A first allograft nephrectomy was associated with inferior second graft survival. We recommend that recipients of second transplants should be considered as high risk if they had undergone prior allograft nephrectomy.

The UK National Registry of ABO and HLA Antibody Incompatible Renal Transplantation: Pretransplant Factors Associated With Outcome in 879 Transplants

BACKGROUND

ABO and HLA antibody incompatible (HLAi) renal transplants (AIT) now comprise around 10% of living donor kidney transplants. However, the relationship between pretransplant factors and medium-term outcomes are not fully understood, especially in relation to factors that may vary between centers.

METHODS

The comprehensive national registry of AIT in the United Kingdom was investigated to describe the donor, recipient and transplant characteristics of AIT. Kaplan-Meier analysis was used to compare survival of AIT to all other compatible kidney transplants performed in the United Kingdom. Cox proportional hazards regression modeling was used to determine which pretransplant factors were associated with transplant survival in HLAi and ABOi separately. The primary outcome was transplant survival, taking account of death and graft failure.

RESULTS

For 522 HLAi and 357 ABO incompatible (ABOi) transplants, 5-year transplant survival rates were 71% (95% confidence interval [CI], 66-75%) for HLAi and 83% (95% CI, 78-87%) for ABOi, compared with 88% (95% CI, 87-89%) for 7290 standard living donor transplants, and 78% (95% CI, 77-79%) for 15 322 standard deceased donor transplants (P < 0.0001). Increased chance of transplant loss in HLAi was associated with increasing number of donor specific HLA antibodies, center performing the transplant, antibody level at the time of transplant, and an interaction between donor age and dialysis status. In ABOi, transplant loss was associated with no use of IVIg, cytomegalovirus seronegative recipient, 000 HLA donor-recipient mismatch; and increasing recipient age.

CONCLUSIONS

Results of AIT were acceptable, certainly in the context of a choice between living donor AIT and an antibody compatible deceased donor transplant. Several factors were associated with increased chance of transplant loss, and these can lead to testable hypotheses for further improving therapy.

Do we need a different organ allocation system for kidney transplants using donors after circulatory death?

BACKGROUND

There is no national policy for allocation of kidneys from Donation after circulatory death (DCD) donors in the UK. Allocation is geographical and based on individual/regional centre policies. We have evaluated the short term outcomes of paired kidneys from DCD donors subject to this allocation policy.

METHODS

Retrospective analysis of paired renal transplants from DCD's from 2002 to 2010 in London. Cold ischemia time (CIT), recipient risk factors, delayed graft function (DGF), 3 and 12 month creatinine) were compared.

RESULTS

Complete data was available on 129 paired kidneys.115 pairs were transplanted in the same centre and 14 pairs transplanted in different centres. There was a significant increase in CIT in kidneys transplanted second when both kidneys were accepted by the same centre (15.5 ± 4.1 vs 20.5 ± 5.8 hrs p<0.0001 and at different centres (15.8 ± 5.3 vs. 25.2 ± 5.5 hrs p=0.0008). DGF rates were increased in the second implant following sequential transplantation (p=0.05).

CONCLUSIONS

Paired study sequential transplantation of kidneys from DCD donors results in a significant increase in CIT for the second kidney, with an increased risk of DGF. Sequential transplantation from a DCD donor should be avoided either by the availability of resources to undertake simultaneous procedures or the allocation of kidneys to 2 separate centres.

ABO incompatible renal transplants: Good or bad?

ABO incompatible kidney transplantation (ABOi-KT) was previously considered to be an absolute contraindication for patients with end-stage kidney disease (ESKD) due to hyperacute rejection related to blood type barrier. Since the first successful series of ABOi-KT was reported, ABOi-KT is performed increasingly all over the world. ABOi-KT has led to an expanded donor pool and reduced the number of patients with ESKD awaiting deceased kidney transplantation (KT). Intensified immunosuppression and immunological understanding has helped to shape current desensitization protocols. Consequently, in recent years, ABOi-KT outcome is comparable to ABO compatible KT (ABOc-KT). However, many questions still remain unanswered. In ABOi-KT, there is an additional residual immunological risk that may lead to allograft damage, despite using current diverse but usually intensified immunosuppressive protocols at the expense of increasing risk of infection and possibly malignancy. Notably, in ABOi-KT, desensitization and antibody reduction therapies have increased the cost of KT. Reassuringly, there has been an evolution in ABOi-KT leading to a simplification of protocols over the last decade. This review provides an overview of the history, outcome, protocol, advantages and disadvantages in ABOi-KT, and focuses on whether ABOi-KT should be recommended as a therapeutic option of KT in the future.

Campath, calcineurin inhibitor reduction and chronic allograft nephropathy (3C) study: background, rationale, and study protocol

Background

Kidney transplantation is the best treatment for patients with end-stage renal failure, but uncertainty remains about the best immunosuppression strategy. Long-term graft survival has not improved substantially, and one possible explanation is calcineurin inhibitor (CNI) nephrotoxicity. CNI exposure could be minimized by using more potent induction therapy or alternative maintenance therapy to remove CNIs completely. However, the safety and efficacy of such strategies are unknown.

Methods/Design

The Campath, Calcineurin inhibitor reduction and Chronic allograft nephropathy (3C) Study is a multicentre, open-label, randomized controlled trial with 852 participants which is addressing two important questions in kidney transplantation. The first question is whether a Campath (alemtuzumab)-based induction therapy strategy is superior to basiliximab-based therapy, and the second is whether, from 6 months after transplantation, a sirolimus-based maintenance therapy strategy is superior to tacrolimus-based therapy. Recruitment is complete, and follow-up will continue for around 5 years post-transplant. The primary endpoint for the induction therapy comparison is biopsy-proven acute rejection by 6 months, and the primary endpoint for the maintenance therapy comparison is change in estimated glomerular filtration rate from baseline to 2 years after transplantation. The study is sponsored by the University of Oxford and endorsed by the British Transplantation Society, and 18 centers for adult kidney transplant are participating.

Discussion

Late graft failure is a major issue for kidney-transplant recipients. If our hypothesis that minimizing CNI exposure with Campath-based induction therapy and/or an elective conversion to sirolimus-based maintenance therapy can improve long-term graft function and survival is correct, then patients should experience better graft function for longer. A positive outcome could change clinical practice in kidney transplantation.

Trial registration

ClinicalTrials.gov, NCT01120028 and ISRCTN88894088

Cyst Infection in Renal Allograft Recipients With Adult Polycystic Kidney Disease: The Diagnostic Value of Labeled Leukocyte Scanning: Case Reports

Occult infection following renal transplantation is a common diagnostic problem facing nephrologists and transplant surgeons. Patients with adult polycystic kidney disease (APKD) are prone to recurrent infections in their native kidneys and this can present with little if any localizing signs. Conventional radiological imaging with computed tomography or ultrasonography has a low sensitivity and specificity in such patients due to anatomic distortion and poor native renal function, and therefore identifying the source of sepsis can be difficult. Two cases are presented where patients with APKD who had received kidney transplants were investigated unsuccessfully for occult sepsis. White cell-labeled scanning identified the location of the infection in the patients' native polycystic kidney in both cases, allowing targeted treatment in the form of native nephrectomy. White cell-labeled scanning has an important role in the investigation of occult infection in renal allograft recipients with APKD.

Efficacy of Early Biopsy in Kidney Allograft Recipients With Delayed Graft Function

It is accepted that kidney transplants that display delayed graft function (DGF) show poorer survival and function, particularly when an acute rejection episode (ARE) occurs. A diagnostic biopsy to establish the reason for DGF, or acknowledge an ARE, even if borderline, can improve short- and long-term graft survivals. From January 2002 to September 2006 we retrospectively evaluated 358 kidney transplant recipients. We performed a biopsy to evaluate the cause of DGF in all patients who required dialysis, or had serum creatinine levels that increased, remained unchanged, or decreased less than 10% per day on three consecutive days during the first week after transplantation. An ARE was found in 18.8% (n = 19) of the biopsies. Early biopsy for patients with DGF is a safe method that allows uncovering of an ARE that would otherwise be undetected. The immediate recognition and treatment of rejection episodes can certainly increase long-term survival and function of renal transplants.

Kidney Transplantation From Donors With Viral B and C Hepatitis

INTRODUCTION

The success of renal transplantation as a treatment for end-stage renal disease has created a chronic shortage of donor organs. We present our experience in transplanting kidneys from donors with hepatitis B virus (HBV) or hepatitis C virus (HCV) among matched serology-positive recipients.

MATERIALS AND METHODS

From January 2002 to November 2005, 44 patients with end-stage renal disease and HCV seropositivity underwent kidney transplantation. In 28 transplants in HCV+ recipients, the donor was HCV+ (DC+/RC+) and in 16 of these cases the donor (one living donor) was HCV- (DC-/RC+). In the same period 14 patients with HBV infection and HbsAg seropositivity underwent kidney transplantation: eight received their graft from a cadaveric HbsAg-positive donor (DB+/RB+), while six patients received their graft from an HbsAg-negative donor.

RESULTS

Viral reactivation was higher among DC+/RC+ (21.4%) than DC-/RC+ patients (6%). Graft survivals were 90% and 88% for DC+/RC+ and DC-/RC+, respectively; patient survivals were 100% for DC+/RC+ and 94% for DC-/RC+. Among the group of DB+/RB+, all the patients developed an HBV-DNA positivity in the early postoperative period. Patient and graft survivals were 100% in both groups.

CONCLUSIONS

Our results suggest that HBV- and HCV-positive donors can be considered as an alternative donor source, because their kidneys are allocated to the matched serology-positive recipients, shortening their time on the waiting list.

Use of Hepatitis B Core Antibody-Positive Donor Kidneys in Hepatitis B Surface Antibody-Positive and -Negative Recipients

INTRODUCTION

The rate of hepatitis B virus transmission via organs from with isolated hepatitis B virus core antibody-positive (HBcAb+) donors in kidney transplant recipients seems very low.

PATIENTS AND METHODS

Over 4 years, we performed 36 transplants from Ig HBcAb+, hepatitis B surface antigen (HBsAg)-negative donors into recipients with a history of prior hepatitis B virus (HBV) infection or reported vaccination (28 patients) and in recipients who were not immunized and received a pretransplant prophylaxis with hepatitis B immunoglobulins. We examined the HBV-related outcomes in these 36 patients in comparison with 40 recipients of allografts from HBcAb- donors.

RESULTS

No patient receiving an allograft from an HBcAb+ donor developed clinical HBV infection or HBSAg positivity. The rate of seroconversion was 14.2% in immunized patients, 12.5% in nonimmunized patients, and 0% in the control group. The 17.8% of immunized patients developed elevated transaminases after transplant, in comparison with 25% and 10% in the nonimmunized patients and the control group, respectively. Graft and patient survival was 93% and 93% for immunized patients, 100% and 100% for nonimmunized patients, and 98% and 95% for the control group, respectively.

CONCLUSION

The use of anti-HBc antibody-positive kidneys was associated with no risk of transmission of HBV infection, without affecting graft and patient survival, and could be considered a safe way to expand the donor pool. Our preliminary results suggest that such kidneys could be safely transplanted even in not immunized patients who underwent a prophylaxis with hepatitis B immunoglobulins.

Kidney Transplantation From Hepatitis C Virus–Positive Donors Into Hepatitis C Virus–Positive Recipients: A Safe Way to Expand the Donor Pool?

INTRODUCTION

Because the disparity between the number of patients waiting for kidney transplants and the number of available cadaveric renal allografts continues to increase, there is a clear need to review the inclusion criteria for cadaveric donors.

PATIENTS AND METHODS

From January 2001 to March 2004, 24 patients with end-stage renal disease and hepatitis C virus (HCV) seropositivity underwent a kidney transplantation. In 10 transplants in HCV-positive recipients, the donor was HCV-positive (D+/R+) and in 14 cases the donor (1 living donor) was HCV-negative (D-/R+).

RESULTS

Two of 3 HCV-RNA-negative recipients who received a HCV-RNA+ kidney became HCV-RNA+ in the posttransplantation period. There was a low rate of acute rejection (8.3%). One D+/R+ patient experienced an acute vascular rejection, which finally resulted in graft loss, due to the resurgence of severe infectious disease. The serum creatinine levels at 6 months posttransplantation were similar in both groups. Acute liver dysfunction was observed in 1 patient. There was no death in the entire series. Graft survival was 92% and 90% for D+/R+ and D-/R+, respectively.

Kidney Transplantation From Cadaveric Donors Unsuitable for Other Centers and Older Than 60 Years of Age

INTRODUCTION

The demand for kidney transplants and the improvement in recipient outcomes over the last years have stimulated surgeons to expand the criteria for usable donor organs, by accepting older patients to expand their donor pool. We herein report our experience with kidney transplants from donors aged older than 60 years, who have been declined by other transplantation centers.

PATIENTS AND METHODS

Sixty kidney transplantations were performed with grafts procured from donors aged older than 60 years. Forty-five patients received a single kidney graft (SKG) and 15 received a dual kidney graft (DKG). Mean donor age was 62 years for SKG and 64 years for DKG. Double kidney transplantations were performed with the ipsilateral allocation of both grafts.

RESULTS

No primary graft nonfunction occurred. Delayed graft function was observed in 22 SKG (48.8%) and in 7 DKG (46.6%). Acute rejection rates were 9% for SKG and 0% for DKG. One-year patient survival rates were 95% and 100% for SKG and DKG, respectively. Mean serum creatinine levels at 1-year posttransplantation were 1.9 mg/dL for SKG and 1.3 mg/dL for DKG. There were no surgical postoperative complications and mortality. Death censored 1-year graft survival rate was 88% for SKG and 94% for DKG.

CONCLUSIONS

Our experience with marginal donors who have been declined by other transplantation centers has demonstrated that such organs, with accurate selection criteria, could be safely allocated to elderly recipients with no increase in postoperative complications, guaranteeing satisfactory results in the short and medium term, allowing a significant improvement in the number of transplants.

Kidney Transplantation From Hepatitis B Surface Antigen–Positive Donors Into Hepatitis B Surface Antigen–Positive Recipients: Preliminary Findings

INTRODUCTION

The success of renal transplantation as a treatment for end-stage renal disease has created a chronic shortage of donor organs. We present our initial experience in transplanting kidneys from hepatitis B surface antigen (HbsAg)-positive donors into HbsAg-positive recipients.

MATERIAL AND METHODS

From January 2002 to March 2004, 5 patients with end-stage renal disease, hepatitis B virus (HBV) infection, and HbsAg seropositivity underwent a kidney transplantation from a cadaveric HbsAg-positive donor. The median time on the waiting list was 8 months, compared with the median of 3 years on the national waiting list.

RESULTS

One patient experienced an acute rejection; 1 patient had an increase in serum level of aspartate aminotransferase (AST)/alanine aminotransferase (ALT) with no signs of recurrence of hepatitis. Graft and patient survival at a median follow-up of 12 months was 100%.

CONCLUSIONS

Although the number of patients is small and the follow-up is short, our results suggest that HbsAg-positive donors can be considered as an alternative donor source because their kidneys are allocated to the matched serology-positive recipients, shortening their time on the waiting list.

Kidney transplantation from marginal donors

AIM

The increasing demand for transplantation and the shortage of available organs limit the success of organ transplant programs. The use of marginal donors to expand the donor pool is receiving increased attention. We reviewed a 28-month experience of kidney transplants from marginal donors to assess the impact on patient and graft survival.

PATIENTS AND METHODS

From January 2001 to May 2003, 78 kidney transplants were performed, including 50 grafts from cadaver donors and 28 from living donors with 3 patients receiving a double kidney transplant. The patients were divided into 4 groups: 31 patients received a kidney from an ideal cadaver donor (group 1a); 19 patients received a graft from a marginal cadaver donor (group 1b); 19 patients received an ideal living related kidney (group 2a); and 9 patients received a marginal living kidney graft (group 2b).

RESULTS

Twenty-eight grafts from marginal donors were transplanted with an average follow-up of 16 months (range, 1-28 months). The graft survival rates for groups 1a, 1b, 2a, and 2b were 93%, 79%, 100%, and 100% and patient survival rates were 96%, 89%, 100%, and 100%, respectively.

CONCLUSION

Despite the observation that use of marginal donors has been associated with a worse outcome compared with ideal donors, we of such grafts resulted in improved quality of life and survival expectancy compared with maintenance dialysis. The marginal kidney donors represent a feasible way to improve the donor pool.

Early de novo malignancies after kidney transplantation

INTRODUCTION

Immunosuppressed renal transplant patients display a higher incidence of carcinoma than the general population. The chronic use of immunosuppressive therapy to prevent acute rejection increases the long-term risk of cancer. We reviewed our experience to identify factors affecting the development of de novo neoplasms.

PATIENTS AND METHODS

Between January 2000 and May 2003, 135 renal and three combined kidney-pancreas transplantations were performed.

RESULTS

Sixteen (11.6%) cancers were diagnosed in nine renal transplant recipients (6.5%). Tumors presented at a mean time of 14 months. Three patients displayed in malignancies; three, Kaposi's sarcoma; one, papillary microcarcinoma of the thyroid; one, bladder carcinoma; and one, breast carcinoma.

CONCLUSION

Although de novo malignancies occur more frequently many years after kidney transplantation, our experience demonstrates that they can occur early during the posttransplant follow-up. Skin malignancies showed the best prognosis, probably because of early detection and treatment. Patients with Kaposi's sarcoma benefit from reduction or cessation of immunosuppression, but this entails a higher risk of graft loss. Solid organ de novo malignancies are often more aggressive than those in normal population; the life expectancy of these recipients is low.

Living kidney transplantation: a starting experience

INTRODUCTION

We present our initial experience with living kidney transplantation.

PATIENTS AND METHODS

From January 2001 to December 2002, we performed 27 living kidney transplants using immunosuppression with induction basiliximab, cyclosporine (n = 10 patients), or tacrolimus (n = 17), mycophenolate mofetil, and steroids.

RESULTS

Nineteen (70.3%) donors were women and 8 (29.7%) were men of mean age 50.6 years. Four donors were over 65 years of age at the time of living donation. Donor morbidity was 5.5%: namely, one wound infection and one asymptomatic acute pancreatitis. There were no differences between the preoperative and the postoperative mean serum creatinines and systolic blood pressure values. All living donors are in good health with a mean serum creatinine of 0.80 mg/dL at a mean follow-up of 15.2 months. Nineteen (70.3%) recipients were men and 8 (29.7%) were women of mean age 36 years. Acute rejection occurred in 6 (22.2%) recipients. It was more common among spousal donors and among cyclosporine-treated recipients. Patient and graft survivals at a mean follow-up of 15.2 months was 100%.

CONCLUSIONS

Our early results showed that accurate selection and preoperative management of potential living donors lead to excellent results in kidney transplantation. The health of the living donors was not impaired by the donation. The rate of early postoperative complications was low. Living donor kidney transplantation, in our geographical area with a low-rate of cadaveric donor transplants, is an alternative to expand the donor pool, which offers better results in term of patient and graft survival.

Severe Neurotoxicity in Tacrolimus-Treated Living Kidney Transplantation in Two Cases

Two living kidney-transplant recipients under tacrolimus-based immunosuppressive therapy experienced severe neurotoxicity, with tonic-clonic seizures. In both cases the dosage reduction did not result in improvement of symptoms, which completely disappeared after modification of the immunosuppressive regimen from tacrolimus to cyclosporine. Severe neurotoxicity, with seizures or uncommon clinical features, such as serious myalgias, is not foreseeable. We recommend the conversion to cyclosporine-based immunosuppression in such cases.

Renal allograft rupture caused by acute tubular necrosis

Renal allograft rupture is a rare but potentially lethal complication of kidney transplantation. A renal allograft recipient receiving quadruple immunosuppressive therapy developed a spontaneous allograft rupture 13 days after kidney transplantation. Warm ischaemia time during the transplant was 80 minutes. The ruptured kidney graft could not be salvaged because of the patient's haemodynamic instability. The histopathological examination showed interstitial oedema with severe acute tubular necrosis with no signs of acute rejection. The most common causes of renal graft rupture are acute rejection and vein thrombosis, while acute tubular necrosis may only rarely be responsible for this complication. Renal graft rupture may be the result of interstitial damage attributed both to the prolonged warm ischaemia time during the transplant and to post-transplant acute tubular necrosis in the absence of graft rejection. In those patients whose haemodynamic status cannot be stabilized by appropriate aggressive haemodynamic support therapy, graft nephrectomy should be considered the only definitive treatment.

[Early de novo neoplasia after renal transplantation]

INTRODUCTION

The chronic use of immunosuppressive therapy in transplant recipients to prevent acute rejection increases the long-term risk of cancer. The overall incidence of de novo malignancies (DNM) after kidney transplantation ranges from 6% to 11%.

PATIENTS AND METHODS

Between January 2000 and December 2002, 135 renal and 3 combined kidney-pancreas transplantations were performed.

RESULTS

Of 138 solid organ transplant recipients, a total of 16 (11.6%) cancers were diagnosed in 10 renal transplant recipients (7.2%). Six patients were male and three female, with a mean age of 47 years (range, 19-63, years). Tumor presented at a mean time of 14 months (range, 2-24, months) after transplantation. There were three patients with skin cancers, three with Kaposis's sarcoma, one with renal cell cancer, one with bladder carcinoma and one with breast cancer.

CONCLUSIONS

Although the DNM occurs more frequently many years after a kidney transplantation, our experience demonstrated that they can occur early in the follow-up. Skin malignancies had the best prognosis, probably because of early detection and treatment. Kaposi's sarcoma benefits from reduction or cessation of immuno-suppression, but there is a higher risk of graft loss. Solid organ de novo malignancies are often more aggressive than in normal population, and the life expectancy of these recipients is very low. Careful long-term screening protocols are needed for detection of such malignancies in an early stage.

[Treatment of post kidney transplantation erythrocytosis (PTE) with ACE inhibitors]

BACKGROUND

Post kidney transplantation erythrocytosis is a frequent complication in male subjects. in our experience, it occurs in approximately 20% of transplant patients recciving cyclosporine inununosuppression therapy.

METHODS

Twenty-two patients with post kidney transplantation erythrocytosis were treated using ACE-inhibitors (lisinopril) at a dose of 2-5-5 mg/day for a mean period of 15 months. Owing to tbe onset of collateral effects, 27% of these patients requested the conversion of ACE into angiotensin II receptor antagonists (AII). Twenty out of 22 patients were male (90%).

RESULTS

Treatment resulted in a 15% reduction of hematocrit values compared to basal levels, which remained stable over time. No collateral effects were recorded, either for the kidneys or in terms of hypotension.

CONCLUSIONS

ACE-inhibitors (lisinopril) or alternatively the use of angiotensin II receptor antagonists, like Iosartan at low doses, is an effective and safe treatment for patients developing post-transplantation erythrocytosis (PTE).

[Treatment of post kidney transplantation erythrocytosis (PTE) with ACE inhibitors]

BACKGROUND

Post kidney transplantation erythrocytosis is a frequent complication in male subjects. In our experience, it occurs in approximately 20% of transplant patients receiving cyclosporine immunosuppression therapy.

METHODS

Twenty-two patients with post kidney transplantation erythrocytosis were treated using ACE-inhibitors (lisinopril) at a dose of 2-5-5 mg/day for a mean period of 15 months. Owing to the onset of collateral effects, 27% of these patients requested the conversion of ACE into angiotensin II receptor antagonists (AII). Twenty out of 22 patients were male (90%).

RESULTS

Treatment resulted in a 15% reduction of hematocrit values compared to basal levels, which remained stable over time. No collateral effects were recorded, either for the kidneys or in terms of hypotension.

CONCLUSIONS

ACE-inhibitors (lisinopril) or alternatively the use of angiotensin II receptor antagonists, like Losartan, at low doses, is an effective and safe treatment for patients developing post-transplantation erythrocytosis (PTE).

Efficacy of nonwoven fabric bioreactor immobilized with porcine hepatocytes for ex vivo xenogeneic perfusion treatment of liver failure in dogs

We have developed a new bioartificial liver bioreactor filled with porcine hepatocytes immobilized on polyester nonwoven fabric (NWF). In this study, we investigated the efficacy of our hybrid bioartificial liver system incorporating the NWF bioreactors and an immunoglobulin adsorbent column for perfusion treatment in a canine liver failure model. Xenogeneic perfusion treatment for operative canine liver failure models were performed for 3 h, and survival time, intracranial pressure, and blood and cerebrospinal fluid data were documented. Treatment was carried out without obstruction by immunological rejection when immunoglobulin adsorbent columns were used with the NWF bioreactors in combination. Dogs treated with this system exhibited a restricted increase of intracranial pressure and significant compensatory effects on blood and cerebrospinal amino acid imbalances as shown by a significant improvement of Fischer's ratio. On the other hand, relatively low capacity for ammonia elimination was shown as compared with homologous direct hemoperfusion.

[Warm ischemia in kidney from non-heart beating donor . Instrumental evaluation]

A dramatic shortage of kidneys available for transplantation, due do the widespread reduction in consent, has urged us to explore alternative sources of kidney harvesting, in the attempt to reduce the current gap between the small number of donations and the large number of patients on waiting-list. We set our attention on non-heart-beating donors (NHBD). In the "first step" of our research, we tested an experimental technique, by using commercial pigs' kidneys, that has been useful to determinate the maximum warm ischemic time that a kidney of NHBD could tolerate. Parameters of this research were the resistance of the kidney in perfusion machine and the renal scintigraphy. Our results permitted to establish that the maximum warm ischemic time that a kidney of NHBD could tolerate, is 50 minutes (p > 0.001). This experimental technique could be employed to remove every doubt about the effective condition of NHBD kidney before the transplant, in the outlook, by using those kidneys, to reduce the organ shortage.