Transplant Kidney Research Articles

Infections following rejection therapies in kidney and liver transplant recipients.

Infections are known complications of solid-organ transplant. Treatment for rejection may increase risk of infection. We aimed to study frequency of infection and identify the risk factors for infections in solid organ transplant (SOT) (liver and kidney) recipients treated for rejection. This is a retrospective chart review of all liver and kidney transplant recipients treated for rejection at our institution from 2014 to 2020. We collected information on episodes of acute rejection in the first year of transplant and infections within 6 months following rejection treatment. We identified 257 transplant patients treated for rejection. One hundred twelve (43.6%) developed infections, with a total of 226 infections. Urinary tracts infections were the most common, 72 (31.9%), followed by cytomegalovirus viremia in 37 (16.4%), bacteremia in 24 (10.6%), and BK virus in 14 (6.2%). Female sex (p = .047), elevated neutrophil count at rejection (p = .002), and increased number of rejection episodes (p = .022) were predictors of infection in kidney and simultaneous liver-kidney recipients. No specific type of induction or rejection therapy was identified as a risk factor for infection, likely due to the prophylaxis protocols at our institution. Infection post rejection treatment was associated with higher graft loss (p = .021) and mortality (p = .031) in kidney transplant recipients. Infections are common complications after treatment of SOT rejection. Female gender, higher neutrophil at time of rejection, and increased numbers of rejection episodes were predictors of infections after rejection in simultaneous liver-kidney and kidney transplant patients. Infections were predictors of graft loss at 6 months and mortality at any point in follow-up in kidney transplant patients.

Prevalence of cardiovascular diseases in kidney transplant recipients and its relationship with asymmetric dimethylarginine, fibroblast growth factor-23 and multiple inflammatory markers.

Asymmetric dimethylarginine (ADMA) is an endogenous inhibitor of endothelial nitric oxide synthase, a marker of endothelial damage and progression of atherosclerosis. Research confirms the association of ADMA with an increased risk of cardiac complications and an increased risk of death, graft loss among kidney transplant recipients (KTRs). The aim of our study was to establish the significance of ADMA and FGF-23 as biomarkers of cardiovascular risk as well as predictors of graft failure and progression of chronic transplant kidney disease in comparison to CKD subjects. In addition, an analysis of the relationship between ADMA, FGF23 and cardiovascular diseases in CKD subjects and KTRs was performed. The study group included 132 KTRs. The control group consisted of age- and sex-adjusted 40 individuals with clinically stable CKD. ADMA, FGF-23, hs-CRP and IL-6 were measured by the enzyme-linked immunoassay method (ELISA). Parameters of body mass composition such as fat mass, FTI, lean tissue mass, LTI, body water and overhydration were assessed by multi-frequency bioimpedance analysis (BIA). Cardiovascular diseases (CVDs) were present in 31.8% of KTRs. Independent variables related to nutritional status (SGA, s-albumin), according to multivariate regression, may have an impact on the prevalence of CVD in the kidney transplant recipients' group. Our study findings suggested a correlation between ADMA and serum albumin (r=-0.41, p<0.05), oxLDL (r=-0.42, p<0.05) and overhydration (OH%, r=0.28, p<0.05). Moreover, administration of statins and/or angiotensin-converting-enzyme inhibitors was significantly related to a reduction of ADMA in KTRs. We have also identified a significant positive correlation between FGF-23 levels and inflammatory markers (hs-CRP, IL-6) and negative with overall index of renal function (eGFR-CKD EPI, eGFR-MDRD). Nutritional status, inflammation and endothelial dysfunction markers (ADMA, FGF-23) are considerably altered even in stable kidney transplant recipients.

Sleeve Gastrectomy and Liver Omentoplasty Can Increased Il-10 and TGF-Β Expression on Liver Fibrosis in Obesity

BACKGROUND: Obesity is a risk factor happening liver fibrosis because it makes presence of oxidative stress and inflammation that has role on pathogenesis and hepatic fibrosis progression. Until this moment, liver disease management still focused for treat disease primary, the most rational management of liver fibrosis is liver transplant, however number success transplant liver lower from on transplant kidneys, only 70-80% of recipients survived for at least 1 year, so that sleeve gastrectomy and liver omentoplasty procedure could become a choice for treating liver fibrosis on obese patients.&#x0D; AIM: This study aims to investigate correlation between sleeve gastrectomy and omentoplasty on TGF-β and IL-10 in obese rats with liver fibrosis&#x0D; METHOD: This study used a true experiment in-vivo design on male Wistar rat (Spargue Dawley) 4-6 weeks of age. Samples were divided into groups that includes normal control group, positive control group, group with sleeve gastrectomy, and group with both liver liver omentoplasty and sleeve gastrectomy. The level of TGF-β and IL-10 will be measured for descriptive and hypothesis analysis.&#x0D; RESULT: There is an increased level of IL-10 and TGF-β. Statistical analysis result shows a significant increase of IL-10 and TGF-β expression between normal group and control group with group given treatment sleeve gastrectomy and liver liver omentoplasty (p&lt;0.05).&#x0D; CONCLUSION: liver Liver omentoplasty and sleeve gastrectomy procedure on obese mice with liver fibrosis could increases IL-10 expression but could not reduce (TGF-β expression).

Successful Unilateral Dual-Kidney Transplant of Discarded Kidneys From Two Expanded Criteria Donors

In recent years, dual-kidney transplant has become an established method to overcome the inferior quality of donor organs and to allow the recovery of discarded human kidneys. However, in some cases, 1 of the 2 donor kidneys is unsuitable for transplant because of severe pathological changes, and the remaining marginal kidney is often discarded regardless of whether it meets criteria for dual-kidney transplant. Here, we report the use of marginal kidneys from 2 different donors, both of whom had missed kidney donation as a result of the serious pathological changes in their contralateral kidney. We combined the 2 donors' marginal kidneys for dual-kidney transplant, which were implanted into the right iliac fossa of the recipient after cold ischemia times of 13 hours 40 minutes and 30 hours 30 minutes, respectively. The recipient had fully recovered and showed favorable renal function without complications at discharge and at the 1.5-year follow-up. To the best of our knowledge, this is the first case report of successful unilateral dual-kidney transplant of discarded kidneys from 2 expanded criteria donors.

COVID-19 Vaccination in Kidney Transplant Candidates and Recipients.

Kidney transplant candidates and kidney transplant recipients (KTRs) are at particular risk of severe complications of COVID-19 disease. In Western countries, mortality in affected hospitalized KTRs ranges between 19% and 50%. COVID-19 vaccination remains the most important measure to prevent the severity of infection in candidates and recipients of kidney transplant. However, the uraemic condition may affect the vaccine-induced immunity in patients with advanced chronic kidney disease (CKD) and in KTRs. Retention of uraemic toxins, dysbiosis, dysmetabolism, and dialysis can diminish the normal response to vaccination, leading to dysfunction of inflammatory and immune cells. In KTRs the efficacy of vaccines may be reduced by the immunosuppressive medications, and more than half of kidney transplant recipients are unable to build an immune response even after four administrations of anti-COVID-19 vaccines. The lack of antibody response leaves these patients at high risk for SARS-CoV-2 infection and severe COVID-19 disease. The aim of the present review is to focus on the main reasons for the impaired immunological response among candidates and kidney transplant recipients and to highlight some of the present options available to solve the problem.

Translating Organoids into Artificial Kidneys.

Purpose of Review Kidney disease affects more than 13% of the world population, and current treatment options are limited to dialysis and organ transplantation. The generation of kidney organoids from human-induced pluripotent stem (hiPS) cells could be harnessed to engineer artificial organs and help overcome the challenges associated with the limited supply of transplantable kidneys. The purpose of this article is to review the progress in kidney organoid generation and transplantation and highlight some existing challenges in the field. We also examined possible improvements that could help realize the potential of organoids as artificial organs or alternatives for kidney transplantation therapy.Recent FindingsOrganoids are useful for understanding the mechanisms of kidney development, and they provide robust platforms for drug screening, disease modeling, and generation of tissues for organ replacement therapies. Efforts to design organoids rely on the ability of cells to self-assemble and pattern themselves into recognizable tissues. While existing protocols for generating organoids result in multicellular structures reminiscent of the developing kidney, many do not yet fully recapitulate the complex cellular composition, structure, and functions of the intact kidney. Recent advances toward achieving these goals include identifying cell culture conditions that produce organoids with improved vasculature and cell maturation and functional states. Still, additional improvements are needed to enhance tissue patterning, specialization, and function, and avoid tumorigenicity after transplantation.SummaryThis report focuses on kidney organoid studies, advancements and limitations, and future directions for improvements towards transplantation.

S2692 Abscess-Enteric Fistula of Failed Kidney Transplant Presenting With Gastrointestinal Bleeding

Introduction: Lower gastrointestinal (GI) bleeding is a common occurrence, with the vast majority of cases being due to diverticula, vascular ectasias, cancers, and hemorrhoids. In rare cases, a large vessel can form a fistula with the GI tract, causing bleeding. We present a case where an abscess surrounding a failed transplant kidney eroded into the external iliac vein and presented as a slow lower GI bleed. Case Description/Methods: A 65-year-old man with a failed renal transplant and known colovesicular fistula presented with hypotension. Labs showed a significant leukocytosis, an elevated lactate, and a hemoglobin of 6.3 g/dL. He was started on broad spectrum antibiotics, and then developed intermittent episodes of small-volume bright red blood per rectum. The patient had an upper endoscopy and colonoscopy one month prior for GI bleeding which had not identified a source. Computed tomography angiography of the abdomen and pelvis revealed a fistulous communication between the sigmoid colon and a multiloculated right lower quadrant collection (Figure). The collection encased the transplanted kidney and right iliac vasculature. Extraluminal extravasation of intra-arterial contrast was noted, concerning for either active arterial bleed or pseudoaneurysm. The patient underwent emergent exploratory laparotomy which revealed a necrotic transplant kidney densely adhered to the surrounding colon and a right external iliac artery pseudoaneurysm. Bleeding was noted from a defect in the right external iliac vein. The kidney was removed, the pseudoaneurysm was stented, and the vein defect was oversewn. Unfortunately, the patient had a complicated post operative course and died. Discussion: In patients with evidence of small-volume rectal bleeding but a clinical picture concerning for a more significant bleed, cross-sectional imaging can be necessary to make the appropriate diagnosis. In this case, imaging identified the abscess-enteric fistula, and laparoscopy revealed that the bleeding was due to a defect in the iliac vein. Abscess-enteric fistulas are associated with post-surgical states or small localized perforations. This patient likely developed a microperforation that infected the failed transplant kidney, creating an abscess which eroded into the iliac vein. GI bleeding was only intermittent and a source was not identified on prior luminal imaging, possibly due to the small size of the fistula tract. This pathology is unfortunately not amenable to endoscopic intervention and often requires surgery.Figure 1.: Computed tomography angiography of the abdomen and pelvis with a multiloculated right lower quadrant collection encasing a transplanted kidney and right iliac vasculature.

Differences in Skin Cancer Rates by Transplanted Organ Type and Patient Age After Organ Transplant in White Patients

Although it is known that patients with thoracic organ transplants develop skin cancer more frequently than those who receive nonthoracic organ transplants, patterns of risk for subsequent skin cancers are unknown. To further characterize organ transplant recipients who develop multiple skin cancers and assess for patterns of development of additional skin cancers beyond the first skin cancer diagnosis by patient age and transplanted organ type. This cohort study used validated electronic health record-based data from a single tertiary care academic medical center to identify 5129 solid organ transplant recipients who underwent transplant surgery between 1992 and 2017 and were older than 18 years at the time of transplant. The cohort was limited to White patients because they have the highest skin cancer risk based on phenotype. The mean follow-up was 6.6 years. Data were analyzed June 9, 2021, to May 31, 2022. Differences in rates of skin cancer development for first and subsequent skin cancers were measured using t test or analysis of variance and χ2 tests for continuous and categorical variables. Rates of skin cancer development were compared based on organ type and patient age at transplant using Fine-Gray tests and cumulative incidence plots. A total of 5129 organ transplant recipients (mean [SD] age, 51.3 [12.9] years; 3287 men [64.1%]) were included. Of these, 695 patients (13.6%) had development of at least 1 skin cancer, with 6842 skin cancers identified in the cohort overall. Compared with liver transplant recipients, heart, lung, or kidney recipients were more likely to develop at least 1 skin cancer (χ2 test, 25.6; df, 4; P < .001). There was no significant difference by transplanted organ type in the rate of developing a second or third skin cancer; however, the age at transplant was associated with the time to developing a second (χ2 test, 20.4; df, 4; P < .001) or third (χ2 test, 10.9; df, 4; P < .02) skin cancer. This cohort study found that there was no difference by organ type for development of subsequent skin cancers in organ transplant recipients, and recipients of all organ types developed additional skin cancers at high rates after the initial skin cancer.

Case Report: Horseshoe Kidney Transplantation Using Split Technique

With the increasing demand for donor organs and its limited availability, kidneys with atypical anatomy are being used more and more. The experience with transplanting horseshoe kidneys is limited. Understanding variations in uretero–pelvic anatomy and aberrant vascular anatomy is of paramount importance for the utilization of horse-shoe kidneys for transplantation. We describe our experience in procuring a horse-shoe kidney from a deceased donor, splitting the kidney and transplantation into 2 recipients.

A high-throughput drug discovery pipeline to optimize kidney normothermic machine perfusion.

Kidney transplantation is the only definitive therapy for end-stage kidney disease. The shortage of organs for transplantation is the main limitation of this life-saving treatment. Normothermic machine perfusion (NMP) is a novel preservation technique with the potential to increase the number of transplantable kidneys through reducing delayed graft function and organ evaluation under physiological conditions. To date, the cellular effects and possible pharmacological interventions during machine perfusion are incompletely understood. A major limitation is the technically complex, time-consuming, and small-scale replication of NMP in rodent models. To overcome this, we developed a 3D-printed, high throughput ex-vivo mouse kidney slice incubator (KSI) mimicking mouse kidney NMP by working under closely resembling conditions. KSI significantly reduced the time per experiment and increased the sample throughput (theoretical: 54 incubations with n = 500/day). The model recapitulated the cellular responses during NMP, namely increased endoplasmic reticulum stress (ER stress). Using KSI, five pharmacological interventions against ER stress taken from the literature were tested. While four were ineffective and excluded, one, β-Nicotinamide-adenine-dinucleotide (NADH), ameliorated ER stress significantly during KSI. The test of NADH in mouse kidney NMP replicated the positive effects against ER stress. This suggests that testing the addition of NADH during clinical kidney NMP might be warranted.

Impact of Glomerulitis on Long-term Outcomes After Kidney Transplantation.

Background.The Banff classification scheme provides a framework for interpreting transplant kidney biopsies and has undergone various updates in the past 2 decades especially related to antibody-mediated rejection. The clinical significance of early glomerulitis seen within 4 mo on protocol biopsies has received limited attention. We hypothesized that early glomerulitis seen on protocol biopsies will lead to significant adverse outcomes as assessed by histopathology and allograft outcome.Methods.A single-center retrospective study of a cohort of patients who underwent protocol biopsies within 4 mo after transplantation with timely follow-up protocol biopsies were assessed. Patients with recurrent glomerulonephritis were excluded.Results.We calculated glomerulitis (g) scores for 2212 biopsy specimens and identified 186 patients with glomerulitis (g > 0) and 2026 patients without glomerulitis (g = 0). The progression to chronic transplant glomerulopathy at 1 and 2 y was higher in patients with g > 0 as compared with g = 0 (year 1, 10.7% versus 2.3% [P < 0.001]‚ respectively; year 2, 17.2% versus 4.3% [P < 0.001], respectively) with no difference in other chronic lesions. The death-censored graft failure rate was higher in patients with g > 0 as compared with g = 0 (hazard ratio, 1.68 [95% CI, 1.07-2.65]; P = 0.02). We did not find any difference in outcomes in glomerulitis group based on donor-specific antibody.Conclusion.Our findings suggest that early glomerulitis (seen within 4 mo after transplantation) may lead to clinically significant long-term changes and thus could be a target for early intervention therapies.

POS-077 RISK FACTORS AND OUTCOMES OF TUBERCULOSIS IN INDIAN KIDNEY TRANSPLANT RECIPIENTS

Tuberculosis (TB) is one of the commonest opportunistic infections in kidney transplant recipients and can have diverse clinical presentations leading to a delay in the diagnosis. We evaluated risk factors, clinical presentation, impact of TB on patient, and the graft outcomes. We studied 703 kidney transplant recipients from 1985-2018 at a tertiary care centre in western India. Demographic details, past history of TB, immunosuppression regimens, time to diagnosis of tuberculosis post-transplant, clinical presentations, duration of treatment, adverse effects of treatment, and its outcome on patient and graft were studied. Tuberculosis was diagnosed in 103 recipients (14.6%) post-transplant. The mean (SD) age of recipients was 35.12±10 years, with 93 (90.2%) being males and 102 recipients (99.1%) from a living donor. Nineteen recipients (18.4%) had tuberculosis before transplant. The median (IQR) time to diagnosis of TB post-transplant was 24 months (8-48). In 41(39.8%) recipients, development of tuberculosis was preceded by anti-rejection therapies. Pulmonary involvement was the most common organ involvement in 72 recipients (69.9%), extrapulmonary in 31 (30%) and disseminated in 2 (1.9%). Among the extrapulmonary involvements, gastrointestinal involvement was seen in 9 recipients (8.7%) followed by musculoskeletal in 7(6.8%), lymphadenitis in 6 (5.8%), central nervous system in 3 (2.9%), cutaneous involvement in 2 (1.9%), genitourinary TB in 1 (0.9%) and transplant kidney in 1 (0.9%). The median (IQR) duration of treatment was 12 months (5-18). Four recipients had relapses after completion of treatment. Adverse effects of treatment included transaminase elevation seen in 38 (38.6%) recipients followed by acute gastritis in 19 (18.4%), hyperuricemia in 17 (16.5%) and sensorineural hearing loss in 3 (2.9%). Multidrug-resistant TB was diagnosed in 3 recipients (2.9%). The pre-transplant median (IQR) dialysis vintage was 8 months (6-12). New onset diabetes after transplant was the most common comorbidity observed in 28 (27.18%) recipients, followed by Hepatitis C in 16 (15.55%), Hepatitis B in 12 (11.6 %), Cytomegalovirus (CMV) in 6(5.8%) and HIV in 2 recipients (1.9%). Immunosuppressive regimens at time of transplant included azathioprine in 61 recipients (59.2%), mycophenolate mofetil in 40(38.8%), tacrolimus in 38(36.8%), cyclosporine in 26(25.2%) and steroids in 103(100%) recipients. Acute graft dysfunction during treatment was seen in 42 recipients (40.7%). Three recipients (2.9%) developed graft failure. Seventy-two recipients (69.9%) survived after treatment, 16 (15.5%) expired due to TB, and 15(14.5%) were lost to follow-up. Tuberculosis remains a common infectious complication after kidney transplant and is associated with significant morbidity and mortality.

Management of renal cell carcinoma in transplant kidney: a systematic review and meta-analysis.

After transplantation, approximately 10% of renal cell carcinomas are detected in graft kidneys. These tumors (gRCC) present surgeons with the difficulty of finding a treatment that guarantees both oncological clearance and maintenance of function. We conducted a systematic review and an individual patient data meta-analysis on the oncology, safety and functional outcomes of the available treatments for gRCC. A systematic search was performed across MEDLINE, EMBASE, and Web of Science including any study reporting perioperative, functional and survival outcomes for patients undergoing graft nephrectomy (GN), partial nephrectomy (PN) or thermal ablation (TA) for gRCC. Quade's ANCOVA, Spearman Rho and Pearson χ2, Kaplan-Meier, Log-rank and Standard Cox regression and other tests were used to compare treatments. Studies' quality was evaluated using a modified version of Newcastle Ottawa Scale. A number of 29 studies (357 patients) were included. No differences between TA and PN were found in terms of safety, functional and oncological outcomes for T1a gRCCs. When applied to pT1b gRCC, PN showed no difference in complications, progression or cancer-specific deaths compared to smaller lesions; PN validity for pT2 gRCCs should be considered unverified due to lack of sufficient evidence. The efficacy and safety of PN or TA for multiple gRCC remain controversial. In case of non-functioning, large (T≥2), complicated or metastatic gRCCs, GN appears to be the most reasonable choice. Quality of evidence ranged from very low to moderate. Studies with large cohorts and longer follow-up are still needed to clarify oncological and functional differences. PN and TA might be offered as a nephron-sparing treatment in patients with T1a gRCC. There is no significant difference between these options and GN in terms of oncological outcomes and complications. PN and TA offer similar functional outcomes and graft preservation. PN for T1b gRCC seems feasible and safe, but its validity should be considered unverified.

247.1: Conditional Altruistic Living-Donor Kidney Donation in Israel and Its Impact on Living-Donor Kidney Transplant Growth

Introduction: With a limited number of deceased organ donors in Israel, transplant tourism was often used as an alternative source for kidneys until the enactment of the Israel Transplant law in 2008 which severely limited that activity. In an effort to find a legitimate path for the supply of kidneys for transplant, the law approved altruistic donation and established a regulated central governmental mechanism to ensure an altruistic motivation for donation. A year later, in 2009, the Matnat Chaim organization started its initiative to promote altruistic donation within the Jewish sector according the highest imperative of saving another’s life according to religious beliefs and social behaviour. Here, we report the results of that activity over the last 8 years. Methods: We used Israel Transplant Centre database and the Matnat Chaim organization’s database reporting the transplant activity for the period of 2013-2021. We looked at the growth of deceased and living-donor kidney transplantation and the proportion of altruistic kidney donations out of the total number of living-donor transplants over that period. We also reviewed the donors’ pre-donation questionnaires to learn about their preferences regarding their paired recipients in terms of age, social sector and religious observance. Results: Over the period studied, the number of kidney transplant candidates on the waiting list increased from 755 to 917 patients while the number of kidney transplants from deceased donors increased from 127 to 149 (excluding combined kidney-liver or kidney-pancreas transplants). The total number of live-donor transplantation increased from 261 to 476. The primary growth in the number of kidney transplants came from altruistic donations, with an increase from 32 to 215 donors a year (X6.7), and their proportion within the overall live donor total increased from 24 to 66% (figure 1). It should be noted that in many cases, Matnat Chaim was responsible for facilitating donation within the family after an initial interview of patients who approached the organization. Although in the majority of cases altruistic donors donated their kidney to a recipient within their community or religious group, on other occasions donors agreed to change the original directed allocation and donate their kidney within a paired exchange program (48 donors) or directly to a highly sensitized patient on the waiting list. However, for many of the altruistic donors, conditional donation was a prerequisite and had they not been allowed to donate within their community, they would not have donated a kidney at all. Conclusions: Conditional altruistic donation within a community is a legitimate path with a major potential to increase organ donation. Unlike non-conditional donation where kidneys are allocated to the waiting list, our system of conditional altruistic donation may raise some ethical issues; however, we consider it a valid option on a scale between a family donation and altruistic non-directed donation. The abstract is in memory of my friend Rabbi Yeshayahu Heber, the founder and chairman of Matnat Chaim. Rabbi Heber was a transplant recipient who died far before his time during the first wave of the COVID-19 pandemic, in April 2020. Over 1200 kidney recipients are alive today due to his vision and determination.

POS-098 MILKY URINE IN RENAL ALLOGRAFT RECIPIENT - CAN NATIVE KIDNEY BE THE CULPRIT ?

Milky urine can be caused due to both infectious and non-infectious causes. We present a case of 48 years old male, 6 years post kidney transplant who presented as milky urine and was initially managed with diethylcarbamazine (DEC) and intravenous antibiotics. As he was not responding he was evaluated further to be diagnosed as candiduria arising from left native kidney. He had a quick response to left native nephrectomy and liposomal amphotericin. 48 years old male patient, who was 6 years post kidney transplant (Basic disease - diabetic nephropathy), with normal graft function on triple drug immunosupressants ( tacrolimus, mycophenolate and pednisolone) presented with complaint of milky white urine during morning hours only. He was afebrile and had no symptoms of burning or pain during micturition. His urine examination showed few pus cells and was hazy in appearance. Urine cytology for malignant cells showed no evidence of atypical cells. Urine for fat globules was negative though triglycerides were 470 mg/dl and urine was labelled as chylous. His ultrasound was suggestive of mild pelvicalyceal fullness of transplant kidney which was confirmed by CT scan. His leucocyte counts, calcium and phosphorus were within normal range. His early morning smear sample showed no evidence of wuchereria bancrofti microfilariae. He was emperically started on DEC 6mg/kg. After 5 days his urine culture yielded growth of klebsiella species and was treated with injectable ceftriaxone-sulbactum combination as per culture sensitivity report for 2 weeks. He was asymptomatic till the time he was on antibiotics and again developed episodes of milky urine. He also passed some fleshy material in urine was sent for histology. He was posted for cystoscopy which revealed whitish efflux from left native uretric orifice, which was sent for cytology and left uretric catheterization was done. Both the tissue and fluid showed colonies of budding yeast cell and pseudohyphae suggestive of candida species. Considering the non functional status of left native kidney (by imaging and history of anuria pre transplant), left laproscopic native nephrectomy was done and in view of post transplant immunosupressed state, intravenous liposomal amphotericin was given for 2 weeks. He had a quick response to the treatment. In post transplant urinary tract infections, we should also focus on native kidneys especially in diabetic population. There are many case reports of recurrent urinary tract infections post transplant due to native pyelonephritis requiring native nephrectomy.

Medium and Long-Term Clinical Outcomes of Kidney Transplantation in Patients With Prune Belly Syndrome: A Single-Centre Experience

To present the medium and long-term outcomes of kidney transplantation performed in patients with Prune Belly Syndrome (PBS) which is one of the congenital anomalies of the kidney and urinary tract (CAKUT). Thirteen kidney transplantations were performed in nine patients with PBS from January 1994 to December 2020. Demographics, surgical features, graft and patient survival rates were analyzed. Survival outcomes was compared with 106 age- and donor-type matched controls who underwent transplantation because of nonurological causes. The median ages of PBS patients at the time of first and second transplantation were 19 and 34 years old, respectively. One patient had postoperative Clavien grade 3a complication. Eight of 13 transplants are still functional at the last follow-up. Eight patients underwent pretransplant urological operations in preparation for kidney transplantation, while 4 patients underwent urological operations in the post-transplant period. Graft survival for PBS transplants at 5, 10, and 15 years were 90.9%, 57.7%, and 38.5%, respectively. Graft survival for control cohort at 5, 10, and 15 years were 89.9%, 80%, and 74%, respectively. The patient and graft survival rates were similar between PBS and control groups (P=.449, P=.134, respectively). This single-center study showed that the medium-term graft survival rates in patients with PBS are encouraging and comparable to non-CAKUT transplant patients, however long-term graft survival rates were found to be proportionally inferior. To help determine the reasons for long-term transplant kidney function deterioration and how to improve them we suggest that multicenter international collaboration will be needed.

The shortage of kidneys for transplant: Altruism, exchanges, opt in vs. opt out, and the market for kidneys

In 2007 we published a paper on organ transplants that used data from 1990–2005. We proposed a radical solution of paying individuals to donate kidneys, and claimed that this would clean out the waiting list for kidney transplants in a short period of time. In this paper, we revisit the topic, and examine 14 years of additional data to see if anything fundamental has changed. We show that the main altruistic based policies implemented, such as kidney exchanges or opt out systems for organ procurement, have been unable to solve the problem of shortages. Our analysis suggests that, because of the reaction of direct living donors to increases in other sources of donations, the supply curve of kidney transplants is highly inelastic to altruistic policies. In contrast, a market in organs would eliminate organ shortages and thereby eliminate thousands of needless deaths.

EP-506 Kidney transplant rejection rate comparing Alemtuzumab versus Basiliximab during covid pandemic against pre-covid period

Abstract Aims To review kidney transplant rejection rate following change in immunosuppression regime due to covid pandemic. Induction immunosuppression changed from Alemtuzumab pre-covid to Basiliximab during covid pandemic period. Maintenance immunosuppressant included the addition of prednisolone to tacrolimus and mycophenolate in the covid period. Methods Retrospective analysis of patients that underwent cadaveric kidney transplant in a single transplant surgical unit. Rejection was confirmed following transplant kidney biopsy. Results Total of 192 patient records were reviewed. 96 patients underwent kidney transplant between March to November 2019 (pre-covid group). 96 patients underwent kidney transplant between March to July 2020 (covid pandemic group). Rejection number pre-covid group was 6 (total number of biopsy was 30). Rejection number covid group was 5 (total number of biopsy was 14). Pre-covid group follow up was for 16 months. Covid group follow up period was for 6 months. Conclusions Early follow up result suggests possibly higher rejection rate with Basiliximab when compared to Alemtuzumab group. Longer term follow up in post-covid kidney transplant needs to be carried out to draw stronger conclusion. Risk of lymphocyte depleting induction agent during covid crisis versus potential higher risk of rejection with non-depleting agent needs to be balanced.

How a compensated kidney donation program facilitates the sale of human organs in a regulated market: the implications of Islam on organ donation and sale

BackgroundAdvocates for a regulated system to facilitate kidney donation between unrelated donor-recipient pairs argue that monetary compensation encourages people to donate vital organs that save the lives of patients with end-stage organ failure. Scholars support compensating donors as a form of reciprocity. This study aims to assess the compensation system for the unrelated kidney donation program in the Islamic Republic of Iran, with a particular focus on the implications of Islam on organ donation and organ sales.MethodsThis study reviews secondary documents for philosophical argumentation and ethical analysis of human organ donation and sale for transplantation.Results and discussionAccording to Islamic law, organ donation is an act of sadaqatul jariyah, and individuals are permitted to donate organs with the intention of saving lives. The commercialization of humans as organ sellers and buyers is contrary to the Islamic legal maxim eethaar, undermining donors of ‘selfless’ or ‘altruistic’ motivations. Such an act should be considered immoral, and the practice should not be introduced into other countries for the sake of protecting human dignity, integrity, solidarity, and respect. I, therefore, argue that Iran’s unrelated kidney donation program not only disregards the position of the Islamic religion with respect to the provision or receipt of monetary benefits for human kidneys for transplantation but that it also misinterprets the Islamic legal proscription of the sale of human organs. I also argue that the implementation of Iran’s unrelated kidney donor transplantation program is unethical and immoral in that potential donors and recipients engage in a bargaining process akin to that which sellers and buyers regularly face in regulated commodity exchange markets. Conversely, I suggest that a modest fixed monetary remuneration as a gift be provided to a donor as a reward for their altruistic organ donation, which is permissible by Islamic scholars. This may remove the need to bargain for increased or decreased values of payment in exchange for the organ, as well as the transactional nature of ‘buyer and seller’, ensuring the philosophy of ‘donor and recipient’ is maintained.ConclusionsOffering a fixed modest monetary incentive to organ donors would serve to increase organ supply while protecting donors’ health and reducing human suffering without legalizing the human organ trade.

Implementing a Health Utility Assessment Platform to Acquire Health Utilities in a Hemodialysis Outpatient Setting: Feasibility Study.

BackgroundPatients with end-stage kidney disease (ESKD) wait roughly 4 years for a kidney transplant. A potential way to reduce wait times is using hepatitis C virus (HCV)–viremic kidneys.ObjectiveAs preparation for developing a shared decision-making tool to assist patients with ESKD with the decision to accept an HCV-viremic kidney transplant, our initial goal was to assess the feasibility of using The Gambler II, a health utility assessment tool, in an ambulatory dialysis clinic setting. Our secondary goals were to collect health utilities for patients with ESKD and to explore whether the use of race-matched versus race-mismatched exemplars impacted the knowledge gained during the assessment process.MethodsWe used The Gambler II to elicit utilities for the following ESKD-related health states: hemodialysis, kidney transplant with HCV-unexposed kidney, and transplantation with HCV-viremic kidney. We created race exemplar video clips describing these health states and randomly assigned patients into the race-matched or race-mismatched video arms. We obtained utilities for these 3 health states from each patient, and we evaluated knowledge about ESKD and HCV-associated health conditions with pre- and postintervention knowledge assessments.ResultsA total of 63 patients with hemodialysis from 4 outpatient Dialysis Center Inc sites completed the study. Mean adjusted standard gamble utilities for hemodialysis, transplant with HCV-unexposed kidney, and transplantation with HCV-viremic kidney were 82.5, 89, and 75.5, respectively. General group knowledge assessment scores improved by 10 points (P<.05) following utility assessment process. The use of race-matched exemplars had little effect on the results of the knowledge assessment of patients.ConclusionsUsing The Gambler II to collect utilities for patients with ESKD in an ambulatory dialysis clinic setting proved feasible. In addition, educational information about health states provided as part of the utility assessment process tool improved patients’ knowledge and understanding about ESKD-related health states and implications of organ transplantation with HCV-viremic kidneys. A wide variation in patient health state utilities reinforces the importance of incorporating patients’ preferences into decisions regarding use of HCV-viremic kidneys for transplantation.