Recovery Of Graft Function Research Articles

Serum Neutrophil Gelatinase-Associated Lipocalin and Cystatin C for Assessing Recovery of Graft Function in Patients Undergoing Living-Donor Kidney Transplantation.

Neutrophil gelatinase-associated lipocalin (NGAL) can be used as an early indicator of acute kidney injury (AKI), and cystatin C is also suggested to be an ideal marker of glomerular filtration rate (GFR), but they were not sufficiently studied in recipients without delayed graft function (DGF) after living-donor kidney transplant (LDKT). The aim of the study is to investigate whether serum NGAL and cystatin C can assess the recovery of renal function after LDKT. 49 adult patients that had undergone LDKT between January 2012 and March 2014 were prospectively enrolled. Serum creatinine, NGAL, and cystatin C were measured on day 0-7, day 10, day 14 and month 9 after transplant. Recovery of graft function was evaluated by the time needed to reach eGFR > or = 60 mL/min/1.73 in2 Poor long-term graft outcome was defined as eGFR < 60 mL/min/1.73 M2 at 9 months. No DGF was recorded. Serum NGAL level decreased to normal earlier than creatinine after transplant. Cystatin C declined rapidly, but still stayed above the normal range. Serum NGAL on day 0 (p = 0.028) and cystatin C on day 2 (p < 0.001) were independent predictors of the time for graft function recovery in multivariate analysis. Compared to recipients with fair long-term graft outcome (eGFR > 60 mL/min/1.73 m2 at 9 months), recipients with poor long-term graft outcome (eGFR < 60 mL/min/1.73 m2 at 9 months) displayed higher serum NGAL on day 2 (p = 0.045), older age (p = 0.002), longer time on dialysis (p = 0.02), and lower donor eGFR (p = 0.045). There were correlations between serum NGAL and eGFR on day 0 and day 2. Correlations between serum cystatin C and eGFR on day 0, day 2, and month 9 were all significant. Serum NGAL may be used as an early predictor of recovery of post-transplant graft function after LDKT, but may not be used for real-time assessment of GFR. At the same time, the predictive ability of serum cystatin C needs to be further assessed.

Hepatic Arterial Buffer Response Maintains the Homeostasis of Graft Hemodynamics in Patient Receiving Living Donor Liver Transplantation.

In living donor liver transplantation (LDLT), the hepatic hemodynamics plays important roles in graft regeneration, and the hepatic blood inflows are associated with graft size. However, the data of interplay between the hepatic arterial buffer response (HABR) and graft-to-recipient weight ratio (GRWR) in clinical LDLT are lacking. To identify the effect of the HABR on the hepatic hemodynamics and recovery of graft function and to evaluate the safe lower limit of the GRWR in carefully selected recipients. Portal venous and hepatic arterial blood flow was measured in recipients with ultrasonography, and the graft functional recovery, various complications, and survive states after LDLT were compared. In total, 246 consecutive patients underwent LDLT with right lobe grafts. In total, 26 had a GRWR < 0.7 % (A), 29 had a GRWR between 0.7 and 0.8 % (B), and 181 had a GRWR > 0.8 % (C). For small-for-size syndrome, there was no significant difference (P = 0.176). Graft survival rates at 1, 3, and 5 year were not different (P = 0.710). The portal vein flow and portal vein flow per 100 g graft weight peaks were significantly higher in the A. Hepatic arterial velocity and hepatic arterial flow decreased in all the three groups on postoperative day 1; however, the hepatic arterial flow per 100 g graft weight was close to healthy controls. HABR played important roles not only in the homeostasis of hepatic afferent blood supply but also in maintaining enough hepatic perfusion to the graft.

Dimethyloxalylglycine treatment of brain-dead donor rats improves both donor and graft left ventricular function after heart transplantation

Hypoxia inducible factor (HIF)-1 pathway signalling has a protective effect against ischemia/reperfusion injury. The prolyl-hydroxylase inhibitor dimethyloxalylglycine (DMOG) activates the HIF-1 pathway by stabilizing HIF-1α. In a rat model of brain death (BD)-associated donor heart dysfunction we tested the hypothesis that pre-treatment of brain-dead donors with DMOG would result in a better graft heart condition. BD was induced in anesthetized Lewis rats by inflating a subdurally placed balloon catheter. Controls underwent sham operations. Then, rats were injected with an intravenous dose of DMOG (30 mg/kg) or an equal volume of physiologic saline. After 5 hours of BD or sham operation, hearts were perfused with a cold (4°C) preservation solution (Custodiol; Dr. Franz Köhler Chemie GmbH; Germany), explanted, stored at 4°C in Custodiol, and heterotopically transplanted. Graft function was evaluated 1.5 hours after transplantation. Compared with control, BD was associated with decreased left ventricular systolic and diastolic function. DMOG treatment after BD improved contractility (end-systolic pressure volume relationship E'max: 3.7 ± 0.6 vs 3.1 ± 0.5 mm Hg/µ1; p < 0.05) and left ventricular stiffness (end-diastolic pressure volume relationship: 0.13 ± 0.03 vs 0.31 ± 0.06 mm Hg/µ1; p < 0.05) 5 hours later compared with the brain-dead group. After heart transplantation, DMOG treatment of brain-dead donors significantly improved the altered systolic function and decreased inflammatory infiltration, cardiomyocyte necrosis, and DNA strand breakage. In addition, compared with the brain-dead group, DMOG treatment moderated the pro-apoptotic changes in the gene and protein expression. In a rat model of potential brain-dead heart donors, pre-treatment with DMOG resulted in improved early recovery of graft function after transplantation. These results support the hypothesis that activation of the HIF-1 pathway has a protective role against BD-associated cardiac dysfunction.

Hypoxia preconditioning induced HIF-1α promotes glucose metabolism and protects mitochondria in liver I/R injury

Ischemia and reperfusion (I/R) injury is one of the main lesions after liver transplantation. This study aims to detect hypoxia-induced HIF-1α protects transplanted liver against I/R injury by promoting glucose metabolism to decrease mitochondrial injury and apoptosis on rat model. The rats were given a treatment of 90 min non-lethal hypoxic preconditioning to induce and increase the HIF-1α expression. The autologous orthotopic liver transplantation model was used to imitate liver I/R injury. Hypoxic-induced HIF-1α was detected to increase in liver tissue after 90-minute hypoxic environment (HP vs. Ctrl, *P<0.001). After operation, the expression of HIF-1α in liver tissue was also stayed at a high level. At 24h after operation, several genes were promoted, such as the levels of HK-2 (HP vs. AT, 24h, *P=0.004), Lactate dehydrogenase (LDHA) (HP vs. AT, 24h, *P=0.003), pyruvate dehydrogenase kinase (PDK-1) (HP vs. AT, 24h, *P=0.007), even the NF-κB and Erk pathways. From the TUNEL assay, the apoptosis in hypoxic preconditioning liver tissue was decreased compared with non-HP operative group at 12h after operation. The expressions of cleaved-caspase 3 (HP vs. AT, *P=0.0119) and PARP (HP vs. AT, *P=0.0134) in HP group were also significantly lower than AT group. The hypoxia-induced HIF-1α could promote glucose metabolism to protect hepatocellular mitochondria from damage. It could be a useful way to protect liver against I/R injuries and inflammatory injury, and particularly promote the recovery of graft function.

Application of NGAL and Cys c in predicting graft function during early period after kidney transplantation

To assess the diagnostic values of novel biomarkers, such as neutrophil gelatinase-associated lipocalin (NGAL) and cystatin c (Cys c), in the diagnosis of delayed graft function (DGF). A total of 114 patients undergoing kidney transplantation from deceased donors from October 2012 to October 2013 were enrolled. Recipients on dialysis during the first postoperative week were included into DGF group while those without DGF into early graft function (EGF) group. sNGAL, sCys c and serum creatinine (sCr) were measured pre-operation, as well as at 4, 12, 24, 72 and 168 h post-operation. Furthermore, uNGAL leveks were measured at 4, 12 and 24 h post-transplantation. The receiver operating characteristic (ROC) curve and area under the curve (AUC) were used to evaluate the predictive value of DGF. Among 114 recipients enrolled, 23 presented DGF and 91 EGF. In EGF group, within 4 h post-transplantation sNGAL and sCys c decreased more significantly than sCr (51.31% (40.30%, 62.31%), 56.39% (50.02%, 68.40%) vs 21.40% (6.77%, 27.44%), P = 0.009 and 0.029 respectively). Between two groups, differences of sequential decrease were observed earlier in sNGAL and sCys c than uNGAL and sCr. It demonstrated better performance in predicting DGF. The AUC of sCr was between uNGAL and sNGAL, sCys c. Combination of both sNGAL and sCys c yielded a ROC-AUC of 1.000. sNGAL and sCys are ideal for predicting the recovery of graft function during early period after kidney transplantation. And a combination of both biomarkers may dramatically improve the specificity and sensitivity of diagnosing DGF.

Urinary tract infections during the first year after renal transplantation: one center's experience and a review of the literature.

The aim of the study was to evaluate the incidence, clinical manifestations, microbiology, risk factors, and the influence of UTIs on renal graft function. We analyzed clinical data, urine cultures performed within the first 12months after RTx, and renal function within 24months in consecutive patients undergoing RTx at Gdańsk Transplantation Centre between January 2007 and December 2009. We studied data from 209 RTx recipients, 59.3% men, with a mean age of 46.4±14yr. We observed 322 UTI episodes in 111 patients, including asymptomatic bacteriuria (53%, n=170), lower UTIs (25%, n=82), upper UTIs (22%, n=57), and 13 cases of urosepsis. Thirty-eight percent of UTIs were diagnosed during the first post-transplant month. The most frequently isolated uropathogen was Enterococcus faecium (36%, n=44) and from the second month E.coli (58%, n=114). Risk factors were female gender, induction use, history of recurrent UTIs before RTx, acute rejection (AR), CMV infection, vesico-ureteral reflux or strictures at uretero-vesical junction, and high comorbidity. Renal graft function measured by eGFR was significantly worse in patients suffering from UTIs from the baseline. However, the evolution of renal graft function did not differ significantly between patients with and without UTIs. Lower renal graft function may promote UTIs or UTIs may not allow a complete recovery of graft function after transplantation.

The effect of remote ischemic postconditioning on graft function in patients undergoing living donor kidney transplantation.

We evaluated whether remote ischemic postconditioning (RiPoC) could improve initial graft function in living donor kidney transplantation (KT). Patients undergoing living donor KT were randomly assigned to either RiPoC (n=30) or control group (n=30). Immediately after reperfusion in the RiPoC group, three cycles of ischemia and reperfusion, lasting 5 min each, were performed on one upper limb. Renal function was assessed before surgery, 2 hr after surgery, and at 12-hr intervals for 96 hr postsurgery by measuring serum creatinine (sCr) and the estimated glomerular filtration rate (eGFR). Urine output and urine creatinine were assessed until postoperative day 7, and hospital stay and complication rates were compared. The time for sCr to reach 50% of its preoperative level was significantly shorter in the RiPoC group than in the control group [12 (12-24) hr for RiPoC vs. 24 (21-36) hr for the control, P=0.005]. The number of patients whose sCr was reduced by 50% within 24 hr was significantly greater in the RiPoC group than in the control group [n=26 (87%) in RiPoC vs. n=18 (60%) in control, P=0.020]. However, there were no differences in sCr and eGFR thereafter, the incidence of graft dysfunction or complication rates between groups. In this study, RiPoC appeared to hasten the recovery of graft function within 24 hr but did not affect the graft function thereafter. However, considering most recipients had immediate graft function, further studies with deceased donors or studies powered to detect a smaller difference are needed.

Pain Control After Liver Transplantation Surgery

BackgroundAlthough post–liver transplantation pain is not as severe as expected from the size of the surgical incision, optimal pain control becomes crucial to aid compliance with the ventilator, improve respiratory function, and facilitate an early weaning from mechanical ventilation. MethodsBecause the majority of analgesics are primarily metabolized and excreted by the hepatobiliary system, a poor recovery of graft function will result in a decrease in clearance and reduced elimination of the drug. On the other hand, if the liver is working well, the metabolism of analgesics improves significantly with minimal accumulation. Morphine-based analgesia has been associated with a higher risk of sedation and respiratory depression compared with major abdominal surgical procedures. Fentanyl and sufentanil in continuous intravenous infusion may be preferred in the presence of hemodynamic instability or bronchospasm. Sufentanil produces shorter-lasting respiratory depression and long-lasting analgesia than does fentanyl. ResultsThe provision of potent continuous analgesia, independent of the duration of infusion, and the unique pharmacokinetics, not significantly affected by the functional status of the graft, make remifentanil appropriate for the majority of liver-transplanted patients. Unlike for patients with very severe pain after major abdominal surgery, liver transplant recipients usually benefit from tramadol, either in repeated intravenous boluses or continuous intravenous infusion.Paracetamol has been included as adjuvant (or sole agent, rarely) in the analgesic treatment of mild to moderate postoperative pain. The combination treatment (paracetamol plus tramadol) is a reasonable, safe option with improved analgesia and concurrent reduction in the incidence of some opioid-related side effects. ConclusionsFrequent review of the patient's response is mandatory when potent opioids are used because dose-dependent respiratory depression is a serious and potentially life-threatening adverse effect. The benefits provided by epidural analgesia in this particular setting should be weighed against the risks because in the presence of markedly deranged perioperative blood clotting, the development of epidural hematoma represents a disastrous complication.

Serum neutrophil gelatinase-associated lipocalin and recovery of kidney graft function after transplantation.

BackgroundNeutrophil gelatinase-associated lipocalin (NGAL) is a marker for acute kidney injury. We studied whether serum NGAL predicts delayed graft function (DGF) and recovery of kidney function after transplantation.MethodsSerum NGAL was analyzed using commercial ELISA and point-of-care (POC) (Triage®, Biosite) methods. Serum samples were collected from 176 consecutive, deceased-donor kidney recipients just before transplant surgery and on day 1 and 14 after transplantation. The first 132 samples were analyzed with both methods and the remaining samples with the POC method.ResultsThe correlation between the ELISA and POC methods was 0.89, p < 0.0001 and hence the POC method was used for the remaining analyses. DGF was seen in 66/176 patients. Day 1 sNGAL was significantly higher in DGF (588 ng/ml, SD 189.6) compared to early graft function (355 ng/ml, SD 166.2, p < 0.0001) and this difference persisted on day 14. Day 1 sNGAL predicted DGF with an area under the curve (AUC) of 0.853 (CI 0.792-0.914, p < 0.0001). At the optimal cutoff level of 423 ng/ml the sensitivity was 87% and the specificity 77%. In a multivariate analysis, day 1 sNGAL emerged as an independent predictor of DGF. The sNGAL also predicted DGF lasting longer than 14 days with an AUC of 0.825 (CI 0.751-0.899, p < 0.0001). At the optimal cutoff level of 486 ng/ml, the sensitivity was 80% and specificity 75%.ConclusionSerum NGAL predicts clinically significant DGF and is useful in the care of kidney transplant recipients.

Is plasma and urine neutrophil gelatinase-associated lipocalin (NGAL) determination in donors and recipients predictive of renal function after kidney transplantation?

ObjectivesDelayed graft function (DGF) is still a major issue in kidney transplantation. Plasma and urine neutrophil gelatinase-associated lipocalin (NGAL) were evaluated in a population of kidney donors and recipients to investigate their performance to predict early renal function. Design and methodsPlasma (pNGAL) and urine (uNGAL) samples were obtained from donors before organ procurement, and from recipients before transplantation, and then 6, 24 and 48h after the procedure. Kidney transplantations were performed from both living donors (LDs, n=17) and deceased donors (DDs, n=80). Recovery of renal function was evaluated as the time to reach serum creatinine <2mg/l or glomerular filtration rate (GFR)>40mL/min. Logistic regression was used to assess the ability of different variables to predict the occurrence of DGF. ResultsPlasma NGAL levels were significantly lower in LDs than in DDs. No episodes of DGF were recorded among LD kidney recipients, but DGF was observed in 25% of patients in the DD group. There was no correlation between donor pNGAL and uNGAL values and the occurrence of post-transplant DGF. Recipient pNGAL performed better than uNGAL in terms of predicting DGF occurrence. Donor pNGAL and uNGAL values did not influence the time needed to reach serum creatinine levels of <2mg/dl after transplantation. When time to reach eGFR of >40mL/min is considered, only donor uNGAL seems to be a predictor of graft function recovery. However, recipient pNGAL values obtained 24 and 48h after transplantation, but not uNGAL values, were found to be a significant predictor of graft function recovery. ConclusionsPlasma NGAL level determination in recipients, but not in donors, proved to be a reliable predictor of DGF occurrence and renal function restoration, but too long for an interval to be able to compete with biomarkers currently used in clinical practice.

Retrospective Study On Recurrent Glomerulonephritis (RGN) in The Transplanted Kidney: Our Case Study.

Despite advances in prevention of acute rejection and improved short- and long-term kidney graft survival, RGN remains problematic and poorly characterized. This study analyzed the incidence of various histological types of RGN in our center in the last twenty years. It also sought to identify the potential risk factors for recurrence. We studied 1319 renal transplant patients who had been followed at our center (1992-2012). 451 patients underwent percutaneous needle biopsy of the transplanted kidney. Demographic, clinical and histological features of the RGN were compared with a control group (n. 58 with no GN). Potential risk factors for disease recurrence were analyzed. The histological diagnoses were different: 156/451 (34.58%) chronic allograft nephropathy (CAN), 89/451 (19.73%) GN, 84/451 (18.62%) acute rejections, 78/451 (17.29%) acute tubular necroses, 26/451 (5.76%) normal, 11/451 (2.43%) thrombotic microangiopathy, 7/451 (1.55%) cortical necrosis. For 39/89 (43.82%) patients of the GN group, primary kidney disease was unknown. The histological diagnoses in this group were: 17/39 (43.58%) IgA nephropathy (IgAN), 7/39 (17.94%) FSGS, 5/39 (12.82%) necrotizing extracapillary GN, 6/39 (15.38%) MPGN. 22/89 (24.71%) of patients showed a de novo GN. The histological diagnoses were: 8/22 (36.4%) IgAN, 5/22 (22.7%) FSGS, 2/22 (9.1%) necrotizing extracapillary GN, 3/22 (13.63%) MGN, 1/22 (4.54%) amyloidosis. The remaining 28/89 (31.46%) showed RGN with 22/28 (78.57%) IgAN, 3/28 (10.71%) FSGS, 3/28 (10.71%) MPGN. Interestingly, in our cohort we found a significant correlation of RGN with young age ( 36.6 ± SD in recurrent GN vs. 42.4 ± SD in non recurrent GN (p=0.02)) and the presence of CAN (8/28 in RGN vs. 4/58 in control group (p=0.006)). We did not find significative differences between RGN on control group for age at transplant, sex, living/deceased donors, duration of dialysis, type of dialysis if HD or PD, delayed graft function recovery, type of immunosuppressive therapy, re-transplantation, acute rejection, chronic allograft nephropathy.Post-transplant glomerulonephritis can be de novo or recurrence of the original glomerular disease. In our study, we found IgAN as the most common form of RGN. It is possible that the young age of the transplant patient and the development of a chronic allograft dysfunction during transplantation expose the patient to the development of a RGN.

Acute Humoral Rejection in the Absence of Anti-HLA Antibodies, a French Nation-Wide Study.

Antibody mediated rejection (ABMR) is usually associated with donor-specific anti-HLA antibodies (DSA). Evidence of ABMR in patients with no DSA strongly suggests the implication of non-HLA antibodies. We implemented a retrospective nation-wide study to improve undertanding of non-HLA ABMR. Inclusion criteria were: first or re-transplantion, deceased or living-donor; acute allograft dysfunction during the first three months; allograft biopsy showing a total score of glomerulitis and peritubular capillaritis≥3 according to the Banff classification; absence of identified anti-HLA DSAs using Luminex®. Demographical and clinical parameters were collected for 36 cases. Recipient age was 53±19 yrs. Donor age was 53±12 yrs. Cold ischemia time was 12±8 hrs. All patients received induction therapy (94% basiliximab, 6% thymoglobuline), a CNI (69% tacrolimus, 31% cyclosporine), MPA and steroids. Rejection was diagnosed at day 12±9 in the absence of graft function recovery in 30% of patients. The remaining 25 patients defined a poor serum creatinine nadir of 289±169 μmol/L at day 15±22. Acute graft dysfunction (393±230 μmol/L) led to the diagnosis of acute rejection at day 25±34. No anti-HLA DSA were observed. Mean g+ptc score was 3,8 [3-6]. In addition, intimal arteritis and interstitial inflammation (i ≥1) were observed in 50% and 69% of cases, respectively. Additional lesions included haemorragic suffusion and thrombotic microangiopathy in 26% and 9% of cases, respectively. Therapeutic strategies included steroids pulses (86%), thymoglobulines (37%), rituximab (31%), IVIG (49%) and plasmapheresis (49%). Primary non function was observed in 2 cases. At last follow up (3±1 yrs) serum creatinine was 178±92 μmol/l. 6% of patients were back to dialysis. This study provides a close clinico-pathological description of non-HLA ABMR, and will be followed by additional histological and mechannistic analyses.

Severe infections requiring intensive care unit admission in kidney transplant recipients: impact on graft outcome.

Kidney transplant recipients are at risk for life-threatening infections, which may affect the long-term prognosis. We retrospectively included all kidney transplant recipients admitted for sepsis, severe sepsis, or septic shock to the medical intensive care unit (ICU) of the Saint-Louis Hospital, Paris, France, between 2000 and 2010. The main objective was to identify factors associated with survival without graft impairment 90 days after ICU discharge. Data were available for 83 of 100 eligible patients. The main sites of infection were the lungs (54%), urinary tract (24%), and bloodstream (22%). Among documented infections (55/83), 80% were bacterial. Fungal infections were more common among patients transplanted after 2005 (5% vs. 23%, P = 0.02). Mechanical ventilation was used in 46 (56%) patients, vasopressors in 39 (47%), and renal replacement therapy (RRT) in 34 (41%). In-hospital and day-90 mortality rates were 20% and 22%, respectively. On day 90, among the 65 survivors, 39 (47%) had recovered their previous graft function and 26 (31%) had impaired graft function, including 16 (19%) who were dependent on RRT. Factors independently associated with day-90 survival and graft function recovery were baseline serum creatinine (odds ratio [OR] for a 10 μmol/L increase 0.94, 95% confidence interval [CI] 0.88-1.00) and cyclosporine therapy (OR 0.30, 95% CI 0.11-0.79). Sepsis was chiefly related to bacterial pneumonia or urinary tract infection. Pneumocystis jirovecii was the leading opportunistic agent, with a trend toward an increase over time. Infections often induced severe graft function impairment. Baseline creatinine and cyclosporine therapy independently predicted the outcome.

1020 Robotic kidney transplantation with regional hypothermia: Results from a prospective two-arm non-randomized controlled trial (IDEAL Phase 2b)

INTRODUCTION AND OBJECTIVES: Minimally invasive approaches to kidney transplantation (KT) have recently been described. We recently developed and described a novel technique of robotic KT (RKT) which allows intra corporeal graft cooling. Here, we sought to assess the comparative effectiveness of robotic and open KT (OKT) by evaluating peri and post-operative outcomes. METHODS: During Jan-May 2013, a total of 83 patients with end stage renal disease underwent KT at a tertiary referral center. Sixty six patients met the selection criteria and were enrolled into this prospective two-arm non-randomized controlled trial (IDEAL Phase-2b). Primary outcome was post transplant graft function. Secondary outcomes measured included surgical and immunologic complications, and peri-operative parameters. All patients had a minimum follow up of 6 months. RESULTS: Twenty five and 41 patients underwent RKT and OKT, respectively. There were no significant baseline differences between the two groups. Mean serum creatinine at discharge was 1.3 and 1.4 mg/dl in RKT and OKT patients, respectively (p1⁄40.71). Post-operative pain and analgesic requirements were significantly less in patients undergoing RKT (p1⁄40.01) (Fig 1). No patient undergoing RKT required post transplant dialysis whereas 2 (4.8%) patients undergoing OKT did. The incidence of lymphocele was markedly reduced in patients undergoing RKT detected by per protocol non contrast CT done at 3months (0% vs. 23.8%; p1⁄40.05; Fig 1). There was 1 graft loss in the OKT group; and 1 patient death (1.5 months post transplant secondary to congestive heart failure) in the RKT group (Table 1). CONCLUSIONS: RKT with regional hypothermia is safe and easily reproducible. Early outcomes are equivalent to OKT; with a propensity towards lower complications, quicker graft function recovery and shorter patient convalescence.

PD30-01 WITHDRAWN: SURGICAL COMPLICATIONS AND GRAFT FUNCTION FOLLOWING LIVE-DONOR EXTRAPERITONEAL RENAL TRANSPLANTATION IN CHILDREN 20 KG OR LESS

INTRODUCTION AND OBJECTIVES: Minimally invasive approaches to kidney transplantation (KT) have recently been described. We recently developed and described a novel technique of robotic KT (RKT) which allows intra corporeal graft cooling. Here, we sought to assess the comparative effectiveness of robotic and open KT (OKT) by evaluating peri and post-operative outcomes. METHODS: During Jan-May 2013, a total of 83 patients with end stage renal disease underwent KT at a tertiary referral center. Sixty six patients met the selection criteria and were enrolled into this prospective two-arm non-randomized controlled trial (IDEAL Phase-2b). Primary outcome was post transplant graft function. Secondary outcomes measured included surgical and immunologic complications, and peri-operative parameters. All patients had a minimum follow up of 6 months. RESULTS: Twenty five and 41 patients underwent RKT and OKT, respectively. There were no significant baseline differences between the two groups. Mean serum creatinine at discharge was 1.3 and 1.4 mg/dl in RKT and OKT patients, respectively (p1⁄40.71). Post-operative pain and analgesic requirements were significantly less in patients undergoing RKT (p1⁄40.01) (Fig 1). No patient undergoing RKT required post transplant dialysis whereas 2 (4.8%) patients undergoing OKT did. The incidence of lymphocele was markedly reduced in patients undergoing RKT detected by per protocol non contrast CT done at 3months (0% vs. 23.8%; p1⁄40.05; Fig 1). There was 1 graft loss in the OKT group; and 1 patient death (1.5 months post transplant secondary to congestive heart failure) in the RKT group (Table 1). CONCLUSIONS: RKT with regional hypothermia is safe and easily reproducible. Early outcomes are equivalent to OKT; with a propensity towards lower complications, quicker graft function recovery and shorter patient convalescence.

Retroperitoneal laparoscopic left living donor nephrectomy: report of 35 cases

Objective To report our experience of 35 retroperitoneal laparoscopic left living-related donor nephrectomies.Methods A total of 35 related donors underwent retroperitoneal laparoscopic living donor nephrectomy from November 2011 to February 2013.The operation was performed through 3 lumbar ports.After the kidney was liberated fully and the ureter was severed 7-8 cm under the lower pole of kidney,a 5-6 cm incision was made below the rib,from the anterior auxiliary line to the umbilical.The left hand of the operator held the kidney and vessels,renal artery and vein were blocked with Hem-o-lok separately and then severed.Then the kidney was taken out quickly from the donor and infused immediately.Results The 35 cases accepted the operation successfully.Two kidneys had 3 arteries,and 6 had 2 arteries.The mean operative time was (98±25) min (70-186 min).Warm ischemia time was (2.7±0.8) min (1.8-4.5 min).And the estimated blood loss was (65±30) ml (20-350 ml).No patient needed blood transfusion.Complications appeared in 3 cases,including lumbar vein injury in 1 patient,hematoma of renal subcapsule in 1 patient and short term lymphatic leakage in 1 patient.No further treatment was required.Hospital stay after operation was (6.5±1.5) d.All the 35 donors were followed up for 7 (1-15) months,and all of them were healthy.One recipient showed delayed graft function recovery,whose level of creatinine declined to normal within 3 weeks.And the level of creatinine declined to normal within 2 weeks in the other 34 recipients.Conclusion Retroperitoneal laparoscopic living relatives donor nephrectomy is a safe and reliable procedure,which can replace the traditional open surgery. Key words: Laparoscopes ; Directed tissue donation ; Living donor; Nephrectomy ; Kidney transplantation

The Benefits of Pulsatile Machine Perfusion of Standard Criteria Deceased Donor Kidneys at a Geographically Remote Transplant Center

Benefits of pulsatile machine perfusion (pumping) of standard criteria donor (SCD) kidneys are unclear. Our center is located 4½ hours from our Organ Procurement Organization. We evaluated outcomes of pumping SCD kidneys under such circumstances by conducting a retrospective examination of all SCD kidneys transplanted between January 2007 and March 2012, comparing kidneys pumped (28 [group 1]) versus standard cold storage (77 [group 2]). Group 1 had fewer delayed graft function (DGF, 3.57% vs. 23.38%, p = 0.02) and slow graft function (SGF, 7.14% vs. 24.68%; p = 0.047) and faster serum creatinine recovery curve (p < 0.001) than group 2. Having a kidney pumped decreases the incidence (odds ratio [OR], 0.059) of DGF, SGF, or primary nonfunction. Group 1 were quicker to reach an estimated glomerular filtration rate (eGFR) >30 ml/min (OR, 4.186; confidence interval [CI], [2.448-7.157]) or an eGFR >60 ml/min (OR, 2.669; CI [1.255-5.679]). Pumping the SCD kidneys in a geographically remote transplant center tended to be better than those preserved in cold storage. However, except recovery curve of serum creatinine during the first postoperative month, other parameters failed to reach statistical significance in the post hoc examination of the contemporary groups. Prospective paired kidney study is required to scrutinize this finding.

Vasculopathy in the kidney allograft at time of transplantation delays recovery of graft function after deceased-donor kidney transplantation

The purpose of this study was to evaluate the impact of donor and recipient characteristics on duration of delayed graft function (DGF) and 1-year serum creatinine (SCr), as a surrogate endpoint for allograft survival. We reviewed 120 first cadaver kidney transplants carried out consecutively at our center to examine the effect on 1-year SCr of the presence and duration of DGF. DGF rate was 68%, with a median duration of 12 days (range, 1-61). Forty-four (38%) patients presented DGF lasting 12 or more days (prolonged DGF group). Mean donor age was 43 ± 13 years, 37% had hypertension and in 59% the cause of brain death was cardiovascular accident. The mean cold ischemia time was 23 ± 5 hours. Twenty-seven (23%) donors were classified as expanded-criteria donors according to OPTN criteria. The mean recipient age was 51 ± 15 years. The recipients median time in dialysis was 43 months (range, 1-269) and 25% of them had panel reactive antibodies > 0%. Patients with prolonged DGF presented higher 1-year SCr in comparison with patients without DGF (1.7 vs. 1.3 mg/dL, respectively, p = 0.03). In multivariate logistic regression analysis, the only significant factor contributing to the occurrence of prolonged DGF was the presence of vascular lesions in the kidney allograft at time of transplantation (HR 3.6, 95% CI 1.2-10.2; p = 0.02). The presence of vasculopathy in the kidney allograft at time of transplantation was identified as an important factor independently associated with prolonged DGF. Prolonged DGF negatively impacts 1-year graft function.

A novel model for orthotopic liver transplantation in rats using hepatic rearterialization and biliary extradrainage system

BackgroundAlthough the rat orthotopic liver transplantation (OLT) model has existed for many years, only a few models can be applied for dynamic bile collection. The aim of this study was to introduce a dependent rat OLT model with hepatic rearterialization and an expediently dynamic bile collection system. MethodsForty-five male Sprague–Dawley rats were divided into the following three groups (n = 15 each): group A, OLT without hepatic rearterialization; group B, OLT with hepatic rearterialization; group C, OLT with hepatic rearterialization and a biliary extradrainage system. In groups B and C, a modified sleeve anastomosis between the donor common hepatic artery and the recipient proper hepatic artery was performed to restore the hepatic artery blood flow. In group C, after hepatic rearterialization, biliary extradrainage and jejunum stoma were performed to reestablish the bile flow, and a waistcoat-like external fixator was introduced to protect this system. ResultsThe surgical success rates in groups A, B, and C were 100% (15/15), 93% (14/15), and 93% (14/15), respectively. In groups B and C, the hepatic artery patency rates were 93% and 86% on postoperative day 3 and postoperative day 21, respectively. Also, the liver function and bile duct integrity were preserved better than that in group A. In group C, the biliary extradrainage system was well preserved and bile collection was easily performed. ConclusionsThe rat OLT model with hepatic rearterialization and a convenient biliary extradrainage system was satisfactory in maintaining the survival rate, hepatic artery patency rate, and recovery of graft function, so it can be applied in various studies after transplantation.

62-P: C1Q BINDING ASSAY CAN PREDICT OUTCOMES IN AMR

Luminex single antigen assay (SAB-IgG) is used to monitor the efficacy of treatment for AMR, but frequently reduction of DSA by SAB-IgG does not correlate with clinical improvement. We investigated if DSA-C1q can be a better predictor of response to AMR therapies than DSA-IgG. We studied 32 kidney transplant (KTx) patients (Pts) treated for AMR and tested DSA-IgG and DSA-C1q in pre- and post-treatment samples. We analyzed the association of DSA-IgG and DSA-C1q with graft loss (GL) and resolution of AMR, and examined data by Fisher exact test. We identified 3 groups on the basis of response to treatment: non-responders with GL, partial responders with residual graft dysfunction, and complete responders with recovery of graft function. 35% of Pts (n=11) were non-responders, and 18% were partial responders (n=6). Before treatment, DSA-IgG was detected in 100% and DSA-C1q in 82% (n=14) of non- and partial responders. After treatment, DSA-IgG and DSA-C1q were detected in 88% (n=15). KTx function recovered in 15 of 32 Pts (47%), and in 87% of responders DSA-IgG remained detectable after treatment in spite clinical improvement. DSA-C1q was detectable in pre-treatment sera of 47% of responders compared to 82% in non- and partial responders. All responders had undetectable C1q-DSA after-treatment. DSA-IgG after treatment of AMR is not associated with efficacy of treatment when GL and resolution of AMR are used as endpoints. Notably, post-treatment DSA-C1q shows a significant association with GL and resolution of AMR. DSA-C1q appears to be a better marker of efficacy of therapy in patients with AMR than DSA-IgG, and may predict clinical success or failure. [figure1]