Cadaveric Kidney Transplantation Research Articles

Reflections on My Lifetime Teacher: Dr. Willem J. Kolff.

Reflections on My Lifetime Teacher: Dr. Willem J. Kolff.

Study of The Effects of N-Acetylcysteine on Oxidative Stress Status of Patients on Maintenance-Hemodialysis Undergoing Cadaveric Kidney Transplantation.

N-acetylcysteine (NAC) is a potent antioxidant that acts through regenerating glutathione stores and scavenging oxygen-free radicals. This study assesses the short-term effects of NAC in cadaveric kidney transplant (KT) recipients. A double blind, randomized, placebo controlled trial was designed and patients were randomly assigned to receive either NAC or placebo. Glutathione peroxidase (GPX) activity in erythrocytes and serum malondialdehyde (MDA) levels were measured and serum creatinine levels and estimated glomerular filtration rate (eGFR) determined in the early phase after transplantation, were also compared between two study groups. Thirty-seven males and 20 females, with mean ± SD age of 44.6 ± 12.4 years completed the study. Significant difference (P = 0.02) was seen between GPX activity reduction in the placebo group, and that of the NAC group and on the levels of MDA there was no significant difference between two study groups (P = 0.53). Significant improvement in immediate graft function (IGF), (68% versus 40%, P = 0.05) and the first week eGFR were observed in the NAC group compared to the placebo group (52.46 ± 2.77 versus 38.75 ± 19.67 mL/min/1.73 m2, P = 0.02). It seems that the protective mechanisms of NAC, other than its antioxidant properties, can be favorable in KT patients.

What Can We Do When All Collapses? Fatal Outcome of Collapsing Glomerulopathy and Systemic Lupus Erythematosus With Diffuse Alveolar Hemorrhage: Case Report

IntroductionCollapsing glomerulopathy (CG) is a rare form of glomerular injury. Although commonly associated with human immunodeficiency virus (HIV) infection, it can occur in association with systemic lupus erythematosus (SLE). Case ReportWe present the case of a 50-year-old man, with chronic kidney disease secondary to focal and segmental glomerulosclerosis, who received a cadaveric kidney transplant in 2007.There were no relevant intercurrences until May 2015, when he presented with nephrotic range proteinuria (± 4 g/d). A graft biopsy was performed and it did not show any significant pathological changes. In September, he developed a full nephrotic syndrome (proteinuria 19 g/d) and a graft biopsy was repeated. CG features were evident with a rich immunofluorescence. Antinuclear antibodies (ANA) and anti-double-stranded DNA (anti-dsDNA) antibodies were positive; the remaining immunologic study was normal. Viral markers for HIV, hepatitis C virus (HCV), and hepatitis B virus (HBV) were negative. The patient was treated with corticosteroid pulses and plasmapheresis (seven treatments). A rapid deterioration of kidney function was seen and he became dialysis dependent. He was discharged with a low-dose immunosuppressive treatment. In October, he was hospitalized with diffuse alveolar hemorrhage (DAH). The auto-immune study was repeated, revealing complement consumption and positive titers of ANA and Anti-dsDNA antibodies. Anti-neutrophil cytoplasmic antibodies (ANCAs) and antiglomerular basement membrane antibody (anti-GBM) were negative. Treatment with intravenous corticosteroids, plasmapheresis, and human immunoglobulin was ineffective and the outcome was fatal. ConclusionThis case report highlights the possible association of CG and SLE. To our knowledge, it is the first case of SLE presenting with CG and DAH, with the singularity of occurring in a kidney transplant recipient receiving immunosuppression.

En Bloc Cadaver Kidney Transplantation From a 9-Month-Old Donor to an Adult Recipient: Maturation of Glomerular Size and Podocyte in the Recipient.

BackgroundFavorable outcomes of en bloc pediatric donor kidney transplantation to adult recipients are attributed primarily to grafting of twice the nephron mass of a single kidney.MethodsThe kidneys of a 9-month-old male infant were transplanted en bloc in a 56-year-old man. Biopsies were performed 1 hour postreperfusion, 6 months and 3.5 years posttransplant.ResultsWarm and cold ischemia times were 21 and 426 minutes, respectively. The recipient was released from hemodialysis 10 days posttransplant and discharged 91 days posttransplant when serum creatinine was 0.9 mg/dL. At 4 years and 9 months posttransplant, serum creatinine was 1.0 mg/dL, and estimated glomerular filtration rate was 58.0 mL/min per 1.73 m2. The grafts increased in size until they reached adult size by 3 months posttransplant. The glomerular area and volume, respectively, increased from 5.9 × 103 μm2 and 0.34 × 106 μm3 at 1 hour postreperfusion to 14.9 × 103 μm2 and 1.27 × 106 μm3 at 3.5 years posttransplant, both of which were less than half of adult size. At 1 hour postreperfusion, podocytes were structurally immature. At 6 months posttransplant, podocyte immaturity was still evident. At 3.5 years posttransplant, podocytes were mature.ConclusionsThese findings suggest that podocytes and glomerular size of pediatric donor kidneys can continue to mature in adult recipients at rates appropriate for donor age when transplanted en bloc. The maturational levels of podocytes and glomeruli may also be a factor involved in favorable outcomes of en bloc pediatric donor kidney transplantation.

Hypoxia-Inducible Factor-1α Expression in Kidney Transplant Biopsy Specimens After Reperfusion Is Associated With Early Recovery of Graft Function After Cadaveric Kidney Transplantation

BackgroundIschemia/reperfusion injury during kidney transplantation (KTx) delays allograft recovery. Hypoxia-inducible factor-1α (HIF-1α) is the key regulator of the protective response to ischemia/reperfusion injury. We evaluated the impact of the HIF-1α signaling pathway on allograft recovery during cadaveric KTx. MethodsBetween 1996 and 2015, 46 patients underwent cadaveric KTx. The expression levels of HIF-1α-related proteins, including phosphoinositide 3-kinase, phosphorylated (p)-Akt, p-mammalian target of rapamycin, p-Eukaryotic translation initiation factor 4E, p-S6 ribosomal protein, and HIF-1α, were immunohistochemically evaluated and semi-quantitatively scored in graft biopsy specimens after 1 hour of revascularization. Ten kidney biopsy specimens collected during donor nephrectomy for living KTx were used as controls. Delayed graft function (DGF) was defined as the need for dialysis within 1 week of KTx. We compared the staining scores of each protein and several clinical parameters between patients with and those without DGF. ResultsExpression levels of all six proteins in specimens after revasculization were elevated compared with those in controls. Thirty-five patients had DGF. Expression levels of PI3K, p-AKT, p-mTOR, p-eIF4E, and HIF-1α were significantly higher in patients without DGF than in those with DGF. Univariate analysis identified expression levels of p-Akt, p-S6, and HIF-1α, in addition to donor type (heart beating/non-heart beating), cold ischemic time, and donor age as significant predictors of DGF. Of these, only expression levels of HIF-1α and donor type were independently associated with DGF in multivariate analysis. ConclusionsUp-regulation of HIF-1α in allografts after reperfusion may be a predictor of early recovery after cadaveric KTx.

Analysis of Donor Factors for Non–Heart-Beating Donors With Regard to Cadaveric Kidney Transplantation in the Western Region of Japan

BackgroundKidneys from non–heart-beating donors are thought to be marginal, and careful evaluation is required. Mass analyzed data are limited, and each transplant surgeon must evaluate these organs on the basis of their own experience. MethodsWe analyzed the data of 589 kidneys used for kidney transplantation from 304 non–heart-beating donors from January 2002 through December 2013 at the Japan Organ Transplant Network West Japan Division. The age of the donors, cause of death, and total ischemic time of more than 24 hours were factors that influenced the graft survival of the organs. ResultsOn the other hand, the final serum creatinine level before donation (maximum, 12.4 mg/dL), the presence and duration of anuria (maximum, 92 hours), and the presence of cannulation did not influence the graft survival rate. ConclusionsIn multivariate analysis of Cox proportional hazards regression analysis, graft survival was significantly related to the age of the donor (over 70 years of age), cause of death (atherosclerotic disease), and total ischemic time of more than 24 hours.

The World's Youngest Cadaveric Kidney Transplant: Medical, Surgical and Ethical Issues.

BackgroundWe report here the first successful transplant from a preterm cadaveric donor. This was performed in November 1994. The donor, who had been born at about 33 weeks of gestation, was diagnosed as having agenesis of the corpus callosum. The transplant was carried out 10 days after the donor's birth. The recipient was a 17-month-old boy with a diagnosis of Denys-Drash syndrome (WT1 mutation).MethodWe describe and analyze the ethical, social, cultural, medical and surgical issues encountered and how these were addressed. The major issue of determining death in a beating heart, very young donor was dealt with in the absence of worldwide experience and guidelines.ResultsThe transplanted recipient has lived with the grafted pair of kidneys for more then 22 years. He has led a relatively normal life.ConclusionsIt is possible for immature preterm deceased donor kidneys to be transplanted into a 17-month-old recipient and for the grafted kidneys to grow with the recipient and function for 22 years. There were challenges in ethically determining the death of the donor, in surgical techniques to obviate potential surgical complications, and in postoperative care of the recipient, but these were managed successfully.

Short-Term Outcomes of 100 Consecutive Kidney Transplantations in a 3-Year Period: A Single-Center Experience

BackgroundThe results of kidney transplantation have improved significantly in the last decade with patient and graft survival rates that range from 92% to 95%. MethodsWe analyzed the clinical results in the last 100 consecutive patients with a follow-up of 6–42 months at our institution. We also made a general evaluation of the patients before surgery as candidates for transplantation and divided them into 3 groups (good, moderate, and poor). ResultsWe had 8 living donors and 92 cadaveric kidney transplantation cases. Principal cause of donor death was cerebrovascular disease accounting for 64%. Mean age of recipients was 55.1 ± 12.9 years with a total of 65 males. Currently there are 96 functioning allografts. During this 3-year period, 2 patients suffered graft loss and 2 patients died with a functioning allograft. We studied whether there were statistically significant differences in renal function (Modification of Diet in Renal Disease Study Equation [MDRD]) at 12 months and at last visit with respect to the evaluation of recipient as candidate for renal transplantation. ConclusionOur observations suggest great improvement of early results of renal transplantation in recent years, including complex cases. In this 3-year period we had a patient survival rate of 98% and a graft survival rate of 96% of cases. Further dedicated prospective studies that aim to evaluate or to propose possible recipient-related predictors for kidney transplantation outcomes in different populations are needed.

Renal transplantation experience in Cairo University hospitals

Worldwide, the population treated with renal replacement therapy is increasing, representing ~1.3 million patients who undergo dialysis and 400 000 patients who are alive with a kidney transplant. Transplantation is more predictable than it was 20–30 years ago and innovation over the last 20 years has been rapid, delivering substantial short-term and medium-term improvements. Many reports have been published about the epidemiology of renal transplantation in different countries. The aim of this study was to identify the epidemiology of renal transplantation in Cairo University hospitals. This is a retrospective study that was conducted at the King Fahd Unit, Faculty of Medicine, Cairo University, on 282 patients. All patients were followed up for a period of at least 1 year. Demographic data, history taking, clinical examination, immunosuppressive medications protocol, and laboratory investigations were recorded for every patient. Of the 282 patients included in the study, 68.1% of recipients were male and 31.9% were female, whereas 52.5% of donors were male and 47.5% were female. An overall 98.6% of our patients received living kidney transplants, whereas 1.4% received cadaveric kidney transplants. The most common cause of end-stage renal disease was unknown etiology. The mean BMI increased significantly after transplantation to reach 22.6±4.0 (P=0.0001). Hypertension was the most common disease among the patients; 82.2% of our patients were already hypertensive before transplantation. The majority of our recipients were male patients in their second and third decades of life, Moreover, the majority of donors were also male individuals in their second and third decades of life. Most of the transplants carried out by us are living-donor procedures.

Early and Long-Term Outcomes of Kidney Grafts Procured From Multiple-Organ Donors and Kidney-Only Donors

BackgroundThe deceased-donor kidney pool consists of 2 different populations: multiple-organ donors (MOD) and kidney donors alone (KDA). In MOD, more complicated procedure and lowest priority for kidney procurement may affect graft survival. On the other hand, poor donor status and higher comorbidity are more frequent in KDA transplants. The aim of this study was to provide detailed characteristics of the 2 groups of kidney donors (KDA vs MOD) in our center and to analyze the potential influence of the donor type on the early and long-term kidney graft function and recipient outcome. MethodsWe performed a retrospective analysis of 729 first cadaveric kidney transplant recipients: 499 of them received the organ from MOD, 230 from KDA. ResultsThe frequency of delayed graft function (DGF) was higher in KDA than in MOD transplants (38.7 vs 25.1%; P < .001). Multivariate logistic regression analysis revealed that donor age, KDA, and early acute rejection independently increased the risk of DGF occurrence, whereas recipient age and cold ischemia time increased the risk of primary graft nonfunction. Kidney excretory function was significantly worse in KDA up to 10 years after transplantation. There were no differences in kidney graft and patient survivals, frequency of proteinuria, acute rejection, and cytomegalovirus episodes, and post-transplantation diabetes. Conclusions(1) The use of a kidney from KDA negatively affects early and late kidney graft function compared with MOD. (2) The long-term kidney graft and patient survivals are not affected by the type of organ procurement.

Nephropathy Evolving Within the First Two Posttransplant Months With No Typical Cytopathic Lesions: Two Cases Presentation

BackgroundWe report 2 cases of polyomavirus-associated nephropathy (PyVAN) emerging within the initial 8 posttransplant weeks. These cases were characterized by intraepithelial BK virus replication without typical nuclear inclusions in epithelial cells. Methods and ResultsA 70-year-old male recipient of a cadaveric kidney transplant had experienced unsatisfying graft function since the time of transplantation (Tx). One month after Tx, results of a graft biopsy revealed mild tubulointerstitial inflammation. No intraepithelial nuclear inclusions suggestive of viral infection were present at that time. The patient received intravenous methylprednisolone, and the dosage of tacrolimus was increased. Due to a further drop in the glomerular filtration rate, a subsequent kidney biopsy was performed during posttransplant week 10, which revealed lesions typical of PyVAN. Retrospectively performed SV40 staining revealed that intragraft polyomavirus replication was already present on posttransplant day 30. Basic immunosuppression reduction and ciprofloxacin administration were followed by BK viremia elimination, stabilization of graft function, and resolution of PyVAN. In another patient, a 62-year-old male recipient of a cadaveric renal graft, BK viremia was monitored from the time of Tx. Two months after Tx, the patient was found to have a BK viral load of 6 × 4 log10/mL. Results of the graft biopsy revealed fully preserved tubular epithelium, but SV40 staining was positive in some of these cells. After basic immunosuppression reduction and introduction of ciprofloxacin, the BK viral load dropped to 1 × log10/mL with graft function stabilization. ConclusionsPyVAN may emerge as early as 4 weeks after Tx, with near-normal or acute rejection–like graft morphology. The early monitoring of plasma BK viral load, as well as SV40 staining, avoids misdiagnosis of this severe posttransplant complication.

Study of Cadaveric Kidney Transplantation: A Single Center Experience

BackgroundTo increase the number of cadaveric kidney transplants in Japan, it is necessary to proactively perform transplantation from marginal donors. We had the opportunity to frequently perform kidney transplantation from expanded-criteria donors (ECDs), and it is anticipated that there will be increases in the number of ECD kidney transplants. MethodsIn our institution, 18 patients underwent cadaveric kidney transplantation from January 2001 to December 2011. Sixteen of those patients were classified into 2 groups according to donation after brain death (BD) or after cardiac death (CD). We also classified donors as ECDs or standard-criteria donors (SCDs). ResultsKidney graft survival and engraftment were observed in all of the patients. Renal function at 1 year after transplantation was significantly better in the BD group than in the CD group. However, there was no significant difference between the groups in renal function at 3 and 5 years. Renal function at 1 and 3 years after transplantation was significantly better in the SCD group than in the ECD group, but there was no difference in renal function between the SDC and ECD groups at 5 years. ConclusionsThe results were good for all of the patients. There are many reports that graft survival rate at 3–5 years after transplantation from ECDs is poorer than from SCDs. However, no statistically significant difference was found in kidney function at ≥5 years between the ECD and SCD groups in our patients.

MP32-08 THE EFFECT OF HYPOXIA-INDUCIBLE FACTOR-1? EXPRESSION IN BIOPSY SPECIMEN AFTER REPERFUSION ON THE EARLY RECOVERY OF GRAFT FUNCTION AFTER CADAVERIC KIDNEY TRANSPLANTATION

You have accessJournal of UrologyTransplantation & Vascular Surgery: Renal Transplantation & Vascular Surgery II1 Apr 2016MP32-08 THE EFFECT OF HYPOXIA-INDUCIBLE FACTOR-1? EXPRESSION IN BIOPSY SPECIMEN AFTER REPERFUSION ON THE EARLY RECOVERY OF GRAFT FUNCTION AFTER CADAVERIC KIDNEY TRANSPLANTATION Teruyuki Oda, Takeshi Ishimura, and Masato Fujisawa Teruyuki OdaTeruyuki Oda More articles by this author , Takeshi IshimuraTakeshi Ishimura More articles by this author , and Masato FujisawaMasato Fujisawa More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.1303AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Ischemia/reperfusion injury during kidney transplantation delays allograft recovery. Hypoxia-inducible factor-1a (HIF-1a) is considered to be the key regulator of cell response to hypoxia and regulates several genes responsible for tissue protection. In this study, we evaluated the expression levels of major proteins mediating HIF-1a signaling by immunohistochemical staining of graft biopsy specimens at 1-h of revascularization during cadaveric kidney transplantation, and examined the correlation between these findings and recovery of allograft function. METHODS Between 1996 and 2015, 46 patients underwent cadaveric kidney transplantation at our institution. Of these, 15 patients received kidneys from heart beating donors (HBDs) and 31 from non-heart beating donors (NHBDs). Immunohistochemical staining was performed to evaluate the expression levels of HIF-1a-related proteins, including PI3K, phosphorylated (p)-Akt, p-mammalian target of rapamycin (mTOR), p-eIF4E, p-S6 ribosomal protein, and HIF-1a in graft biopsy specimens at 1 h of revascularization (1H). Based on the percentage of positive staining area in the specimen, immunohistochemical findings were scored from 0 to 3. 0-hour biopsy specimens from 10 who underwent living-donor kidney transplantation (0H) were used as control. Delayed graft function (DGF) was defined as the need for dialysis within the first week after kidney transplantation. We compared the staining score of each protein and several clinical parameters between patients with and without DGF. RESULTS Expression levels of all 6 proteins were elevated at 1 H compared with those at 0H, with significant differences for pAKT, pS6, and HIF-1a. Thirty five patients experienced DGF. We observed significant higher expression of all 6 proteins, in patients without DGF than in DGF patients. Univariate analysis identified the expression levels of p-Akt, p-S6, and HIF-1a, in addition to donor type (HBD/NHBD), cold ischemic time, and donor age as significant predictors of DGF. Of these 6 significant parameters, only the expression levels of HIF-1a and donor type were found to be independently associated with DGF on multivariate analysis. CONCLUSIONS In conclusion, up-regulation of HIF-1a in allograft biopsy specimens after reperfusion might be a predictor of early recovery of graft function in cadaveric kidney transplantation. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e430 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Teruyuki Oda More articles by this author Takeshi Ishimura More articles by this author Masato Fujisawa More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Cadaver Kidney Demand Forecasting and Classification Modelling of Kidney Allocation–A Case Study

Cadaver kidney transplantation is one of the most promising treatment options available to end stage renal disease patients. However there has been a lot of ethical, operational and medical issues centered on the waiting list and kidney allocation. The initial phase of the study uses time series forecasting techniques to addresses the growth and style of cadaver kidney demand in a variety of scenarios. The second phase deals with the kidney allocation, characterizing the demarcation between met demand (allocated) and unmet demand (not allocated) using classification technique, a prominent tool of data mining. It is observed from the study that the overall demand for kidney shows an increasing linear trend in the future. It is also seen that aged patients, patients with blood group O etc. poses higher risk of non-allocation. The study highlights the need for a comprehensive and holistic system for kidney allocation.

The Evolution of Living Kidney Donation and Transplantation in Older Adults.

Kidney transplantation is a good option for adults aged 65 and older with end-stage renal disease because it has been shown to reduce morbidity and mortality, improve quality of life, and is more cost-effective than other renal replacement options. However, older age has been a deterrent to access to the deceased donor waiting list, and individuals aged 65 and older have a lower probability of being referred to and listed for transplantation compared to younger adults. Because the deceased organ supply is limited, living donor kidney transplantation offers an effective alternative for older adults facing long waiting times for cadaveric organs. This article describes the evolution of living kidney donation and transplantation in older adults over 15years using the Organ Procurement and Transplantation Network/Scientific Registry of Transplant Recipients database. Between 1997 and 2011, 28,034 kidney transplantations were performed in adults aged 65 and older. Living-donor and cadaveric kidney transplantation increased in older adults over the 15-year period. Offspring are the most common living donors in this age group, followed by unrelated donors (e.g., friends), whereas the most common donors in younger transplant recipients are spouses, siblings, and parents. The number of living kidney donors aged 65 and older is slowly increasing, although the total number of transplants in this age group remains low. The expansion of living-donor kidney transplantation in the aging population may offer a solution for organ shortage and thereby improve the quality of life of older adults. More research is needed to understand the older donor-recipient relationship and barriers to transplantation in this population.

Association between flow cytometric crossmatching and graft survival in Thai cadaveric-donor kidney transplantation.

The flow cytometry cross-match (FCXM) technique is a sensitive method and has been reported to predict and protect graft rejection more efficiently than the conventional complement-dependent cytotoxicity cross-match (CDCXM) and the anti-human globulin-complement dependent cytotoxicity (AHG-CDC) methods. We performed retrospective FCXM in 270 cadaveric donor kidney transplant patients with negative CDC and AHG. The correlation between FCXM with graft rejection and graft survival within 1 year to 3 years was analysed. There were 97 (35.9%) samples with positive FCXM. Only 7 (2.6%) of the 270 samples had evidence of antibody-mediated rejection (AMR) at the first year, which increased to 10 (3.7%) AMR samples after 3 years. Interestingly, there was a significant association between FCXM results with the graft outcome at 1 year (P = 0.046). However, when the association was analysed at 3 years after transplantation, it did not reach statistical significance. FCXM detected concordant positive results in 4 out of 8 samples. These samples had mean fluorescence intensity (MFI) of the donor-specific antibody (DSA) higher than 2,000. The DSA was identified by a single antigen bead. Although positive FCXM, particularly for HLA class I, was significantly associated with graft loss from AMR within 1 year of transplantation in this study, there were a lot of FCXM false positives, as high as 35.9%. Additional studies are required to further assess the usefulness of FCXM in Thailand.

Severe Anemia Due to Parvovirus Infection Following Treatment with Rituximab in a Pediatric Kidney Transplant Recipient : Anemia after Treatment of Rituximab in Kidney Recipient Patient

Rituximab (RTX), a monoclonal antibody against the B-cell marker CD20, is commonly used as a treatment for antibody-mediated diseases or B-lymphocytemediated diseases. Destruction of B cells may reverse the disease course in many conditions; however, patients who are treated with RTX cannot respond appropriately to de novo infection due to lack of B lymphocytes. Here, we report one such case. A 7-year-old renal allograft recipient presented with severe anemia due to parvovirus infection after RTX treatment. The patient had focal segmental glomerulosclerosis and had received cadaveric kidney transplantation 6 months previously. She was treated with high-dose steroid for acute rejection and RTX for Epstein Barr Virus infection 3 months previously. At presentation, her hemoglobin level was 5.4 g/dL and leukocyte and platelet counts were normal. She had microcytic normochromic anemia and high viral load of parvovirus B19(70,578 copies/mL). Intravenous immunoglobulin (200 mg/kg·d) treatment controlled the progression of anemia and parvovirus infection. De novo parvovirus infection during the B lymphocyte-depletion period may have precipitated the severe anemia in this case. Close monitoring of infection is required after RTX therapy.

Assessment of Hemostasis after Plasma Exchange Using Rotational Thrombelastometry (ROTEM).

BackgroundTherapeutic plasma exchange (TPE)-based protocols immediately before cadaveric donor kidney transplantation have been extensively used in highly sensitized recipients. Plasma is generally preferred over human albumin as replacement fluid to avoid depletion of coagulation factors and perioperative bleeding. The aim of this study was to estimate bleeding risk after TPE replaced with albumin using rotational thromboelastography (ROTEM).MethodologyTen patients without overt coagulation abnormalities underwent TPE. Standard laboratory coagulation tests (thromboplastin time, activated partial thromboplastin time (aPTT), international normalized ratio (INR), thrombin clotting time, fibrinogen levels and antithrombin activity) were compared with thrombelastometry analysis (EXTEM and INTEM tests) before and after TPE.Principal FindingsTPE significantly reduced fibrinogen levels (482 ± 182 vs. 223 ± 122 mg/dL), antithrombin activity (103 ± 11 vs. 54 ± 11 %), and prolonged aPTT (28 ± 3 vs. 45 ± 8 s), thromboplastin time (108 ± 11 vs. 68 ± 11 %), INR (0.95 ± 0.06 vs. 1.25 ± 0.16), and thrombin clotting time (18 ± 2 vs. 20 ± 3 s). INTEM and EXTEM analyses revealed significantly prolonged clot-formation time and reduced maximum clot firmness.Conclusions/SignificanceTPE replaced with albumin induces significant changes in global hemostasis parameters thus potentially increasing bleeding risk. Therefore, pretransplant TPE should be considered carefully in indicated patients before kidney transplantation. The role of the ROTEM point-of-care test to estimate the risk of bleeding in renal transplantation needs to be evaluated in further studies.

2012 ERA-EDTA Registry Annual Report: cautious optimism on outcomes, concern about persistent inequalities and data black-outs

The 2012 ERA-EDTA Registry Annual Report contains both good news and bad news. On the bright side, the 2-year survival of patients starting renal replacement therapy (RRT) for chronic kidney disease (CKD), on dialysis or receiving a living-related kidney transplantation, has progressively increased to 82.2, 79.7 and 98.3%, respectively, whereas for cadaveric kidney transplantation it remains stable (96.0–96.1%). On the dark side, inequalities persist between European citizens in access to renal transplantation and in incidence and prevalence of RRT. Living in Greece, Belgium (French- or Dutch-speaking) or Portugal (the GBP countries) is associated with higher chances of initiating RRT than living in other European countries. The adjusted RRT incidence for GBP countries was 188, 201-174 and 220* (* unadjusted) pmp in 2012, respectively (versus 122, 114 and 97 pmp in the Netherlands or two Spanish regions bordering Portugal). In lower income countries, a low RRT incidence may represent lack of access to needed healthcare (e.g. Montenegro 26 pmp). However, how can the high incidence and prevalence of RRT in the GBP countries be explained? Do GBP citizens have access to RRT that is denied, rejected or considered unnecessary in other high income countries? Does the GBP healthcare system fail to prevent progression of CKD? Do local genetic or environmental factors favour CKD progression? Unravelling the underlying reasons is an urgent research need: only an understanding of the causes will allow correction of the problem. Unavailability of data from some large countries (e.g. Germany and Italy) is not helpful.

Robotic Partial and Radical Nephrectomy in Renal Allograft: Demonstration of Technique

Introduction: Renal tumors in allografts are rare but a serious condition. It presents a challenging clinical scenario where proper radiologic evaluation is commonly hindered by the suboptimal renal function. When surgical intervention is indicated, nephron sparing approaches are confronted with a risk of metastasis in an immunocompromised host, whereas graft nephrectomy results in significant postoperative morbidity and mortality as dialysis is reinitiated. Regardless of the surgical plan, graft surgery can be associated with significant vascular morbidities secondary to the dense desmoplastic reaction surrounding the anastomotic areas. Robotic surgery allows meticulous anastomotic dissection due to benefits of magnification, three-dimensional vision, and enhanced seven degrees of freedom of the robotic instruments. This may increase the chances of graft preservation. Moreover, it offers the benefits of minimally invasive surgery with less pain, shorter hospitalization, and less blood loss if total graft nephrectomy is desired. Methods: In this video, we are describing our technique of both robotic partial and total graft nephrectomy in a patient who was found to have a 1.4 cm allograft mass. The patient is a recipient of an extended criteria cadaveric kidney transplant 3 years before presentation. Evaluation was triggered by the fact that the recipient of the contralateral cadaveric kidney developed donor-derived squamous cell carcinoma originating from the allograft. Results: In this video, we demonstrated the key steps in the procedure, which included early control of the external iliac artery, release of the desmoplastic reaction around the transplanted vessels, vascular pedicle control, lysis of adhesions between the kidney and anterior abdominal wall, ultrasound-guided tumor excision, and renorrhaphy. Finally, the frozen section of the partial nephrectomy specimen revealed squamous cell cancer with negative margin. However, we felt that a radical nephrectomy was clinically indicated. Final pathology revealed T3 squamous cell carcinoma. Conclusion: Robotic approach may play a role in partial and the more commonly performed graft nephrectomy. It may provide an opportunity for better vascular dissection and offer the patient a minimally invasive approach to this challenging procedure. No competing financial interests exist. Runtime of video: 8 mins