Living-related Kidney Transplantation Research Articles

Acute Rejection and Infectious Complications in ABO- and HLA-Incompatible Kidney Transplantations.

BackgroundPatients receiving ABO-incompatible (ABOi) or human leukocyte antigen (HLA)-incompatible (HLAi) kidney transplantation (KT) require potent immunosuppression and are thus at a higher risk of infectious complications. We evaluated the clinical outcomes of KT stratified by ABO and HLA incompatibilities and identified the factors associated with the clinical outcomes.Material/MethodsRecipients who underwent living-related KT between 2012 and 2017 were included and classified into 4 groups: ABO-compatible and HLA-compatible (ABOc/HLAc), HLA-incompatible (ABOc/HLAi), ABO-incompatible (ABOi/HLAc), and ABO-incompatible and HLA-incompatible (ABOi/HLAi). Cox proportional hazards regression analyses were carried out to evaluate the risk factors of acute rejection. Out of the 1732 patients who underwent KT, 1190, 131, 358, and 53 were in the ABOc/HLAc, ABOi/HLAc, ABOc/HLAi, and ABOi/HLAi groups, respectively.ResultsThe ABO/HLAi group showed the lowest 5-year graft survival rate (91.7%). Death-censored graft survival was not significantly different among the groups. The mortality rate from infections was significantly higher in the ABOi/HLAi group (7.5%) than the other groups. Antibody-mediated rejection-free graft survival was the lowest in the ABOi/HLAi group, with significant differences compared with the ABOi/HLAc group (P=0.02) and the ABOc/HLAi group (P=0.03). ABOi/HLAi (hazard ratio [HR], 2.63; 95% confidence interval [CI], 1.04–6.65; P<0.01) and combined infection (HR, 1.91; 95% CI, 1.45–2.51; P<0.01) were significant risk factors for acute rejection.ConclusionsPatients with both ABO and HLA incompatibilities showed inferior rates of overall patient and graft survival due to infectious complications. Infection was a prominent risk factor of acute rejection following KT after adjusting for possible confounders including ABO and HLA incompatibility.

Double-Filtration Plasmapheresis Plus Low-Dose Anti-thymocyte Globulin and Tacrolimus in Asian Living-Donor Kidney Transplantation With Donor-Specific Anti-HLA Antibody

BackgroundPretransplant desensitization protocols, including plasmapheresis, intravenous immunoglobulin, induction antibody therapy, and intensive maintenance immunosuppression, are generally employed in kidney transplant recipients who have positive status for donor-specific anti-HLA antibody (DSA). To avoid serious infectious complications, the authors designed a novel low-dose protocol in Thai patients undergoing DSA+ living-related kidney transplantation (LRKT). MethodsA retrospective cohort study of the patients who underwent DSA+ LRKT was conducted. The novel protocol consisted of 3 to 5 sessions of pretransplant double-filtration plasmapheresis (DFPP) with or without low-dose intravenous immunoglobulin together with low-dose anti-thymocyte globulin (ATG) induction (1-1.5 mg/kg/d for 3-4 days) and low-dose tacrolimus (Tac) (trough level 5-10 ng/mL), mycophenolate, and prednisolone. ResultsThe study included 17 patients. The lymphocyte crossmatch via complement-dependent cytotoxicity was negative in 12 patients and positive for B cell immunoglobulin M in 5 patients. The novel desensitization protocol resulted in a decrease of at least 50% of DSA mean fluorescence intensity from baseline (from 4320 ± 549 before DFPP to 1601 ± 350 before transplantation, P < .005) and successful kidney transplantation with good allograft function in all cases. Early DSA rebound was observed in 3 patients after transplantation, and kidney biopsy revealed subclinical antibody-mediated rejection in 1 patient and diffuse C4d staining without cell infiltration in 2 patients. There were good long-term outcomes in patient and graft survival (100% and 94.1%, respectively). Only 1 allograft loss occurred because of nonadherence. The majority of patients have stable allograft function with serum creatinine less than 1.5 mg/dL. However, infections, including CMV and other organisms, were commonly observed. ConclusionsDesensitization protocol with DFPP, low-dose ATG, and Tac provides excellent outcomes in living donor kidney transplantation in highly sensitized Asian populations.

COMPARISON OF CLINICAL OUTCOMES OF LIVING DONOR KIDNEY TRANSPLANTATION IN FEMALE RECIPIENTS WITH BIRTH HISTORY ACCORDING TO THE RELATION TO A DONOR

Live-donor kidney transplantation has significantly increased the size of the donor pool, and live-unrelated kidney transplantation, especially spousal donation has increased exponentially. Living unrelated and related kidney transplantation has been shown to have similar allograft survival. However, the effect of donor-recipient relationship in living-related and unrelated kidney transplantation on graft and patient survival remains uncertain. Thus, the aim of this study was to evaluate the effect of live-donor types and graft outcomes. From January 2009 to January 2018, a total of 2,680 kidney transplants were performed at Asan Medical Center, while 2,060 living donor kidney transplantations were performed. We studied 864 female recipients from living donors with pregnancy history, and HLA-incompatible, retransplantation and those without or unknown pregnancy history were excluded. The female recipients were categorized into three groups; Offspring-to-mother (Group I), husband-to-wife (Group II), and other unrelated donors (Group III). The primary endpoint of this study was biopsy-proven acute rejection and graft survival. We also evaluated delayed graft function (DGF), death-censored graft failure and mortality. Number of HLA ABDR mismatch was significantly lower in group I and there were more ABO incompatible kidney transplantation in group II compared to the other groups. There were 4 (2.3%), 3 (1.9%), and 3 (5.4%) cases of mortality in group I, group II, and group III, respectively (p= 0.352). There was no significant difference in the one, three, and five years patient survival among groups (p=0.444). There was no significant difference in the biopsy-proven acute rejection between the three groups. Clinical rejection and DGF occurred at a high rate in group II compared to group I and group III, but there was no statistically significant difference between the three groups. We conclude that both offspring and spousal living donor transplants have similar patient and graft survival and can be considered whenever feasible for female recipients with multiple donor options.

Rapidly Progressive Invasive Urothelial Carcinoma With Flat and Infiltrative Growth Pattern in the Graft Kidney After Living-Related Kidney Transplantation: A Case Report

BackgroundBecause immunosuppression is necessary for kidney transplant recipients, malignant tumorigenesis of recipient organs is a concern; however, few studies have discussed the malignant alteration of transplanted grafts that have been functional for a long time. In addition, a urothelial carcinoma (UC) in transplanted kidney graft is a rare disease. Case reportA 62-year-old man had end-stage renal failure 31 years ago and received a kidney transplant from his father. Acute renal failure due to obstruction of the transplanted ureter was diagnosed. Ultrasound, ureterogram, and non-enhanced computed tomography scans revealed no obvious evidence of any neoplastic lesion. We treated the obstruction and hydronephrosis with transplant ureter stenting. However, the regional lymph nodes enlarged, and it became necessary to change the ureteral stent frequently because of stent stenosis; therefore, he underwent lower transplant ureteral resection and reconstruction. Histopathology confirmed a UC with a flat and infiltrative growth pattern. The patient then underwent graftectomy including right external iliac vein resection and reconstruction; however, because of numerous metastatic nodules, radical surgery could not be performed. The patient subsequently died because of septic shock after the second surgery. ConclusionWe report a case of an invasive UC with a flat and infiltrative growth pattern derived from a transplant kidney graft that occurred 31 years after a living-donor transplant that could not be treated immediately and was difficult to diagnose.

Successful Management of COVID-19 Pneumonia Following Live-Related Kidney Transplant in a 74-Year-Old Recipient

Background: COVID-19 infection is the most recent worrying viral pandemic worldwide. Little is understood regarding the course of illness and subsequent immediate and long-term complications. Despite numerous ongoing trials, there is still no agreed mode of treatment for this viral illness. Live-donor renal transplantation is the gold standard treatment for end-stage renal disease. Those patients undergoing renal transplantation are deemed particularly high risk for contracting COVID-19 secondary to the effects of immunosuppression. This case report discusses management of COVID-19 infection in a 74-year-old male, who underwent a live-related kidney transplant. Case Presentation: A 74-year-old Caucasian male patient, developed renal failure due to diabetic nephropathy since 2012. The patient was transplanted in 2013 with a graft from a deceased donor, but unfortunately this kidney failed in 2014, aetiology unknown. Haemodialysis was recommenced until he received a second kidney transplant from a live-related donor in March 2020. Unfortunately, postoperative recovery was complicated with COVID-19 infection. The clinical signs and symptoms, along with details surrounding presentation are discussed. This includes the rationale behind the management of such highrisk immunosuppressed patients with COVID-19 infection. Conclusion: There is still no consensus about the best modality for treating COVID-19 infection in recipients of solid organ transplantation. From our experience, temporarily stopping the anti-proliferative immunosuppressant (e.g. Mycophenolate mofetil) during the acute illness seemed to enhance recovery of the acute phase of the disease.

1075 - Live related kidney transplantation in double renal arteries: Is 70/30 percent luminal discrepancy the new cutoff for Pajama bench reconstruction?

1075 - Live related kidney transplantation in double renal arteries: Is 70/30 percent luminal discrepancy the new cutoff for Pajama bench reconstruction?

Novel delivery of cellular therapy to reduce ischemia reperfusion injury in kidney transplantation.

Ex vivo normothermic machine perfusion (NMP) of donor kidneys prior to transplantation provides a platform for direct delivery of cellular therapeutics to optimize organ quality prior to transplantation. Multipotent Adult Progenitor Cells (MAPC® ) possess potent immunomodulatory properties that could minimize ischemia reperfusion injury. We investigated the potential capability of MAPC cells in kidney NMP. Pairs (5) of human kidneys, from the same donor, were simultaneously perfused for 7 hours. Kidneys were randomly allocated to receive MAPC treatment or control. Serial samples of perfusate, urine, and tissue biopsies were taken for comparison. MAPC-treated kidneys demonstrated improved urine output (P=.009), decreased expression of injury biomarker NGAL (P=.012), improved microvascular perfusion on contrast-enhanced ultrasound (cortex P=.019, medulla P=.001), downregulation of interleukin (IL)-1β (P=.050), and upregulation of IL-10 (P<.047) and Indolamine-2, 3-dioxygenase (P=.050). A chemotaxis model demonstrated decreased neutrophil recruitment when stimulated with perfusate from MAPC-treated kidneys (P<.001). Immunofluorescence revealed prelabeled MAPC cells in the perivascular space of kidneys during NMP. We report the first successful delivery of cellular therapy to a human kidney during NMP. Kidneys treated with MAPC cells demonstrate improvement in clinically relevant parameters and injury biomarkers. This novel method of cell therapy delivery provides an exciting opportunity to recondition organs prior to transplantation.

Outcome of ABO Blood Type–Incompatible Living-Related Donor Kidney Transplantation Under a Contemporary Immunosuppression Strategy in Japan

BackgroundBecause of the serious donor shortage in Japan, there is an increasing need for ABO blood type–incompatible kidney transplantation (ABOi-KT) in living-related donor kidney transplantation. We evaluated the outcomes of ABOi-KT performed at our hospitals using a contemporary immunosuppression strategy with low-dose rituximab. Patients and MethodsBetween June 2006 and April 2019, 107 patients underwent living-related donor kidney transplantation at our hospitals. The patients were divided into ABO-compatible (ABOc) and ABOi groups. The basic immunosuppression regimen differed between the 2 groups in the use of low-dose rituximab and therapeutic apheresis in the ABOi group. We compared graft survival, patient survival, rejection, viral infection, and posttransplant renal function between the 2 groups. ResultsOf 107 recipients, 37 (35%) underwent ABOi-KT. The 5-year graft survival rates in the ABOc and ABOi group were 91% and 100%, respectively. The Kaplan-Meier analyses showed no difference in graft survival (P = .168) or patient survival (P = .873) between the groups. Biopsy-proven rejection in the ABOc and ABOi groups was observed in 13 (19%) and 7 (19%) patients, respectively (P = .965), and viral infection was observed in 21 (30%) and 10 (27%) patients (P = .747), respectively. Renal function by estimated glomerular filtration rate from 1 week to 5 years after transplantation was similar in both groups. ConclusionsThe outcomes of ABOi-KT with low-dose rituximab were comparable with those of ABOc-KT at our hospitals. ABOi-KT with proper immunosuppression may be an option to help resolve the severe donor shortage in Japan.

SAT-339 Low Dose Induction Immunotherapy with Anti Human T-lymphocyte Immunoglobulin (Grafalon) in High Risk Renal transplantation – A Real-world, Single Centre Experience from India

The current armamentarium of rabbit polyclonals includes thymoglobulin and Grafalon. The experience with the latter has been quite limited as until recently it was not available in India. In addition, its dose and duration are controversial, differs center-wise, and is based on scarce clinical data. The objective of this study was to assess the safety and efficacy of Grafalon induction in live related high-risk kidney transplant patients. (history of blood transfusions, HLA mismatch> 3). This was a single-center, prospective, observational study of 54 renal transplant patients who received Grafalon as induction therapy. All patients underwent living donor kidney transplantation. Pre-transplant CDC and flow crossmatch were negative in all. Grafalon was administered at an average dose of 6.0 mg/kg body weight, as a single dose infusion through peripheral intravenous line over 3 hours on day 0. Tacrolimus, MMF and prednisolone constituted maintenance immunosuppression in all patients. These patients were followed up twice a week for 1 month, once a week for 2nd month and once in 15 days for the 3rd month and thereafter once a month. At each visit, they were evaluated clinically as well subjected to laboratory investigations. Tacrolimus levels were monitored twice a week for the first week, once a week for the first month and thereafter once a month. Microsoft Excel was used to analyse the data. All of the patients tolerated Grafalon infusion well and there were no major infusion reactions or fever requiring temporary stoppage or cessation of the drug. Seven patients (13%) developed biopsy proven acute rejection. Majority of them were mild grade cellular rejections and responded well to steroids with good recovery of renal function. At a mean follow up of 10.65+5.4months, patient survival was 100% and graft survival was 100%. Infection episodes were seen in 7 patients with UTI (n=6) being the commonest cause. There were no documented CMV or BK virus infections. Post-transplant, day 1 serum creatinine was 4.89+2.78 mg/dL which reduced to 1.44 ± 0.8mg/dL (n=49, p<0.0001) at day 10 and 1.24 ± 0.35 mg/dl (n=34, p<0.0001) at day 30. Grafalon (6mg/kg) is associated with an acceptable efficacy and safety profile in renal transplantation. Larger studies are necessary to confirm the findings.

SUN-389 Collagenofibrotic glomerulopathy in kidney transplant recipient: A first report

Collagenofibrotic glomerulopathy (CG) also known as collagen type 3 glomerulopathy is a rare disease characterized by the deposition of collagen type 3 in the glomeruli. The absence of skeletal abnormalities in these patient is one feature that helps in distinguishing CG from nail patella syndrome, another collagen type 3 deposition disease in renal glomeruli. High serum levels of pro-collagen type III peptide were reported in this disease. Patients may have proteinuria, hematuria and/or renal dysfunction. CG is considered a progressive disease with variable rate of progression. CG manifests as membranoproliferative pattern of injury by light microscopy with negative immunofluorescence. The definitive diagnosis is made by electron microscopy with the characteristic subendothelial and mesangial curved and comma-like banded collagen type 3 fibers of 45-65 nm in periodicity. A retrospective chart review of collagenofibrotic glomerulopathy case at the American University of Beirut Medical Center. A 39 years-old man had a living-related kidney transplant 13 years ago for unknown cause ESKD. An allograft biopsy was performed for rise in creatinine and proteinuria without hematuria. He has been maintained on cyclosporine, azathioprine and prednisone for 12 years before a switch to tacrolimus, mycophenolate mofetil (MMF) and prednisone one year, done prior for a rise in creatinine at an outside hospital. He was diagnosed with hypertension and diabetes mellitus three years prior to biopsy. His family history is negative for renal disease.Table 1Laboratory values at the time of kidney biopsyCreatinine1.8-2.2 mg/dlTacrolimus4.624 hours urine protein1.2 grams24 hours urine albumin0.65 gramsHbA1c7.8 %HIV serologyNegativeHepatitis B and C serologyNegativeUrinalysis+ 2 proteinuria, negative hematuria Open table in a new tab Table 2Pathologic FindingsLight microscopy (LM), figure 1 (H&E x400).Mesangial matrix expansion and hypercellularity, endocapillary hypercellularity, thickened glomerular capillary wall and focal double contour formation.Immunofluorescence (IF)Negative for IgA, IgG, IgM, C3, C4, C1q, kappa and lambda.Electron microscopy (EM) figure 2Accumulation of collagen fibers between the capillary basement membranes and swollen endothelial cells, with increased mesangial matrix deposition. Tubules show tubular injury with cytoplasmic vacuolization. No subepithelial, subendothelial or mesangial electron dense deposits are identified. The capillary loops are patent. Open table in a new tab Figure 2View Large Image Figure ViewerDownload Hi-res image Download (PPT) We are reporting the first case of post-transplant Collagenofibrotic glomerulopathy (CG). The recurrence post-transplant points towards a systemic disease process, including genetic predilection. It highlights the importance of considering unrecognized kidney disease causes in patients with unknown cause ESKD.

Robot-Assisted Radical Cystectomy With Orthotopic Neobladder as a Urinary Diversion for a Kidney Transplant Recipient: A Case Report

BackgroundA higher prevalence of bladder cancer is reported in solid organ recipients, and advanced cancer requires radical cystectomy combined with urinary diversion. Surgery is technically challenging in kidney transplant recipients because of urinary tract abnormalities. Here, we describe the use of a robot-assisted approach in a kidney transplant recipient. Case presentationThe etiology of the patient’s end-stage renal disease was bilateral hypoplastic kidney. The patient started to receive hemodialysis at 19 years of age and underwent living-related kidney transplant at 23 years of age. Thirteen years later, he was diagnosed with invasive urothelial carcinoma and underwent robot-assisted radical cystectomy with extracorporeal neobladder construction under open laparotomy. Surgery was indicated to enhance suture flexibility and dissection of the peribladder tissues. Although the patient had an intraperitoneal infection caused by leakage from the vesicourethral anastomosis site and required drainage of the abscess, his condition stabilized after antibiotic treatment. ConclusionThis case outlines the effectiveness of the robot-assisted approach in patients with urinary tract abnormalities, such as kidney transplant recipients.

Impact of One-Year Serum Creatinine on Long-term Renal Graft Survival in a Living-Related Renal Transplant Program.

This study was carried out to determine the impact of one-year posttransplant serum creatinine (SCr) levels on the long-term outcomes of living-related donor kidney transplants. A retrospective cohort study included 773 adult living-related renal transplant recipients from 2010 to 2012, with a minimum follow-up period of five years. Demographics and posttransplantation follow-up data including immunosuppression regimens, rejection episodes, and survival rates were evaluated. Patients were divided into four cohorts (G1, G2, G3, and G4 based on SCr at the end of the 1st year: G1, SCr <88.4 μ mol/L; G2, 88.5≤ SCr ≤ 132.6 μmol/L; G3, 132.7≤ SCr ≤176.8 mol/L; and G4, SCr ≥176.9 μ mol/L). Comparisons between the groups used the Chi-square test for qualitative parameters and analysis of variance for continuous variables. Five-year graft survival for G1 was 98% as compared to 76% in G4 (P <0.001). Recipients of G4 encountered more acute rejection episodes in 21% of the cases as compared to 7.3% in G1 (P = 0.001). Donors were older in G4 (42.07 ± 10.4 years) as compared to G1 (30.1 ± 8.5 years) (P = 0.001). A third of the donors in G1 were HLA identical as compared to 7% in G4. Prediction of long-term graft survival is possible by the SCr level at one year post transplant. This can be of great importance, especially to identify those patients who require close monitoring in follow-up. Donor age, HLA, and acute rejection impact SCr at one year and hence graft outcome.

Research Highlights

Research Highlights

Will you give my kidney back? Organ restitution in living-related kidney transplantation: ethical analyses

In this article, we perform a thought experiment about living donor kidney transplantation. If a living kidney donor becomes in need of renal replacement treatment due to dysfunction of the...

Retrospective genetic analysis illustrates the spectrum of autosomal Alport syndrome in a case of living-related donor kidney transplantation

BackgroundKidney transplantation is the treatment of choice in end-stage renal disease due to Alport syndrome (AS). However, the chances of finding an adequate living-related donor in AS are much worse compared to non-heritable conditions. Successful cases of related living-donor transplantation mostly refer to X-linked AS but are rarely reported in genetically confirmed autosomal AS.Case presentationWe describe the outcome of an exceptional AB0-incompatible kidney donation from father to son in a family with altered COL4A3. While decision-making was based on extensive clinical donor evaluation prior to transplantation, we analyzed the underlying genetic background in retrospect and associated these findings with the phenotype in all available family members. While biallelic COL4A3 variants caused autosomal recessive AS (ARAS) in the son (recipient), heterozygous family members, including the father (donor), showed minimal renal involvement and high-frequency sensorineural hearing impairment later in life indicating mild autosomal dominant Alport syndrome (ADAS). The recipient’s successful participation in the European and World Transplant Games is a testament to the positive outcome of transplantation.ConclusionsIn summary, living-related donor transplantation may be successful in autosomal AS, provided that thorough clinical and genetic evaluation of potential donors is performed. However, unrelated kidney transplantation should be given priority upon unpredictable genetic risk. Individual genetic variant interpretation is an important component of personalized donor assessment and will help to better predict genetic risk in the future.

A Case Report on Post-Transplant Erythrocytosis

Post-transplant erythrocytosis is defined as persistently elevated haemoglobin and haematocrit levels that occur following renal transplantation and persist for more than six months in the absence of thrombocytosis, leukocytosis or other potential causes of erythrocytosis. Here, we report the case history of a 35-year-old male, who underwent live related kidney transplantation ten months ago, presented with high haemoglobin level and high haematocrit. It is an uncommon complication of kidney transplant recipient,whichprompted us to report the case&#x0D; Birdem Med J 2019; 9(2): 170-173

Anesthesia management for living-related kidney transplant in a pediatric patient with uremia complicated with dilated cardiomyopathy: a case report

Anesthesia management for living-related kidney transplant in a pediatric patient with uremia complicated with dilated cardiomyopathy: a case report

An updated analysis of the surgical and urological complications of 789 living-related donor kidney transplantations: Experience of a single center.

This study aims to review retrospectively the surgical and urological complications encountered in 789 cases of living-related donor kidney transplantations (LRDKTs). In this study, the clinical records of 789 LRDKTs, which were performed between 1983 and 2017, were reviewed retrospectively concerning surgical and urological complications. Overall, urological and surgical complications were encountered in 87 (11.02%) of the cases. Of the 789 patients, urological complications were detected in 44 of them (5.6%), including 8 urinary fistula (with 1 distal ureteral necrosis), 10 ureteric stenosis, 1 renal calculus, 9 symptomatic vesicoureteral reflux and 16 lymphoceles requiring intervention. As surgical complications (n=43), vascular complications were encountered in 8 cases; there were 5 cases with renal artery stenosis and 3 with renal vein thrombus. Wound infection was detected in 14 patients. Eighteen patients underwent surgical explorations due to perinephric hematoma during the early postoperative period. Renal allograft rupture due to accelerated rejection was developed in 2 cases. A lower segmental arterial injury occurred in 1 patient during the operation. In our series, urological and surgical complications were detected in 11.02% of the recipients. Although complications still encountered, early identification of these complications with proper management strategies significantly decreases the risk of graft loss.

Comparative effects of human albumin versus modern hydroxyethyl starch in living-donor renal transplant

Background Living-donor renal transplantation is considered the best therapy for renal failure patients. The outcome and graft function are affected by various perioperative variables. Fluid management remains a controversy whether to use crystalloids or colloids with the effect of either type of solution on graft function and overall morbidity. Patients and methods We studied 120 patients with end-stage renal disease, who were on regular hemodialysis scheduled for living-related kidney transplantation. The patients were assigned to receive either 6% hydroxylethyl starch (HES) 130/0.4 (Voluven) (HES group: n=60) or albumin 5% (ALB group: n=60) for intraoperative use. In both groups, normal saline was administered at 10 ml/kg/h. In addition, patients received 250 ml boluses of either Voluven (HES group) with a maximum of 50 ml/kg/day or ALB 5% (ALB group) to maintain their central venous pressure between 12 and 15 mmHg. Blood transfusion was given based on the hemoglobin level ( Results There were no statistically significant differences between the two groups regarding hemodynamic variables, onset of diuresis, or need for postoperative dialysis. Perioperative laboratory workup (BUN, creatinine, creatinine clearance, and INR) were similar in both study groups. Conclusion There are no statistically significant differences between the use of HES solutions and ALB 5% on the outcome of living-donor renal transplant recipients. Using either solutions is comparable to the other with no special side effects.

Upside-down kidney transplantation using single-suture single-knot technique

Aim: The aim of the study was to evaluate the outcomes of upside-down transplanted kidney with single-suture single-knot technique.Methods: From August 2013 till date, a total of 299 living-related kidney transplantations were done in the Department of Urology and Kidney Transplantation Surgery TU Teaching Hospital and Grande International Hospital, Kathmandu, Nepal. Out of them, 71 upside-down kidney transplantations were performed using single-suture single-knot technique. In this study, their overall outcome is evaluated. Results: Our study showed no difference in the overall outcome between upside-down and standard kidney transplantation and even less blood transfusion rate in upside-down group. Conclusion: There should be no hesitation to perform the upside-down kidney transplantation.