Simultaneous Living Donor Kidney Transplant and Laparoscopic Native Nephrectomy: An Approach to Kidney Transplant Candidates with Suspected Renal-Cell Carcinoma

Introduction: Kidney transplant candidates are occasionally found during the pre-transplant evaluation to have a suspicious mass in a native kidney. Further work-up and management of such a mass may delay transplantation for several months, which may create logistic barriers to transplant, particularly if there are timing constraints of the donor. In this study, we report our experience with simultaneous living donor kidney transplant and laparoscopic native nephrectomy, where the indication for nephrectomy was a suspicious lesion. Methods: We performed a retrospective review of patients who underwent simultaneous kidney transplant and native nephrectomy using prospectively collected data. We analyzed relevant patient characteristics, surgical details, pathologic results, and long-term follow-up. Results: We identified 16 patients who underwent simultaneous living donor kidney transplantation and laparoscopic native nephrectomy at our institution between 2013 and 2018. Ten (62.5%) patients were found to have renal-cell carcinoma (RCC) on the final pathology. No patients had recurrent RCC, at a median follow-up of 4 years. Conclusion: For patients who are planning to undergo a living donor kidney transplant and are found to have a small mass that is suspicious for RCC, a simultaneous living donor kidney transplant and laparoscopic native nephrectomy is a possible approach in selected patients.

Acute Rejection, Kidney Allograft Function, and Graft Survival in Patients with Circulating Pre-Transplant IgG Antibodies Directed Against Donor HLA-A, -B, or -C Locus Determined Antigens

The relationship between circulating pre-transplant immunoglobulin G (IgG) antibodies to donor human leukocyte antigen (HLA) -C locus determined antigens alone and acute rejection, kidney allograft function, and graft survival is not fully defined. Also, the impact of circulating pre-transplant IgG antibodies to donor HLA-C locus antigens alone on these outcomes has not been compared with the impact of circulating pre-transplant IgG antibodies to donor HLA-A or -B locus antigens. We conducted a retrospective review of records of 1252 kidney allograft recipients transplanted at our center between January 2010 and January 2016 to identify patients with circulating pre-transplant IgG antibodies directed at kidney donor HLA-A, -B, or -C locus determined antigens. Antibodies were detected and reported using the LABScreen Single Antigen Bead assay with microbeads coated with single HLA class I antigens. Pre-transplant and post-transplant data were collected and the graft outcomes of 16 kidney graft recipients with antibodies to HLA-C locus antigens were compared to the outcomes in 56 recipients with antibodies to HLA-A or -B locus determined antigens. The one-year acute rejection rate was 6% in those with donor-specific antibodies (DSA) to HLA-C locus antigens and 20% in those with DSA to HLA-A or -B locus antigens. The graft survival rate was 100% in those with DSA to HLA-C locus antigens and 95% in those with DSA to HLA-A or -B locus antigens. None of the numerical differences were statistically significant (p>0.05). The presence of circulating pre-transplant IgG antibodies directed at kidney donor HLA-C locus antigens alone may not be associated with an increased risk of acute rejection or a decreased graft survival rate. Our observations support the concept that circulating pre-transplant IgG antibodies directed at kidney donor HLA-C locus antigens alone do not negatively impact kidney allograft outcomes and that the mean fluorescence intensities of the antibodies directed at HLA-C locus alone should not be used to list unacceptable HLA-C locus antigens for kidney allocation. A study with a larger cohort is needed to investigate our hypothesis.

Laparoendoscopic single site live donor nephrectomy: single institution report of initial 100 cases

PURPOSE

Laparoendoscopic single site surgery is a recent advance in minimally invasive urology. We report outcomes from our initial 100 consecutive laparoendoscopic single site live donor nephrectomies done by a single surgeon and provide a matched comparison of conventional laparoscopic live donor nephrectomies done by the same surgeon.

MATERIALS AND METHODS

From 2009 to 2010 at a tertiary referral center 100 consecutive laparoendoscopic single site live donor nephrectomies were performed by a single surgeon through a periumbilical incision using the GelPoint® system. No extraumbilical incisions or punctures were made. A retrospective review was performed using a prospectively managed database of standard perioperative and convalescent parameters. Comparison was made using a matched cohort of conventional live donor nephrectomies done by the same surgeon.

RESULTS

Mean operative time was longer in the laparoendoscopic single site group (156 vs 130 minutes) but there was no difference in estimated blood loss or warm ischemia time. There was no difference in the complication rate between the 2 groups. Mean hospital stay and visual analog pain scores were similar in the groups but the laparoendoscopic group showed improved convalescence with faster return to work, normal activity and 100% recovery. Recipient graft function was equivalent in the 2 groups.

CONCLUSIONS

In this retrospective, matched comparison laparoendoscopic single site live donor nephrectomy was associated with longer operative time but equivalent recipient graft function and improved convalescence. The benefits of laparoendoscopic single site surgery over conventional laparoscopy may be limited. However, with respect to live donor nephrectomy the benefits of laparoendoscopic single site surgery may nevertheless prove beneficial to decrease barriers to live organ donation.

Steroid avoidance in two-haplotype-matched living donor renal transplants with basiliximab induction therapy

BACKGROUND

Induction therapy and haplotype matching are utilized to mitigate immunologic risk in renal transplantation. The incidence of acute rejection (AR) of renal allografts has been reported to be as low as 9.3% within the first year among two-haplotype-matched siblings with no induction and triple-drug maintenance immunosuppression. We report our use of basiliximab induction in a series of two-haplotype-matched living donor renal transplants (LDRT).

METHODS

We retrospectively reviewed 25 patients who received a two-haplotype-matched LDRT with basiliximab induction therapy. The primary endpoints were acute rejection (AR) episodes at 6 and 12 months and 1-year patient and graft survival rates. The secondary endpoints were the incidence of delayed graft function (DGF), cytomegalovirus (CMV), and BK virus (BKV).

RESULTS

The rate of AR at 6 months was 0% (0/25) and 4% (1/25) at 12 months. The 1-year graft and patient survival rates were 100%. The incidence of DGF was 4% (1/25), while the incidences of CMV and BKV were 0%.

CONCLUSION

Basiliximab induction therapy with a steroid-sparing regimen yields favorable results in two-haplotype-matched LDRT, including a notable reduction in the rates of AR as compared to triple-drug maintenance immunosuppression without induction. These patients have excellent graft survival with no increased incidences of secondary infections.

Using a weight-of-evidence approach for management of watersheds

This research used a weight-of-evidence approach to evaluate sources of contaminants in a drinking water watershed that serves as part of the City of Boston's water supply. The approach incorporated land use analysis using GIS, sanitary surveys, traditional water quality monitoring and microbial source tracking (MST) tools. Case-study tributaries were selected based on elevated faecal coliform counts. Land use analysis and sanitary surveys were used to identify suspected microbial sources, including residential septic systems, agricultural animal operations, commercial/industrial operations and wildlife activity. Sampling sites were selected to hydrologically isolate potential contamination sources. Samples were collected seasonally over 1 year and analysed for traditional and MST parameters. Results demonstrated that both septic systems and a horse stable were contributing microbial loads in the first tributary. In the second tributary, septic systems from the townhouses were contributing microbial loads while a plant nursery was contributing organic matter. This evidence was used to evaluate best management practices to mitigate the contamination.