Contraindication For Kidney Transplantation Research Articles

MO984IMPACT OF RECIPIENT BODY MASS INDEX ON KIDNEY TRANSPLANTATION OUTCOME: A SINGLE CENTER EXPERIENCE

Abstract Background and Aims Kidney transplantation is the best treatment modality for ESRD patients. Obesity is not considered a contraindication for kidney transplantation. However, impact of obesity on the recipient after transplantation is considered a point of interest due to high metabolic complications associated with both transplantation and obesity. Our aim is to evaluate the effect of obesity on kidney transplant recipients regarding metabolic derangement, early surgical complications, and patient and graft survival. Method This retrospective, cohort study was performed in Mansoura Urology and Nephrology Center, Egypt and it included 460 kidney transplant recipients (KTRs) who underwent renal transplantation from living donors between March 1976 and December 2015 with age ranged from 19 to 55 years who were divided into 3 groups according to their BMI at time of transplantation: Group I: normal (BMI<25, 230 KTRs), Group II: overweight (BMI 25-30, 70 KTRs), Group III: Obese (BMI >30, 160 KTRs). The 3 groups were compared regarding baseline characteristics, transplantation data, post-transplantation medical, surgical complications, graft outcome, graft and patient survival. Results Baseline demographic data regarding age, sex of both recipients and donors and immunologic data were comparable. Pre-transplant hypertension and hypercholesterolemia was higher among obese and over-weight patients (p value: 0.003, 0.0001). While, incidence of diabetes, ischemic heart disease and hyperuricaemia was comparable. Ischemia time was comparable but time to diuresis was delayed among over-weight group with statistical significant difference (p value: 0.012). No statistical significant difference regarding either induction or maintenance therapy. Obese group had the highest incidence of rejection episodes. The difference has statistical significance (p value< 0.029). Also, the number of rejection episodes was higher among obese and over-weight groups than normal-weight group (p value< 0.006). Incidence of post-transplant hypertension, diabetes and trans-aminitis was more prevalent among obese and over-weight groups (p value< 0.035, 0.0001 and 0.003 respectively). Also, ischemic heart disease and hyperuricemia incidence higher prevalence among over-weight (p value< 0.048 and 0.03 respectively). 57.2% of over-weight and 70.1% of obese patients were controlled for hypertension by more than 1 drug while 73.3% of normal weight patients were controlled by 1 drug (p value: 0.012). Higher percent of obese patients required insulin for diabetic control (p value: 0.001). Lymphocele and wound dehiscence incidence was more frequent among obese and over-weight groups (p value<0.001, 0003). Serum creatinine levels after 1, 2 and 3 years were higher in obese group (p value< 0.035, 0.0001 and 0.003). At last follow-up, serum creatinine and creatinine clearance were comparable. Five, 10 and 15 years graft and patient survival were comparable among the studied groups with no statistical significant difference. Conclusion Metabolic complications of transplantation were exaggerated by obesity. Higher BMI at time of transplantation is associated with higher incidence and difficult control of hypertension, diabetes and surgical complications. Obese patients were controlled by higher doses and additional medications for hypertension and diabetes. Overall graft and patient survival were not affected.

Incidence and Outcome of Post-Transplant Cancer in Kidney Recipients with or without Pre-Transplant Malignancies

Background: Previously, pre-existing cancers were considered a contraindication for kidney transplantation. Meanwhile, due to improved screening and treatment options, the prevalence of dialysis patients with cancer history is increasing. Potentially these patients could be eligible for kidney transplantation.

P1695OUTCOMES OF KIDNEY TRANSPLANTATION IN RECIPIENTS WITH MENTAL RETARDATION

Abstract Background and Aims Mental retardation in patients with chronic kidney disease is a relative contraindication for kidney transplantation. Currently, in the literature there are limited outcome data in renal transplant recipients with mental retardation and approaches to decision of transplantation changes in different centers. The aim of this study is to evaluate the results of kidney transplantation recipients with mental retardation in our center. Method In this study, we examined retrospectively 8 kidney transplant recipients with mental retardation in Renal Transplantation Unit of Ankara University School of Medicine between 2006-2018 years. Results The cause of mental retardation in these patients were; genetic syndromes in three patients, meningoencephalitis in one patient, prematurity in one patient, and chromosomal abnormality in one patient. In two patients, the cause of mental retardation is unknown. All patients had good social support for drug compliance and follow-up. The causes of end-stage renal failure were; cystic kidney disease in three patients, hypertensive nephropathy in one patient and vesicoureteral reflux in one patient. In three patients, the etiology of kidney disease is unknown. At the time of pretransplantation period evaluation, six candidates were receiving hemodialysis and two candidates were receiving peritoneal dialysis respectively. Mean dialysis duration before transplantation was 50.7±22.8 months (min 4-max 180). Cadaveric kidney transplantation was performed in three of eight patients (deceased donor kidney allocated to patient with medical urgency in the event of potential imminent loss of dialysis access in one patient and in normal conditions in two patients) and living kidney transplantation was performed in five patients. The mean follow-up period after transplantation was 54.1±48.0 months. Three patients had early posttransplant complications; including urinary tract infection in three patients, deep vein trombosis in one patient and cardiopulmoner arrest with septic shock secondary to femoral graft infection and parailiac abscess in one patient (Table). No patients underwent graft biopsy and no patients experienced acute rejection episode. At the end of the follow-up time, graft and patient survival were 100%. Conclusion Mental retardation is not a contraindication for kidney transplantation in candidates without the history of noncompliance with proper social support.

1982-P: Laparoscopic Sleeve Gastrectomy as Bridge to Kidney Transplantation: Pilot Study in Subjects with Renal Failure and Obesity

Obesity and associated metabolic complications are established risk factors for the development and progression of chronic kidney disease; however, BMI (body mass index)>35 kg/m2 is a contraindication for kidney transplantation. The aim of our study was to reduce excess body weight via laparoscopic sleeve gastrectomy (LSG) in obese patients with end-stage renal disease (ESRD) in order for them to become eligible for the transplantation program. Subjects with ESRD undergoing hemodialysis or peritoneal dialysis and BMI>35kg/m2 without serious comorbidities were included into the study. Anthropometric and biochemical parameters were measured before and 1, 3 and 6 months after LSG. In the thus far enrolled 7 subjects (6 females, aged 47.6 ± 9.6 years) LSG resulted in improved body weight (118.0 ± 17.6 vs. 107.5 ± 14.5 vs. 105.5 ± 14.4 vs. 99.5 ± 10.7 kg for baseline vs. 1 vs. 3 vs. 6 months, p<0.001) and BMI (42.5 ± 3.8 vs. 38.6 ± 3.2 vs. 37.4 ± 2.8 vs. 37.0 ± 3.1 kg/m2 for baseline vs. 1 vs. 3 vs. 6 months, p<0.001) with 3 subjects achieving target BMI<35 kg/m2 1-6 months after LSG enabling their inclusion in the kidney transplantation waiting list. Weight loss was accompanied by significant decrease of systolic (160.0 ± 25.0 vs. 128.7 ± 31.2 mmHg, p=0.042) and diastolic (99.0 ± 13.6 vs. 75.5 ± 12.0 mmHg, p=0.022) blood pressure with antihypertensive medication being reduced in 2 subjects. The only subjects with diabetes mellitus (type 1) showed improvement in fasting glucose (15.8 vs. 9.3 mmol/l) and HbA1c (84 vs. 68 mmol/mol) and a 25% reduction of prandial insulin dose 1 month after LSG. No peri- or postoperative complications have been observed to date. To conclude, our pilot data suggest LSG to be an efficient and safe method to achieve the necessary weight reduction enabling renal transplantation in subjects with renal failure and higher degrees of obesity. Disclosure V. Hrádková: None. M. Kasalicky: None. S. Rajnochova-Bloudickova: None. I. Lankova: None. H. Kratochvilova: None. M. Mraz: None. K. Dvorakova: None. S. Slaba: None. J. Mendl: None. O. Viklicky: None. J. Fronek: None. M. Haluzik: Advisory Panel; Self; Lilly Diabetes, Sanofi. Consultant; Self; Ethicon US, LLC. Speaker’s Bureau; Self; AstraZeneca, Mundipharma International, Novartis AG, Novo Nordisk A/S. Funding Institute for Clinical and Experimental Medicine (00023001)

P1791HLA DESENSITIZATION- INDIAN EXPERIENCE

Abstract Background and Aims There are many barriers to kidney transplant and one of them is presence of donor specific antibodies (DSAs) in the recipients. Presence of strong DSA is considered a relative contraindication for kidney transplantation, however, if DSAs are of weak to moderate then desensitization is attempted in many centres with good success rate. Desensitizing such patients can be an acceptable approach to increase the donor pool and facilitating transplants. This is a retrospective analysis of patients who underwent desensitization at our centre after availability of luminex single antigen (LSA) assay Method Between April 2014 and December 2018, 825 patients underwent kidney transplantation at our centre. Patients who were CDC negative but positive FCXM were further analysed with LSA to know the presence and strength of DSAs. Our protocol for desensitization consisted of plasmapheresis (PP) 1.5 volume by double filtration on alternate day and low dose IV IG 100 mg/kg after each PP. Whenever MFI was <1000 and/or FCXM was negative, patient was taken for transplant with thymoglobulin induction of 1.5 mg/kg for 2-3 doses. All patients were maintained on triple immunosuppression consisting of tacrolimus, mycophenolate mofetil and corticosteroids. We did not routinely followed DSAs in these patients post-transplant if there was no clinical indication. All adverse events during follow up including new onset diabetes after transplant (NODAT), infections, acute rejections (AR), graft loss and death Results Out of 825 patients, 15 underwent HLA incompatible transplants, of which, 8 were males. All patients were first transplant and 11/13 had history of some sensitizing events in the form of blood transfusion and/or pregnancy. The mean dialysis duration was 8.6 ±14.6 months. FCXM was positive in all the patients with 5 patients had T cell flow positive, 8 had B cell flow positive and 2 had both T & B cell FCXM positivity. Most patients had weak to moderate positive flow cross match. On further evaluation by LSA, all these patients had DSAs, with 3/15 had MFI <1000, 6 had MFI between1000-2000, and remaining 6 had MFI >2000, out of which one patient had MFI of 7195 and six patients had multiple DSAs. These patients underwent desensitization with PP and IVIG and the end point of treatment was either MFI < 1000 or FCXM negative. Post- transplant DSAs were done in patients with high MFI or clinically indicated. Two patients had increase in post-transplant DSA titres requiring post-transplant plasmapheresis. The mean follow up was 29±6 months. On follow up, only 1 patient developed borderline cellular rejection one year after transplant, which responded with pulse steroids. Three patients had biopsy for asymptomatic rise in creatinine but it showed patchy ATN with no evidence of rejection.. One patient developed transient CMV viremia, one patient developed lymph node tuberculosis (TB) and two patients had UTI, all of them responded to treatment. There was no graft or patient loss till last follow up. Conclusion This study shows that HLA desensitisation is feasible and successful in if patients are selected carefully and evaluate thoroughly. HLA incompatible transplant can provide a new lease of life to those patients who would otherwise not get a kidney due to lack of paired exchange and deceased donor program

Obesity in kidney transplantation

The prevalence of obesity among patients with chronic kidney disease continues to increase as a reflection of the trend observed in the general population. Factors affecting the access to the waiting list and the transplantability of this specific population will be analysed. From observational studies, kidney transplantation in obese patients carries an increased risk of surgical complications compared to the nonobese population; therefore, many centres have been reluctant to proceed with transplantation, despite this treatment modality confers a survival advantage over dialysis. As a consequence, obese patients continue to face decreased access to the waiting list, with a lower likelihood of being transplanted and higher waiting times when compared to the nonobese candidates. In this review will be described the current strategies for treatment of obesity in different settings (pretransplant, at transplant and post-transplant). Obesity represents a risk factor for surgical complications but not a contraindication for kidney transplantation; outcomes could be greatly improved with its multidisciplinary and multimodal treatment. The modern technology with minimally invasive techniques, mainly using robotic platform, allows a reduction in the surgical complications rate, with graft and patient survival rates comparable to the nonobese counterpart.

Case report: Can a patient with an active cancer receive a kidney transplant?

Introduction: An active cancer is an absolute contraindication for kidney transplantation and a frequent cause of wait-list patient exclusion for long periods. Waiting time for kidney transplantation after the cancer diagnosis/treatment depends on multiple factors such as type of cancer, stage, histological type, prognosis, and physicians’ opinions. Case description: In this study, we describe a case of a 52-year-old man with medullary thyroid carcinoma classified as T1N1bM0 stage IV-A, who received a human leukocyte antigen identical living donor kidney transplantation despite not being biochemically cured. He received maintenance immunosuppression with tacrolimus, prednisone, and mycophenolic acid, switched to everolimus plus prednisone after 8 months. After 5 years, kidney function is excellent and there is no structural recurrence of the disease on imaging tests, although serum calcitonin levels remain elevated but stable. Conclusion: This is the first report that exposes the case of a patient with an active thyroid neoplasm receiving kidney transplantation. The good prognosis of the active neoplasm and the fact of having an identical human leukocyte antigen optimal donor made us proceed with the transplant with an excellent 5-year outcome.

PF811 PREVALENCE OF RHD VARIANTS AMONGST A PORTUGUESE BLOOD DONOR CENTRE

Background: Donor living kidney transplantation (KT) is an available optionfor end-stage renal disease, improving survival and quality of life when compared with other treatments. ABO incompatibility was considered an important barrier for long but, with the increasing organ shortage and due to improvement of immunosuppression protocols, ABO-incompatible (ABOi) KT has achieved remarkable success in the last decades, with graft survivals and patient overall survivals comparable to compatible transplantations. Consensually, initial goal is to lower patient ABO antibodies titter to ≤1:16 before transplantation, ≤1:8 during the first week and ≤1:16 during the second week after surgery. Thereafter, even a rebound of ABO antibodies does not appear to harm the graft due to accommodation phenomenon. Current strategies for desensitization include B-cell-depleting therapies and intensified immunosuppression as well as plasmapheresis to remove ABO antibodies. Aims: Retrospective evaluation of donor/recipient pairs proposed for ABOi Kidney transplantation between 2015 and 2018. Methods: Donor-patient pairs were proposed by the Kidney Transplantation Centre. Patients were evaluated for ABO/Rh group, relationship with donor, diagnosis, pre-KT isoagglutinin anti-A and anti-B (IgG and IgM), pre-KT donor specific HLA antibodies, post-KT isoagglutinin titter (daily up to D14, at D30, and at sixth month after KT), number of plasmapheresis performed (target: IgG isoagglutinin <1: 8 between D0-D7 and <1:16 to D14), graft function titter (serum creatinine), transfusion support, significant associated complications and overall patient survival. An initial IgG isoagglutinin titter ≥1: 512 was considered contraindication for KT as well as the presence of donor specific anti-HLA antibodies. Immunosuppression protocol included rituximab and basiliximab for B cell depletion and standard triple immunosuppression with tacrolimus, mofetil mycophenolate and corticosteroids. Results: We studied 43 donor-receptor pairs for ABOi-KT over a period of four years. Sixteen patients were excluded due to ABO IgG titters ≥1:512 and 10 out of 17 pairs considered suitable for transplantation were transplanted in the considered period. Results are summarized in table 1. Graft survival so far is 100% on a follow-up period between 7 and 49 months. All patients are independent from dialysis and the creatinine level has steady levels (average of 1.61 mg/dL). However, in one patient a renal biopsy performed at sixteenth month documented an incipient glomerulopathy, even if ABO titters maintained low and no evidence of HLA Ab was found out.Summary/Conclusion: The presented results are in accordance with those described by some authors and confirm that ABOi KT is a viable alternative for the treatment of patients with chronic kidney disease, permit to expand the living donor pool and to reduce the time access to transplantation.

PF810 ABO INCOMPATIBLE KIDNEY TRANSPLANTATION – ONE CENTRE EXPERIENCE

Background:Donor living kidney transplantation (KT) is an available optionfor end‐stage renal disease, improving survival and quality of life when compared with other treatments. ABO incompatibility was considered an important barrier for long but, with the increasing organ shortage and due to improvement of immunosuppression protocols, ABO‐incompatible (ABOi) KT has achieved remarkable success in the last decades, with graft survivals and patient overall survivals comparable to compatible transplantations. Consensually, initial goal is to lower patient ABO antibodies titter to ≤1:16 before transplantation, ≤1:8 during the first week and ≤1:16 during the second week after surgery. Thereafter, even a rebound of ABO antibodies does not appear to harm the graft due to accommodation phenomenon. Current strategies for desensitization include B‐cell‐depleting therapies and intensified immunosuppression as well as plasmapheresis to remove ABO antibodies.Aims:Retrospective evaluation of donor/recipient pairs proposed for ABOi Kidney transplantation between 2015 and 2018.Methods:Donor‐patient pairs were proposed by the Kidney Transplantation Centre. Patients were evaluated for ABO/Rh group, relationship with donor, diagnosis, pre‐KT isoagglutinin anti‐A and anti‐B (IgG and IgM), pre‐KT donor specific HLA antibodies, post‐KT isoagglutinin titter (daily up to D14, at D30, and at sixth month after KT), number of plasmapheresis performed (target: IgG isoagglutinin &lt;1: 8 between D0‐D7 and &lt;1:16 to D14), graft function titter (serum creatinine), transfusion support, significant associated complications and overall patient survival. An initial IgG isoagglutinin titter ≥1: 512 was considered contraindication for KT as well as the presence of donor specific anti‐HLA antibodies. Immunosuppression protocol included rituximab and basiliximab for B cell depletion and standard triple immunosuppression with tacrolimus, mofetil mycophenolate and corticosteroids.Results:We studied 43 donor‐receptor pairs for ABOi‐KT over a period of four years. Sixteen patients were excluded due to ABO IgG titters ≥1:512 and 10 out of 17 pairs considered suitable for transplantation were transplanted in the considered period.Results are summarized in table 1.Graft survival so far is 100% on a follow‐up period between 7 and 49 months. All patients are independent from dialysis and the creatinine level has steady levels (average of 1.61 mg/dL). However, in one patient a renal biopsy performed at sixteenth month documented an incipient glomerulopathy, even if ABO titters maintained low and no evidence of HLA Ab was found out.Summary/Conclusion:The presented results are in accordance with those described by some authors and confirm that ABOi KT is a viable alternative for the treatment of patients with chronic kidney disease, permit to expand the living donor pool and to reduce the time access to transplantation.image

The atrial uremic cardiomyopathy regression in patients after kidney transplantation \u2013 the prospective echocardiographic study

BackgroundIn patients with end stage renal disease (ESRD), left ventricular (LV) hypertrophy with impaired LV function, which is called uremic cardiomyopathy (UC) is often observed. The UC historically has been considered a contraindication for kidney transplantation (KTx). Currently, moderate LV dysfunction does not exclude the possibility of KTx. The amelioration of uremia after KTx improved cardiac function in patients with LV dysfunction. There is a little information on the function of the left atrium (LA) after the KTx procedure. There are no studies evaluating (LA) changes in patients with UC after KTx and determining the possibility of inhibiting the occurrence of LA unfavourable changes (remodelling) and even a possible LA recovery process (reverse remodelling) as a result of a successful KTx. The aim of the study was to assess the LA reverse remodelling in patients with ESRD undergoing KTx.MethodsThe study group consisted of 42 patients, aged 43.3 ± 12.6 followed for 36 months after a deceased donor KTx. The patients were studied at five time points: 1, 3, 6, 12 and 36 months after KTx. In all patients transthoracic echocardiography was performed in order to assess the following LA planimetric parameters: LAmax, LAmin, LAwaveP. LAshortmax, LAshortmin, LAshortwaveP, LAlongmax, LAlongmin, LAlongwaveP, LAcircmax and LAareamax, volumentric parameters: LA volume (LAV), LA volume index (LAVI), and hemodynamic indices: LA ejection fraction (LAEF), LA active emptying fraction (LAAE), LA passive emptying fraction (LAPE), LA index of expansion (LAIE) and LA fractional shortening (LAFS).ResultsThe LAVI values were 34.63 ± 10.34 ml/m2, 32.24 ± 9.59 ml/m2 (p < 0,001), 31.36 ± 9.20 ml/m2 (p < 0,001), 28.29 ± 8.32 ml/m2 (p < 0,001) and 27.57 ± 8.40 ml/m2 (p < 0,001), after: 1, 3, 6, 12 and 36 months after KTx, respectively. The reduction of the LA size was accompanied by gradual LA contractility improvement, which was manifested as an increase of the LA hemodynamic indices such as LAEF, LAAE, LAIE, LAFS and a decrease of LAPE.ConclusionsLA remodelling secondary to atrial uraemic cardiomyopathy is an example of complex cardiomyopathy with elements characteristic of both congestive and infiltrative cardiomyopathy. Early LAVI reduction post KTx mostly depends on changed haemodynamic conditions, whereas the main reason for further decrease of LAVI values is related to resolution of uraemic toxaemia.

Effect of Obesity on Clinical Outcomes of Kidney Transplant Patients

PurposeCorrelating with the obesity epidemic, the number of obese transplant candidates is increasing. This study was designed to evaluate the effect of obesity on the survival of our kidney transplant recipients. MethodsAmong 1033 kidney transplants performed during the last 7.5 years in our center, 750 adult recipients were transplanted from living donors and were evaluated, and 561 of them were included in the study. Demographic and clinical data were collected. Body mass index (BMI) values at the time of transplant and post-transplant during the first year, the presence of delayed graft function, hospitalization duration, number of readmissions within the first year post-transplant, presence of post-transplant diabetes mellitus (PTDM) and cardiovascular disease, and graft and patient survival rates at 1, 3, and 5 years were investigated. ResultsObesity (BMI >30) was observed in 148 (19.7%) at the time of the transplant (initial obesity) and in 174 (23.2%) recipients at post-transplant first year. Initial obesity was not only found to be correlated with delayed wound healing (P = .03), increased hospitalization duration (P = .03), number of readmissions within the first year (P = .04), presence of PTDM (P = .02), and cardiovascular disease (P = .03) but also with lower graft survival rate (P = .04) at the first year. On the other hand, obesity at post-transplant the first year was associated with lower 3- and 5-year grafts (P = .04 and P = .03, respectively) and 5-year patient (P = .03) survival rates. ConclusionObesity should not be considered as a contraindication for kidney transplantation; however, to achieve better results, certain precautions should be taken pre- and postoperatively.

Renal Transplantation in Systemic Lupus Erythematosus: Comparison of Graft Survival With Other Causes of End-stage Renal Disease

IntroductionEnd-stage renal disease (ESRD) due to lupus nephritis (LN) occurs in 10%–30% of patients. Initially systemic lupus erythematosus (SLE) was a contraindication for kidney transplantation (KT). Today, long-term graft survival remains controversial. Our objective was to compare the survival after KT in patients with SLE or other causes of ESRD. MethodsAll SLE patients who had undergone KT in a retrospective cohort were included. Renal graft survival was compared with that of 50 controls, matched for age, sex, and year of transplantation. Survival was evaluated by the Kaplan–Meier test and the Cox proportional hazards model. ResultsTwenty-five subjects with SLE were included. The estimated 1-year, 2- and 5-year survival rates for patients with SLE were 92%, 66% and 66%. Renal graft survival did not differ between patients with SLE and other causes of ESRD (P=.39). The multivariate analysis showed no significant difference in graft survival between the two groups (hazard ratio, HR=1.95, 95% confidence interval [CI] 0.57–6.61, P=.28). The recurrence rate of LN was 8% and was not associated with graft loss. Acute rejection was the only variable associated with graft loss in patients with SLE (HR=16.5, 95% CI 1.94–140.1, P=.01). ConclusionsRenal graft survival in SLE patients did not differ from that reported for other causes of ESRD.

P038 Donor specific anti-a titer for abo incompatible (ABOi) living kidney transplantation

To increase the donor options for our active living kidney donor program, candidates who are blood group B may receive a living donor transplant from a non-A1 or non-A1B donor. ABO incompatible donors (ABOi) are no longer an absolute contraindication for kidney transplantation as long as the recipient titer against ABO A is low. It is well known that there are several variations of non-A1 blood groups, and therefore measurement of anti-A titer against commercial A1 or A2 cells may not provide an accurate measurement of donor reactive IgG antibody to blood group A antigens. Therefore, we have initiated a strategy of assessing anti-A titers using red cells from the prospective non-A1 donor being evaluated. The candidate will have initial non-A1 titers performed with commercially produced A2 red cells as well as red cells from the intended living donor. This will help identify the rare instance of a more or less immunogenic ABO A subgroup. Recipient sera is serially diluted with saline from 1:1 to 1:32 in a standard tube assay. One drop of RBC suspension (50 ul) is added to 2 drops (100 ul) of each sera dilution. Tubes are incubated at RT for 30 min, centrifuged and agglutination macroscopically observed and recorded. This provides measurement of the IgM non-A1 titer present in the recipient. Tubes are then incubated at 37C for 30 min, washed 4 times with saline, IgG added, then centrifuged and agglutination recorded again to provide IgG non-A1 titer results. To be considered compatible for non-A1 or non-A1B donors, the IgG titer obtained with A2 reagent cells should be no higher than 1:16, and no greater than 1:8 with the intended living donor. Titers must be repeated within 48 h prior to transplant. Consistent with initial testing, IgG non-A1 titer results at the time of transplant are considered acceptable if the titer is no greater than 1:16 against commercial A2 red cells, and 1:8 against the red cells of the intended deceased donor. As of the date of this submission we have performed two such ABOi transplants using this testing methodology, with no rejection episodes occurring thus far.

The Impact of Aorto-iliac Calcifications on Patient and Graft Survival in Renal Transplant Recipients Using the TASCII Classification

Introduction Kidney transplantation is the therapy of choice in patients with end-stage renal disease. Aorto-iliac calcifications are a relative contra-indication for renal transplantation, even though the influence on patient and graft survival remains poorly explored. Aorto-iliac calcifications can be classified using the Trans Atlantic Inter-Society Consensus (TASC) II classification, which is based on the presence and extent of aorto-iliac stenotic lesions. The aim of this study is to assess the impact of aorto-iliac calcifications on patient and graft survival using the TASC II classification. Methods This retrospective single-center study included all kidney transplant recipients from 2000-2016 who had imaging-proven pre-transplantation aorto-iliac stenotic lesions. Patients were classified according to the TASC II classification if aorto-iliac stenotic lesions were present. All patients transplanted between 2007-2011 without aorto-iliac stenotic lesions were used as a control group. Primary endpoints were patient and graft survival. Cox regression analysis was used to evaluate risk factors for mortality and graft loss. Results Aorto-iliac stenotic lesions were observed in 78 patients before kidney transplantation. Seven hundred seventy-three patients were included as a control group. Overall patient survival was decreased for every TASC II class (TASC II A: p=0.001; B: p=0.004, C: p<0.001, D: p<0.001). No significant difference was found for 90-day mortality (TASC II A p=0.165; B p=1.000; C p=1.000) and 1-year mortality (TASC II A p=0.143; B p=1.000; C p=1.000) in patients with TASC II A, B or C lesions. Patients with TASC II D lesions had significantly higher 90-day (p=0.006) and 1-year (p <0.001) mortality. Death-censored graft survival was not significantly decreased for TASC II A, B and C compared to the control group (TASC II A p=0.792; B p=0.950; C p=0.160). Multivariate Cox model showed that any TASC II lesion was not a predictor of overall mortality (hazard ratio (HR) 1.52 confidence interval (CI) 0.94-2.46 p=0.091) or graft loss (HR 1.72; CI 0.94-3.17; p=0.080). Discussion This study demonstrates favorable outcomes in patients with TASC II A, B or C lesions with no increased mortality in the postoperative period. As expected, overall patient survival is decreased in patients with TASC II lesions because of cardiovascular comorbidity. The most striking result is similar death-censored graft survival in patients with TASC II A, B or C lesions and patients without any aorto-iliac stenotic lesions. Therefore, kidney transplantation in those patients is possible with favorable outcomes. The TASC II classification seems to be useful to predict patient outcomes. Conclusion Kidney transplantation is a safe procedure in patients with TASC II A, B and C lesions. Graft survival is unaffected by aorto-iliac stenotic lesions. Therefore, aorto-iliac calcifications should not be a contra-indication for kidney transplantation.

Meaning of Positive Anti-HLA Antibodies in Simultaneous Liver-Kidney Transplantation

Background A pretransplant positive cross-match is a contraindication for kidney transplantation, unlike combined liver and kidney transplantation (LKT). It is hypothesized that liver can protect kidney from rejection due to several tolerance inducing mechanisms. Aim To know the meaning of specific and non specific donor anti-HLA antibodies (HLAa) in LKT recipients after measuring periodically Mean Intensity of serum Immunofluorescence (MFI). Methodology MFI Class I and II HLAa were measured each three months in 12 recipients of LKT in a single center study. The mean follow-up was 6 years. We study the influence of positive HLAa on both graft and patient survival, kidney function, antibody mediated acute and chronic rejection comparing with a control group of 51 children in the same center with isolated kidney transplantation and positive HLAa. Results 66% of LKT recipients had positive MFI HLAa; 14% were of class I; 36% of class II and 7% of class I and II. According to HLA DQ antigens were not available in all donors, we only confirmed donor specificity in two recipients. The highest level of MFI HLAa tittre was 10 months after transplantation for class I (17000 MFI) and 53 months for class II (211304 MFI). Survival of the graft at 10 years was 100% in LKT and positive HLAa versus 64% in 51 isolated kidney transplant recipients and positive HLAa. Furthermore, glomerular filtration rate was significantly better in LKT recipients group: 86 versus 71 ml / min / 1.73 m2. There was no rejection in LKT recipients compared to 36% in isolated kidney recipients andthe positive HLAa. Conclusion Positive HLAa are frequent after LKT but this fact does not have bad prognosis and it could probably have a different meaning that the isolated renal transplant. Patients with a LKT and positive HLAa have less risk of rejection, graft loss and better long-term renal function.

P062 Characteristics of pre-formed donor specific anti-HLA antibodies associated with their clearance or persistance

Aim Pre-formed non-cytotoxic donor specific anti-HLA antibodies (DSA) are not a contraindication for kidney transplantation. Such DSA are often cleared post-transplant, having minimal effect on graft function. However, pre-formed DSA can also persist post-transplant, potentially increasing the risk of antibody mediated injury. The aim of this study was to evaluate the characteristics of pre-formed donor specific HLA antibodies (DSA) in relation to their clearance or persistence after transplantation in a large population of kidney allograft recipients. Methods Our study population included 681 patients transplanted at our center from Jan 1st 2009 to Dec 31st 2014. Typing of HLA-A, B, C, DR and DQB genes was performed by DNA methods. Serum anti-HLA antibodies were tested at defined intervals pre- and post-transplantation using Single Antigen Beads (One Lambda/ThermoFisher). Unacceptable HLA antigens were reported to UNET using MFI cutoff values of 5000 (HLA-A, B and DR) and 10,000 (C and DQ). Prospective crossmatches were performed in all cases. Patients were transplanted based on a negative flow cytometry and/or CDC crossmatch. Results Out of 681 recipients, 108 (16%) had pre-formed DSA. At one year post-transplant, DSA were cleared in 67 patients and persisted in 41 patients. Patient age, gender and race, transplant type (live or deceased donor) and the number of DSA per patient did not significantly differ in patients who cleared versus patients with persistent DSA. However, patients with persistent DSA were more likely to have DSA directed to the donor HLA-DQB rather than HLA-A, B, C or DR antigens (p = 0.041; Fig. 1), DSA with higher MFI (p Download : Download high-res image (77KB) Download : Download full-size image Conclusions This study identifies the characteristics of preformed DSA that render them more likely to persist post-transplantation in our patient population. These findings may improve risk stratification of kidney transplant candidates with preformed DSA.

Kidney transplantation from donors with rhabdomyolysis and acute renal failure.

Rhabdomyolysis in deceased donors usually causes acute renal failure (ARF), which may be considered a contraindication for kidney transplantation. From January 2012 to December 2016, 30 kidneys from 15 deceased donors with severe rhabdomyolysis and ARF were accepted for transplantation at our center. The peak serum creatinine (SCr) kinase, myoglobin, and SCr of the these donors were 15569±8597U/L, 37092±42100μg/L, and 422±167μmol/L, respectively. Two donors received continuous renal replacement therapy due to anuria. Six kidneys exhibited a discolored appearance (from brown to glossy black) due to myoglobin casts. The kidney transplant results from the donors with rhabdomyolysis donors were compared with those of 90 renal grafts from standard criteria donors (SCD). The estimated glomerular filtration rate at 2years was similar between kidney transplants from donors with rhabdomyolysis and SCD (70.3±14.6mL/min/1.73m2 vs 72.3±15.1mL/min/1.73m2 ). We conclude that excellent graft function can be achieved from kidneys donors with ARF caused by rhabdomyolysis.

The Diet and Haemodialysis Dyad: Three Eras, Four Open Questions and Four Paradoxes. A Narrative Review, Towards a Personalized, Patient-Centered Approach.

The history of dialysis and diet can be viewed as a series of battles waged against potential threats to patients’ lives. In the early years of dialysis, potassium was identified as “the killer”, and the lists patients were given of forbidden foods included most plant-derived nourishment. As soon as dialysis became more efficient and survival increased, hyperphosphatemia, was identified as the enemy, generating an even longer list of banned aliments. Conversely, the “third era” finds us combating protein-energy wasting. This review discusses four questions and four paradoxes, regarding the diet-dialysis dyad: are the “magic numbers” of nutritional requirements (calories: 30–35 kcal/kg; proteins > 1.2 g/kg) still valid? Are the guidelines based on the metabolic needs of patients on “conventional” thrice-weekly bicarbonate dialysis applicable to different dialysis schedules, including daily dialysis or haemodiafiltration? The quantity of phosphate and potassium contained in processed and preserved foods may be significantly different from those in untreated foods: what are we eating? Is malnutrition one condition or a combination of conditions? The paradoxes: obesity is associated with higher survival in dialysis, losing weight is associated with mortality, but high BMI is a contraindication for kidney transplantation; it is difficult to limit phosphate intake when a patient is on a high-protein diet, such as the ones usually prescribed on dialysis; low serum albumin is associated with low dialysis efficiency and reduced survival, but on haemodiafiltration, high efficiency is coupled with albumin losses; banning plant derived food may limit consumption of “vascular healthy” food in a vulnerable population. Tailored approaches and agreed practices are needed so that we can identify attainable goals and pursue them in our fragile haemodialysis populations.

A High Comorbidity Score Should Not be a Contraindication for Kidney Transplantation.

Currently, potential kidney transplant patients more often suffer from comorbidities. The Charlson Comorbidity Index (CCI) was developed in 1987 and is the most used comorbidity score. We questioned to what extent number and severity of comorbidities interfere with graft and patient survival. Besides, we wondered whether the CCI was best to study the influence of comorbidity in kidney transplant patients. In our center, 1728 transplants were performed between 2000 and 2013. There were 0.8% cases with missing values. Nine pretransplant comorbidity covariates were defined: cardiovascular disease, cerebrovascular accident, peripheral vascular disease, diabetes mellitus, liver disease, lung disease, malignancy, other organ transplantation, and human immunodeficiency virus positivity. The CCI used was unadjusted for recipient age. The Rotterdam Comorbidity in Kidney Transplantation score was developed, and its influence was compared to the CCI. Kaplan-Meier analysis and multivariable Cox proportional hazards analysis, corrected for variables with a known significant influence, were performed. We noted 325 graft failures and 215 deaths. The only comorbidity covariate that significantly influenced graft failure censored for death was peripheral vascular disease. Patient death was significantly influenced by cardiovascular disease, other organ transplantation, and the total comorbidity scores. Model fit was best with the Rotterdam Comorbidity in Kidney Transplantation score compared to separate comorbidity covariates and the CCI. In the population with the highest comorbidity score, 50% survived more than 10 years. Despite the negative influence of comorbidity, patient survival after transplantation is remarkably good. This means that even patients with extensive comorbidity should be considered for transplantation.

Case study: Use of A2 and donor red blood cells for anti ABO a titer

ABO incompatibility (ABOi) is no longer an absolute contraindication for kidney transplantation. Recipients who are either blood group O or B have successfully received kidney transplants from donors who are blood group A, as long as their titer against the donor A antigen is low. Although the predominant A antigen subtype in the population is A1, less than 20% of blood group A individuals are of other subtypes, with weaker antigen expression, A2 being the most common of these. Accurate quantification of the amount of Anti A antibody titer in the recipient against the intended donor is important to determine compatibility for ABOi transplants. A review of the literature demonstrated that there is a high degree of technique variability, especially concerning the target cells utilized to determine such titers. Accordingly, we decided to use A2 and donor RBCs as well as our standard A1 RBCs in our assays, in order to determine the differences in titer when various A subtype cells are utilized as the target. Our case is a 54 year old male; 0% CPRA, blood group O recipient, whose donor was ABO typed as a non-A1. Flow T and B cell crossmatch negative. The transplant program decided to move forward with the ABO incompatible transplant since no other live donors were available. Determination of the Anti-A titer was as follows: Recipient sera was serially diluted with saline from 1:1 to 1:512. One drop of RBC suspension is added to 2 drops (100 ul) of each sera dilution. Three different titrations were performed using commercially produced A1 and A2 RBC as well as donor RBC. Tubes were incubated at RT for 30 minutes, centrifuged and agglutination macroscopically observed and recorded. Tubes were then incubated at 37C for 30 minutes, washed 4 times with saline, IgG added then centrifuged and agglutination recorded again. This procedure allows for determination of both IgM and IgG antibodies against blood group A antigens. IgG titers were 1:16 with A1 RBC; 1:8 with A2 RBC; and 1:8 with donor RBC. Our transplant program considers an IgG titer less than or equal to 1:8 acceptable and the transplant was performed. Recipient is out 11 weeks with no rejection episodes.