Living-donor Recipients Research Articles

Multicenter registry analysis comparing survival on home hemodialysis and kidney transplant recipients in Australia and New Zealand.

In the era of organ shortage, home hemodialysis (HHD) has been identified as the possible preferential bridge to kidney transplantation. Data are conflicting regarding the comparability of HHD and transplantation outcomes. This study aimed to compare patient and treatment survival between HHD patients and kidney transplant recipients. The Australia and New Zealand Dialysis and Transplant Registry was used to include incident HHD patients on Day 90 after initiation of kidney replacement therapy and first kidney-only transplant recipients in Australia and New Zealand from 1997 to 2017. Survival times were analyzed using the Kaplan-Meier product-limit method comparing HHD patients with subtypes of kidney transplant recipients using the log-rank test. Adjusted analyses were performed with multivariable Cox proportional hazards regression models for time to all-cause mortality. Time-to-treatment failure or death was assessed as a composite secondary outcome. The study compared 1411 HHD patients with 4960 living donor (LD) recipients, 6019 standard criteria donor (SCD) recipients and 2427 expanded criteria donor (ECD) recipients. While LD and SCD recipients had reduced risks of mortality compared with HHD patients [LD adjusted hazard ratio (HR) = 0.57, 95% confidence interval (CI) 0.46-0.71; SCD HR = 0.65 95% CI 0.52-0.79], the risk of mortality was comparable between ECD recipients and HHD patients (HR = 0.90, 95% CI 0.73-1.12). LD, SCD and ECD kidney recipients each experienced superior time-to-treatment failure or death compared with HHD patients. This large registry study showed that kidney transplant offers a survival benefit compared with HHD but that this advantage is not significant for ECD recipients.

BKV VIRURIA AND VIREMIA DO NOT PREDICT HOSPITALIZATION FOR INFECTIONS AFTER KIDNEY TRANSPLANTATION

BK polyoma virus (BKV) infection after kidney transplantation, resulting from either reactivation of latent infection in the recipient or transmission through the donor kidney, is understood to be related to the intensity of immunosuppression. Infections after transplantation being a function of immunosuppression burden in general, we hypothesized that early BKV viruria and viremia could indicate the likelihood of individuals needing hospitalization for all infections. We conducted a retrospective study among living donor renal transplant recipients in a program without the routine use of induction immunosuppressive agents, to explore the association between BKV viruria at two months post transplantation and viremia, with hospitalisation for any infection. The electronic case records of all patients who underwent renal transplantation between 8/5/2016 (start of the program) to 31-10- 2019 at IQRAA hospital Kerala, were reviewed to collect data on BKV viruria, viremia and hospitalisation for infections. A total of 149 patients had undergone transplantation during the study period of which nine were excluded from analysis (four patients within two months of transplantation, three patients with non-functioning graft within two months, one death within two months and one patient lost to follow up). 48 patients (34.28%) were detected urine BKV positive by polymerase chain reaction (PCR) around two months after transplantation, 74 patients tested negative and no data were available in 18. 24 out of the 48 patients with viruria had documented viremia by PCR. Among the rest 16 had no viremia, while data were missing in eight. Of the 122 patients with urine BKV data available 100 were ABO compatible (ABOc) transplants and the rest ABO incompatible (ABOi). 39 patients out of the 122 patients (31.96%) with urine BKV data available required hospitalization for infection. The median time to first hospitalization for infection was 139 days The most common causes for first hospital admission with infection after transplantation included lower respiratory tract infection and urinary tract infection/graft pyelonephritis in seven patients each, followed by Cytomegalovirus infection in five. No significant association was documented for hospitalization with infection either for BKV Viruria (χ2 (1, N = 122) =0.28, p = 0.59) or BKV viremia(χ2 (1, N = 58) =0.41, p = 0.51). ABOi transplantation was also not found to be significantly associated with BKV viruria (χ2 (1, N = 122) =0.09, p = 0.75). In this retrospective single centre study of living donor recipients BKV viruria at two months post renal transplant and BKV viremia were not found to be associated with hospitalization for any infection. Viral load cut offs to define severity of infection were not used and could have led to the inclusion of patients with lesser degree of immunosuppression confounding the results.

P1431MULTI-CENTER REGISTRY ANALYSIS COMPARING SURVIVAL ON HOME HEMODIALYSIS AND KIDNEY TRANSPLANT RECIPIENTS IN AUSTRALIA AND NEW ZEALAND

Abstract Background and Aims In the era of organ shortage, home hemodialysis (HHD) has been identified as the possible preferential bridge to kidney transplantation. Data are conflicting regarding the comparability of HHD and transplantation outcomes. This study aimed to compare patient and treatment survival between HHD patients and kidney transplant recipients. Method The Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry was used to include incident HHD patients on day 90 after initiation of kidney replacement therapy and first kidney-only transplant recipients in Australia and New Zealand from 1997 to 2017. Survival times were analyzed using the Kaplan-Meier product limit method comparing HHD patients to subtypes of kidney transplant recipients using the log-rank test. Adjusted analyses were performed with multivariable Cox proportional hazards regression models for time to all-cause mortality. Time-to-treatment failure or death was assessed as a composite secondary outcome. Results The study compared 1411 HHD patients to 4960 living donor (LD) recipients, 6019 standard criteria donor (SCD) recipients and 2427 expanded criteria donor (ECD) recipients. While LD and SCD recipients had reduced risks of mortality compared to HHD patients (LD adjusted hazard ratio [HR] 0.57, 95%CI 0.46-0.71; SCD HR 0.65 95%CI 0.52-0.79), the risk of mortality was comparable between ECD recipients and HHD patients (HR 0.90, 95%CI 0.73-1.12). LD, SCD and ECD kidney recipients each experienced superior time-to-treatment failure or death compared to HHD patients. Conclusion This large registry study showed that kidney transplant offers a survival benefit compared to HHD but that this advantage is not significant for ECD recipients.

P1655HYPERKALAEMIA IN PREVALENT KIDNEY TRANSPLANT RECIPIENTS

Abstract Background and Aims Hyperkalaemia is a common and life-threatening medical emergency present in up to 10% of acute hospital admissions. End-stage Kidney Disease (ESKD) patients undergoing transplantation are at increased risk of hyperkalaemia, a potentially life-threatening medical emergency. Although the prevalence of hyperkalaemia in ESKD is well described, few studies have assessed the incidence and associations of hyperkalaemia in kidney transplant recipients. We evaluated post-transplant hyperkalaemia in a single centre using a large electronic health record dataset of emergency admissions. Methods Prevalent kidney transplant recipients were identified using ICD-10 codes from a complete Electronic Health Records database of all emergency admissions to Addenbrooke’s Hospital, Cambridge between April 2015 and August 2018. We abstracted demographics, comorbidities, concomitant medications, biochemistry results including all blood potassium values, in-hospital prescribing and admission and discharge dates. Data were summarised as frequency (%), mean± standard deviation (SD) or median with interquartile range (IQR) as appropriate. Categorical variables were compared by Chi-squared test and continuous variables by Student's t-test or Mann–Whitney U-test based on their distribution. Factors associated with developing hyperkalaemia were explored using mixed-effects logistic regression and odds ratios (OR) are reported. Results 421 prevalent kidney transplant recipients were admitted a total of 1,065 times via the Emergency Department and a further 475 times direct to the Transplant ward. 324 (77%) were deceased-donor recipients with 83 (20%) living-donor recipients and 14 (3%) simultaneous pancreas kidney (SPK) recipients. Median age of admitted recipients was 56 (IQR 44-65) years and 87% were of white ethnic origin. Mean serum potassium was 4.56±0.72 mmol/L compared to 4.21±0.61 mmol/L amongst the 170,913 non-kidney transplant patients admitted over the same time period (p<0.001). 376 (89%) recipients were prescribed a calcineurin inhibitor. Hyperkalaemia >5.5mmol/L occurred in 282 (67%) of 421 prevalent kidney transplant recipients with 203 (48%) patients including all SPK recipients experiencing moderate-severe hyperkalaemia (K >=6.0mmol/L). Of these, 110 (39%) received emergency treatment with insulin/dextrose. Potassium concentration immediately (≤ 60 min) pre-treatment was 6.26±0.76 mmol/L. The mean reduction in potassium at 4-hours post treatment was 0.89±0.90 mmol/L. Twenty-five of 110 (23%) patients developed hypoglycaemia (glucose <4mmol/L) within 6 hours of treatment and 37/110 (34%) required retreatment with insulin/dextrose within 24 hours. Kidney transplant recipients were at significantly increased risk of developing hyperkalaemia (OR 19.8, 95% Confidence Interval (CI) 16.2-24.4, p<0.001) compared with all admitted patients and this risk persisted after adjustment for age, sex and co-morbidity (OR 3.6, 2.9-4.5, p<0.001). Associations with hyperkalaemia amongst transplant recipients included receiving a deceased-donor kidney (OR 1.96, 1.13-3.40, p=0.017) and exposure to beta-blockers (OR 2.26, 1.36-3.59, p=0.001) and calcineurin inhibitors (OR 6.39, 2.81-14.5, p<0.001). Conclusion Kidney transplant recipients are at greatly increased risk of developing hyperkalaemia. Recipients who become hyperkalaemic are more likely to have received a deceased-donor transplant and be prescribed beta-blockers and calcineurin inhibitors than those who do not. Insulin/dextrose for hyperkalaemia is associated with hypoglycaemia in almost 1 in 4 recipients treated and re-treatment is required in one third of recipients.

Molecular Pathways Underlying Adaptive Repair of the Injured Kidney: Novel Donation After Cardiac Death and Acute Kidney Injury Platforms.

To test the hypothesis that gene expression profiling in peripheral blood from patients who have undergone kidney transplantation (KT) will provide mechanistic insights regarding graft repair and regeneration. Renal grafts obtained from living donors (LD) typically function immediately, whereas organs from donation after cardiac death (DCD) or acute kidney injury (AKI) donors may experience delayed function with eventual recovery. Thus, recipients of LD, DCD, and AKI kidneys were studied to provide a more complete understanding of the molecular basis for renal recovery. Peripheral blood was collected from LD and DCD/AKI recipients before transplant and throughout the first 30 days thereafter. Total RNA was isolated and assayed on whole genome microarrays. Comparison of longitudinal gene expression between LD and AKI/DCD revealed 2 clusters, representing 141 differentially expressed transcripts. A subset of 11 transcripts was found to be differentially expressed in AKI/DCD versus LD. In all recipients, the most robust gene expression changes were observed in the first day after transplantation. After day 1, gene expression profiles differed depending upon the source of the graft. In patients receiving LD grafts, the expression of most genes did not remain markedly elevated beyond the first day post-KT. In the AKI/DCD groups, elevations in gene expression were maintained for at least 5 days post-KT. In all recipients, the pattern of coordinate gene overexpression subsided by 28 to 30 days. Gene expression in peripheral blood of AKI/DCD recipients offers a novel platform to understand the potential mechanisms and timing of kidney repair and regeneration after transplantation.

Should living donor liver transplant selection be subject to the same restrictions as deceased donor transplant?

In the United States, most of the liver allografts come from deceased donors, and our current liver recipient selection process is heavily centered on the ethical principle of utility to maximize the net benefit to the liver recipient community as a group rather than individuals due to the organ scarcity. Although living donor liver transplantation contributes less than 5% of total liver transplant in the United States, these living donor recipients are being subjected to the same selection process designed to benefit the group as a whole rather than the individuals. We would like to examine if these recipients who have living donors should be subjected to the same selection process. There are several disease processes where liver transplantation is the only curative option, and recent studies have shown clear survival benefits with liver transplantation. For those who have living donors, different selection criteria based on their specific disease, not based on the principle of utilization should be used to evaluate their candidacy.

Urinary Biomarkers α-GST and π-GST for Evaluation and Monitoring in Living and Deceased Donor Kidney Grafts.

The aim of this study was to analyze the value of urine α- and π-GST in monitoring and predicting kidney graft function following transplantation. In addition, urine samples from corresponding organ donors was analyzed and compared with graft function after organ donation from brain-dead and living donors. Urine samples from brain-dead (n = 30) and living related (n = 50) donors and their corresponding recipients were analyzed before and after kidney transplantation. Urine α- and π-GST values were measured. Kidney recipients were grouped into patients with acute graft rejection (AGR), calcineurin inhibitor toxicity (CNI), and delayed graft function (DGF), and compared to those with unimpaired graft function. Urinary π-GST revealed significant differences in deceased kidney donor recipients with episodes of AGR or DGF at day one after transplantation (p = 0.0023 and p = 0.036, respectively). High π-GST values at postoperative day 1 (cutoff: >21.4 ng/mg urine creatinine (uCrea) or >18.3 ng/mg uCrea for AGR or DGF, respectively) distinguished between rejection and no rejection (sensitivity, 100%; specificity, 66.6%) as well as between DGF and normal-functioning grafts (sensitivity, 100%; specificity, 62.6%). In living donor recipients, urine levels of α- and π-GST were about 10 times lower than in deceased donor recipients. In deceased donors with impaired graft function in corresponding recipients, urinary α- and π-GST were elevated. α-GST values >33.97 ng/mg uCrea were indicative of AGR with a sensitivity and specificity of 77.7% and 100%, respectively. In deceased donor kidney transplantation, evaluation of urinary α- and π-GST seems to predict different events that deteriorate graft function. To elucidate the potential advantages of such biomarkers, further analysis is warranted.

Assessment of Restored Kidney Transplantation Including the Use of Wider Criteria for Accepting Renal Donors After Cancer Excision.

Background.The transplantation of kidneys after cancer excision (restored kidney transplantation, RKT) warrants further evaluation as a source of kidneys for transplantation. We determined whether larger cancers can be safely transplanted, the risks of adverse events from RKT, and whether RKT confers a survival advantage for patients waiting for transplantation.Methods.In a retrospective cohort study, 23 dialysis patients awaiting transplant underwent RKT at John Hunter Hospital, Australia between 2008 and 2015. Patients were >60 years old and accepted onto the National Organ Matching Service. This RKT Group was divided into donor renal cancers ≤30 mm and >30–≤50 mm. Adverse event profiles for RKT recipients were compared with 22 standard live donor recipients using logistic regression analyses. Recipient and transplant survivals for RKT were compared with 2050 controls from Australian New Zealand Dialysis Transplant Registry using Cox regression models. To increase statistical power for survival analyses, data from 25 RKT recipients from Princess Alexandra Hospital, Brisbane were added, thus creating 48 RKT recipients.Results.There were no significant differences in mortality, transplant failure nor AEs between the 2 cancer Groups. RKT increased the risks of Adverse event profiles (odds ratio: 6.48 [2.92–15.44]; P < 0.001). RKT reduced mortality risk by 30% (hazard ratio [HR]: 0.70 [0.36–1.07]; P = 0.299) compared with those continuing on the transplant list who may or may not be transplanted. RKT significantly reduced mortality risk for those remaining on dialysis (HR: 2.86 [1.43–5.72]; P = 0.003). Transplant survival for RKT was reduced compared with control deceased donor (HR: 0.42 [0.21–0.83]; P = 0.013) and live donor transplants (HR: 0.33 [0.02–0.86]; P =0.023).Conclusions.The use of larger carefully selected cancer-resected kidneys for transplantation appears safe and effective. RKT confers a possible survival advantage compared with waiting for transplantation, an increased survival compared with those remaining on dialysis but reduced transplant survival.

Eplet mismatch analysis and allograft outcome across racially diverse groups in a pediatric transplant cohort: a single-center analysis

HLA eplet mismatch load has been suggested as an improvement to HLA antigen mismatch determination for organ selection. Given that eplet mismatches are determined based on amino acid sequence difference among HLA alleles, and that the frequency of HLA alleles varies between racial groups, we investigated the correlation between eplet mismatch load and allograft outcomes in 110 pediatric kidney transplant recipients who received their first organ from a donor of the same race (SRT) versus a donor of a different race (DRT). Adjusted modified Poisson regression was used to assess the interaction between eplet mismatch load and race mismatch and its effect on outcome. Caucasians and living donor recipients had lower eplet mismatched loads against their donors compared with non-Caucasian and deceased donor recipients. Overall, for the entire population, the risk of de novo HLA-DSA development was significantly increased with higher eplet loads (p < 0.001). Compared with the SRT group, the DRT group had higher eplet loads when compared with their donor, for HLA class I but not HLA class II molecules; however, there was no significant difference in the incidence of de novo HLA-DSA between the 2 groups. The risk of rejection increased significantly for DRT compared with SRT, only when class I eplet load was ≥ 70 (p = 0.04). Together this data show that eplet mismatch load analysis is an effective tool for alloimmune risk assessment. If considered for donor selection, acceptable eplet mismatch loads determined from studies in homogenous populations may restrict transplantation across racially diverse donor and patient groups with no evidence of poor outcome. Therefore, an acceptable eplet mismatch load threshold must consider the heterogeneity of the transplant population.

2456 Fibrosing Cholestatic Hepatitis Following Transplantation of a Hepatits C Virus Positive Donor Liver

INTRODUCTION: Fibrosing cholestatic hepatitis (FSC) is a rare disorder, typically seen in immunosuppressed patients with a history of chronic hepatitis B and C infections. We present a case of a 67-year-old recipient of a hepatitis C virus positive donor liver with subsequent development of FSC. CASE DESCRIPTION/METHODS: We present a case of a 67 year-old gentleman, with a past medical history of HCV cirrhosis and multifocal hepatocellular carcinoma (HCC), who underwent orthotopic liver transplantation (OLT). Prior to transplantation, the patient was treated for HCV with Vosevi/ribavirin with sustained viral response. His course was complicated by multifocal HCC, for which he received treatments with DEB-TACE and Y90. He subsequently underwent OLT with a HCV positive (RNA quantitative positive) donor liver. The patient's post-operative course was complicated by marked elevation in AST and ALT (1610 and 647 respectively) and HCV RNA quantitative (1.5 million), concerning for fibrosing cholestatic hepatitis. A liver biopsy was performed and showed both mild acute cellular rejection (ACR) and cholestasis. The patient was treated with Epclusa for HCV and immunosuppression (prednisone, tacrolimus) for ACR with improvement in his liver enzymes. DISCUSSION: Fibrosing cholestatic hepatitis (FSC) is a rare disorder, typically seen in immunosuppressed patients with a history of chronic hepatitis B and C infections. It is particularly seen in patients following transplantation, namely recipients of donor liver and kidneys. Patients with FSC present with a number of symptoms including malaise, fatigue, jaundice, abdominal pain and progressive liver failure, which may occur over a period of weeks to months. The pathophysiology is related to direct cytotoxic effect of viral antigens on hepatocytes in the setting of immunosuppression. High viral titers and elevated liver enzymes in an immunosuppressed patient should raise concern for FSC. The diagnosis is established with a liver biopsy, which typically reveals hepatocyte ballooning, bridging fibrosis, pericellular and sinusoidal fibrosis as well as intracellular and canalicular cholestasis. This ultimately leads to acute liver failure and may result in rapid graft loss. Given the high rates of mortality associated with FSC, prompt diagnosis and treatment with direct-acting antiviral regimens may be effective in treatment, even in severe cases.

Does Donor Allograft Microsteatosis Matter? Comparison of Outcomes in Liver Transplantation With a Propensity-Matched Cohort.

It has been suggested that microsteatosis does not negatively impact graft survival following liver transplantation (LT). The present study represents the largest series on donor livers with significant microsteatosis and investigates the impact of microsteatosis on perioperative factors such as postreperfusion syndrome (PRS), early allograft dysfunction (EAD), and postoperative renal dysfunction. Clinical outcomes of all patients undergoing LT with donor livers with isolated microsteatosis (≥30%; n=239) between 2000 and 2017 were compared with a propensity score-matched cohort of patients undergoing LT with donor livers with no steatosis (n=239). Patients in the microsteatosis group had a higher rate of PRS (33.1% versus 24.2%; P=0.03), EAD (38.2% versus 23.0%; P<0.001), and continuous renal replacement therapy (CRRT) requirement following LT (10.9% versus 3.6%; P=0.002) than the no steatosis group. No difference in patient (P=0.33) or graft survival (P=0.18) was observed between the 2 groups. On multivariate regression, livers with microsteatosis had an increased risk of graft loss with retransplant recipients (hazard ratio [HR], 1.59; P<0.001), increasing Model for End-Stage Liver Disease (MELD) score (HR, 1.13; P=0.01), and organs from donation after circulatory death donors (HR, 1.46; P=0.003). In conclusion, recipients of donor livers with significant microsteatosis are at an increased risk of PRS, EAD, and postoperative renal dysfunction requiring CRRT. Livers with significant microsteatosis should be avoided in retransplant recipients and in recipients with high biological MELD scores. Once appropriately selected recipients of these livers are able to overcome the initial perioperative implications of using these donor livers, longterm patient and graft survival is similar to recipients receiving grafts with no steatosis.

Association of prevalent vascular disease with allograft failure and mortality in live-donor kidney transplant recipients - a retrospective cohort study.

Limited data exist regarding the impact of prevalent vascular disease after live-donor kidney transplantation. We aimed to determine the associations between the number of prevalent vascular diseases, allograft, and patient outcomes following live-donor transplantation. This cohort study used data from the Australia and New Zealand Dialysis and Transplant Registry. Rates between recipients of live-donor kidney transplants±prevalent vascular disease prior to transplantation were calculated. The associations between vascular disease, allograft failure, and all-cause mortality were assessed using Cox regression modeling. Kaplan-Meier proportions were used to calculate all-cause mortality and death with a function graft stratified by vascular disease burden. Of 4742 live-donor recipients, 428 (9%) and 84 (2%) had prevalent vascular disease at 1 and ≥2 sites, respectively. Compared to recipients without vascular disease, the respective adjusted hazard ratios (95% confidence intervals) for patients with vascular disease at 1 and ≥2 sites were 1.78 (1.41-2.25) and 3.02 (2.03-4.50) for all-cause mortality; and 1.54 (1.26-1.88) and 2.28 (1.54-3.38) for allograft failure. All-cause mortality in recipients with vascular disease at 0, 1 and ≥2 sites was 0.028 (0.025, 0.031), 0.090 (0.073, 0.106) and 0.247 (0.196, 0.282) over the first 5-year post-transplant. There was an incremental association between the number of prevalent vascular disease sites and risk of allograft failure and all-cause mortality in live-donor kidney transplant recipients.

Long-term outcomes of the octogenarian donor liver recipient: The era of the new centurion.

Studies have suggested transplantation using older donor livers results in similar short-term outcomes as younger donor livers; however, little data exist on long-term patient/graft outcomes of the octogenarian liver recipient. Retrospective data were collected from 2 centers, (Valencia, Spain and Rochester, MN, USA) of all recipients of octogenarian donor liver allografts from 2000 to 2011 with follow-up to 2016. The aim was to compare long-term patient/graft survival as well as metabolic outcomes of the recipient with the octogenarian liver vs younger than 60years donor. 78 recipients of older liver allografts were compared to 78 matched controls. No difference in 10-year patient mortality was demonstrated (P=0.074). Octogenarian livers were associated with 3-fold higher likelihood of graft failure (P=0.002) but no increase in the risk of post-LT cardiovascular disease (P=0.60), hypertension (P=0.33), vascular complications (P=0.53), or malignancy (P=0.14). In multivariate analysis, elder livers remained a significant factor associated with rejection (P=0.034) with a trend not reaching statistical significance for graft failure (P=0.052). For appropriately selected recipients, receiving an octogenarian liver does not clearly influence patient survival but does impact early graft survival with a notable increase in early posttransplant rejection rates and re-transplantation. Over 1.5 decades, older allografts have not adversely affected metabolic outcomes.

Plasma electrolyte imbalance in pediatric kidney transplant recipients.

In current practice, pediatric kidney transplant recipients receive large volumes of intravenous fluid intraoperatively to establish allograft perfusion, and further fluid to replace urinary and insensible losses postoperatively. Acute electrolyte imbalance can result, with potential for neurological sequelae. We aimed to determine the incidence and severity of postoperative plasma electrolyte imbalance in pediatric kidney transplant recipients managed with the current standard intravenous crystalloid regimen. A retrospective analysis of plasma electrolytes in the first 72hours post-kidney transplant in 76 children transplanted between January 1, 2015, and January 31, 2018, managed with a standard intravenous fluid strategy used in most UK pediatric transplant centers. Of 76 pediatric transplant recipients of median age 9.9 (range 2.2-17.9) years predominantly managed with 0.45% sodium chloride 5% glucose, 45 (59%) developed acute hyponatremia, 23 (30%) hyperkalemia, and 43 (57%) non-anion-gap acidosis in the postoperative period. Hyperglycemia occurred in 74 (97%) patients. Hyperkalemia was more prevalent in deceased than live donor recipients (P=0.003) and was significantly associated with non-anion-gap acidosis (P<0.001). Recipient weight was not associated with overt electrolyte imbalance. Postoperative plasma electrolyte imbalance is common in pediatric kidney transplant recipients. Current clinical care strategies mitigate the associated risks of neurological sequelae to some degree. Further studies to optimize intravenous fluid therapy and minimize electrolyte disturbance in this group of patients are needed.

Laparoscopic right hepatectomy for living donor.

Many institutions have started or are planning to start a purely laparoscopic right hepatectomy (PLRH) for adult living donor recipients but the experience is relatively very limited. The present review will look at the current status of PLRH and go over some of the technical details important for a safe operation. Necessary elements and different strategies to start a safe and reproducible PLRH program will be discussed. Several publications with a relatively large number of cases have been published in the last few years. The initial results of PLRH seem to be comparable to open donor hepatectomy when performed by surgeons with sufficient expertise laparoscopic and donor hepatectomy. With the ongoing accumulation of experience in laparoscopic liver surgery and living donor liver transplantation, it is most likely that PLRH will be performed more widely than the present time. Institutions should implement a step-by-step approach with proctorship, standardization of surgical procedures and a balanced selection criterion for donors for a safe transition from open method to a PLRH program.

Development of a Pediatric Liver Transplant Program in a Developing Country

According to national transplant statistic in Colombia, Pediatric liver transplantation represent 20% (n=53) of the total of liver transplant performed in 2015. These numbers are growing in consequence with the improving clinical and surgical experience in this area, starting from liver reduction, split and living donation. Here in, we present our experience in the development as we consider, a complete liver pediatric transplant program in our institution. Materials and Methods Data represents a prospective cohort study of pediatric liver transplants, performed from 2007 to 2017 at Fundación Cardioinfantil, Bogota, Colombia. Data is presented according to the type of donor (Deceased: Reduced/Split, Living), age of the recipient and influence of a highly experience center support and accompaniment. Results and Discussion A total of 98 pediatric liver transplants were performed at our institution during this cohort. Fifty five percent of the patients received a transplant from a living donor. The main indications for transplantation were biliary atresia (42%), acute liver failure (9%), malignancy (8%) and cryptogenic cirrhosis (8%). Forty percent of the transplants were performed in children under 10kg. Main complications were arterial stenosis/thrombosis (3%), suprahepatic or portal vein thrombosis/stenosis (8%) and biliary complication (29%). The rate of 1-year biopsy proven acute moderate or severe rejection was 17%. There was a greater survival among living donor recipients (92% vs 72.9%; p 0.012) influenced by the learning curve and the support of a highly experienced center (before 71.4% vs after 87.1%; p 0.06). Conclusion Survival at our center is high compared with that obtained in similar studies in other countries. The support of a highly experienced center is important in order to achieve better results. Key words: Pediatric liver transplantation.

The Calcineurin Inhibitor Tacrolimus Specifically Suppresses Human T Follicular Helper Cells.

T follicular helper (Tfh) cells are key players in the production of antibody-producing B cells via the germinal center reaction. Therapeutic strategies targeting Tfh cells are important where antibody formation is implicated in disease, such as transplant rejection and autoimmune diseases. We investigated the impact of the immunosuppressive agent tacrolimus on human Tfh cell differentiation and function in transplant recipients. Paired blood and lymph node (LN) samples were obtained from 61 transplant recipients immediately prior to organ implantation. Living-donor recipients received a week of tacrolimus prior to kidney transplantation. Deceased-donor recipients served as controls, as tacrolimus was not administered until after the transplant operation. Flow cytometry was used to compare LN and circulating cell subsets. The calcineurin inhibitor (CNIs) tacrolimus specifically suppresses both LN Tfh cells and circulating Tfh cells, but not their regulatory counterparts or other CD4 T cell subsets. Our findings suggest that CNIs may have a more important role in the prevention of antibody formation than previously understood and, therefore, have potential for antibody-associated conditions in which aberrant Tfh function has been implicated in disease.

Tailored Rabbit Antithymocyte Globulin Induction Dosing for Kidney Transplantation.

BackgroundRabbit antithymocyte globulin (rATG) is the most widely used kidney transplant induction immunotherapy in the United States. It was recently Food and Drug Administration approved for this indication with typical dose recommendations of 1.5 mg/kg for up to 7 days given via a central line.MethodsWe theorized that reduced rATG dosing when compared with conventional dosing (6-10.5 mg/kg) is safe and effective, leading to development of a risk-stratified treatment protocol. Five-year data from a retrospective cohort of 224 adult kidney transplants (2008-2013) with follow-up through 2015 is presented. Cumulative rATG doses of 3 mg/kg were administered peripherally to nonsensitized living donor recipients, 4.5 mg/kg to nonsensitized deceased donor recipients. A subset of higher immunologic risk recipients (defined as history of prior transplant, panel reactive antibody greater than 20%, or flow cytometry crossmatch positivity) received 6 mg/kg.ResultsThere were no differences in patient or graft survival between the 3 groups. One-year rejection rates in the first 2 groups were 8.3% and 8.8%, respectively, comparable to contemporaneous rates reported to the Scientific Registry of Transplant Recipients. Dose tailoring permitted substantial cost savings estimated at US $1 091 502. Mean length of stay fell by almost 3 days as the protocol was refined. There were no episodes of phlebitis. Infection rates were comparable with those reported to the Scientific Registry of Transplant Recipients.ConclusionsThe novel findings of the current study include peripheral administration, reduced dosing, favorable safety, excellent allograft outcomes, and clear associative data regarding reduced costs and length of stay.

Is surgical treatment necessary in all hydronephrotic kidney allografts?

Background/Aim. The management of kidney graft hydronephrosis (KGH) is usually surgical, although some cases require expectant management and follow-up. The aim of the study was to discuss the criteria for expectant management or immediate surgical intervention in the series of patients with KGH. Methods. The paper is based on a retrospective study of 42 patients with KGH. The patients underwent kidney transplantation from January 2007 to December 2012. There were 19 cadaveric donor recipients and 23 living donor recipients. The average follow-up was 15,2 (range 12?21) months. The average recipient`s age was 41,6 years. In every case study, the diagnosis of graft hydronephrosis was established using abdominal ultrasonography. The degree of hydronephrosis was estimated on the basis of measuring the maximal diameter of the pelvicalyceal dilatation (PD). Results. There were no patients with graft failure after the period during which they were under medical observation. Hydronephrosis resolved completely in six (14%) patients. The median maximal PD was 28 ? 9 (range 14 ?38) mm and the median last PD was 23 ? 11 (range 0? 35) mm and they did not differ significantly (p = 0.23). The last serum creatinine was significantly lower than the maximal creatinine value (p &lt; 0.05). In twelve (29%) patients renal function normalized. Renal function remained stable during the period of medical observation. At the end of the follow-up, all patients had sterile urine culture. Conclusion. The traditional doctrine, according to which KGH represents an absolute indication for surgery, can be debated; the majority of the patients observed require just active surveillance. Prompt surgical correction is recommended only in cases with increasing pelvicalyceal dilatation and the development of symptoms, progressively decreasing renal function or recurrent urinary tract infection.

One-year survival rate of renal transplant: factors influencing the outcome

One-year survival rate of renal transplant: factors influencing the outcome Siavash Rezapour,1 Aliasghar Yarmohammadi,1,2 Mahmoud Tavakkoli1,2 1Mashhad University of Medical Sciences, 2Urology Department, Montaserie Organ Transplantation Hospital, Mashhad University of Medical Sciences, Mashhad, Iran Background: Renal transplantation remains the treatment of choice for end-stage renal disease, as the procedure not only improves quality of life, but also markedly increases patients&rsquo; survival rates. Organ and patient survival rates are important issues of interest post-transplantation. Aim: To determine the 1-year survival rate of renal transplant, we studied graft function, which is a predictor of survival, among those who received a kidney transplant in the time period between February 2012 and February 2013 at Montaserie Organ Transplantation Hospital. Materials and methods: This is a retrospective cohort study planned to determine patient and organ survival rates after kidney transplantation from living and deceased donors during a 1-year period. We also tried to clarify factors resulting in graft loss. Designated variables were collected using checklists and subsequently entered into SPSS software version 17 and analyzed using the Kaplan&ndash;Meier method and descriptive statistics.Results: From 173 patients included in the study, 67.1% (n=116) were female. The mean age of the recipients was 33&plusmn;12.85 years. In the majority of cases, cause of end-stage renal disease was not clear (n=89, 51.44%). Urinary tract infection (23.1%) was the commonest post-operative complication, followed by delayed graft function, which was diagnosed in 22 (12.7%) recipients. Seventeen cases of graft rejection (9.8%) were recorded and 4 (2.3%) of these cases underwent nephrectomy that will be regarded as graft loss in this paper. Therefore, 1-year graft survival was 90.2%. Graft survival in cadaveric and live-donor recipients was 90.8% and 88.7%, respectively. As there was no mortality reported among graft recipients, 1-year patient survival rate was 100%. It was found that graft rejection was marginally, but not significantly, higher with female donors. (p=0.05).Conclusion: One-year graft survival in our cohort was comparable with reports from the large centers in the world. Female donor can be a possible negative factor for graft outcome. Keywords: renal transplantation, patient survival rate, graft survival rate, cadaveric donor, living donor&nbsp