Carme Facundo

Tratamiento con angioplastia y stent de la estenosis arterial del injerto renal

Transplant renal artery stenosis is a major complication that requires a therapeutic approach involving surgery or angioplasty. The aim of this study was to analyse the evolution of renal transplant patients with renal allograft artery stenosis treated by angioplasty and stent placement. Thirteen patients were diagnosed with transplant renal artery stenosis. Clinical suspicion was based on deterioration of renal function and/or poorly controlled hypertension with compatible Doppler ultrasound findings. The diagnosis was confirmed by arteriography, performing an angioplasty with stent placement during the same operation. A progressive improvement in renal function was observed during the first 3 months after the angioplasty, and renal function then remained stable over 2 years. In addition, blood pressure improved during the first 2 years, and as a consequence there was no need to increase the average number of anti-hypertensive drugs administered (2.5 drugs per patient). In conclusion, angioplasty with stent placement is a safe and effective procedure for the treatment of transplant renal artery stenosis.

Early Macrophage Infiltration and Sustained Inflammation in Kidneys From Deceased Donors Are Associated With Long-Term Renal Function.

Kidney transplants from living donors (LDs) have a better outcome than those from deceased donors (DDs). Different factors have been suggested to justify the different outcome. In this study, we analyzed the infiltration and phenotype of monocytes/macrophages and the expression of inflammatory and fibrotic markers in renal biopsy specimens from 94 kidney recipients (60 DDs and 34 LDs) at baseline and 4 months after transplantation. We evaluated their association with medium‐ and long‐term renal function. At baseline, inflammatory gene expression was higher in DDs than in LDs. These results were confirmed by the high number of CD68‐positive cells in DD kidneys, which correlated negatively with long‐term renal function. Expression of the fibrotic markers vimentin, fibronectin, and α–smooth muscle actin was more elevated in biopsy specimens from DDs at 4 months than in those from LDs. Gene expression of inflammatory and fibrotic markers at 4 months and difference between 4 months and baseline correlated negatively with medium‐ and long‐term renal function in DDs. Multivariate analysis point to transforming growth factor‐β1 as the best predictor of long‐term renal function in DDs. We conclude that early macrophage infiltration, sustained inflammation, and transforming growth factor‐β1 expression, at least for the first 4 months, contribute significantly to the difference in DD and LD transplant outcome.

Biomarkers: New Tool to Detect Subclinical Inflammation?

Introduction Nowadays the gold standard test to detect kidney allograft inflammation is kidney biopsy. Because of subclinical inflammation has a very important roll on long term allograft survival some groups are performing follow-up biopsies to detect this inflammation early and to individualize the immunosuppressive treatment. Inflammation urinary biomarkers can become a new non invasive tool to detect this subclinical inflammation early. The aim of our work is to study the correlation between different subclinical lesions in follow-up biopsies and urinary biomarkers (miRNA-155, miRNA-210 and miRNA-142) Materials and Methods Prospective study where we have included kidney transplant (KT) patients from April 2014 until May 2015. We have determined in urine these biomarkers: miRNA-155, miRNA-210 and miRNA-142 one week after KT and one, two, three and six months after KT. We have performed follow-up biopsies at 4th month after KT and we have analysed the presence of tubulitis, interstitial infiltrate, arteritis and IFTA. Lastly we have correlationed these findings with urinary biomarkers levels. Results We have included 25 recipients from a first KT, all of them with low immunological risk. 60% man. Average age 45 years. 76% recipients from living donor. Average time on dyalisis: 10 months (50% preemptive kT). Induction immunosuppressive treatment: Basiliximab (two doses), tacrolimus, sodic micophenolate and prednisone. Average seric creatinine at 4 month after KT: 100umol/L. Anatomo-pathologic findings: 4% of biopsies with some degree of tubulitis, 63% with some degree of interstitial infiltrate, 9% with some degree of arteritis and 18% with some degree of IFTA. Correlation analysis: miRNA-155 levels are significantly higher in the patients with tubulitis. miRNA-142 levels are significantly higher in the patients with tubulitis, in the patients with arteritis and in the patients with interstitial infiltrate. miRNA-210 levels are significantly lower in the patients with tubulitis and in the patients with arteritis. There isn’t correlation between some biomarker and the presence of IFTA. Conclusion Urinary biomarkers can become in a future a new tool to detect subclinical inflammation early and could replace follow-up kidney biopsies. In this study, mi-RNA 142 would be the most associated with the presence of subclinical inflammation. On the other hand, tubulitis would be the lesion most detected for biomarkers. Are necessary more studies to confirm these results.

Robot-assisted Kidney Transplantation with Regional Hypothermia Using Grafts with Multiple Vessels After Extracorporeal Vascular Reconstruction: Results from the European Association of Urology Robotic Urology Section Working Group

BACKGROUND Kidney transplantation using grafts with multiple vessels (GMVs) is technically demanding and may be associated with increased risk of complications or suboptimal graft function. To date, no studies have reported on robot-assisted kidney transplantation (RAKT) using GMVs. OBJECTIVE To report our experience with RAKT using GMVs from living donors, focusing on technical feasibility and early postoperative outcomes. DESIGN, SETTING, AND PARTICIPANTS We reviewed the multi-institutional, prospectively collected European Association of Urology (EAU) Robotic Urology Section (ERUS)-RAKT database to select consecutive patients undergoing RAKT from living donors using GMVs between July 2015 and January 2018. Patients undergoing RAKT using grafts with single vessels (GSVs) served as controls. In case of GMVs, ex vivo vascular reconstruction techniques were performed during bench surgery according to the case-specific anatomy. INTERVENTION RAKT with regional hypothermia. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Intraoperative outcomes and early (30 d) postoperative complications and functional results were the main study endpoints. Multivariable logistic regression analysis evaluated potential predictors of suboptimal renal function at 1 mo. RESULTS AND LIMITATIONS Overall, 148 RAKTs were performed during the study period. Of these, 21/148 (14.2%) used GMVs; in all cases, single arterial and venous anastomoses could be performed after vascular reconstruction. Median anastomoses and rewarming times did not differ significantly between the GMV and GSV groups. Total and cold ischemia times were significantly higher in the GMV cohort (112 vs 88min, p=0.004 and 50 vs 34min, p=0.003, respectively). Overall complication rate and early functional outcomes were similar among the two groups. No major intra- or postoperative complications were recorded in the GMV cohort. At multivariable analysis, use of GMVs was not significantly associated with suboptimal renal function at 1 mo. Small sample size and short follow-up represent the main study limitations. CONCLUSIONS RAKT using GMVs from living donors is technically feasible and achieved favorable perioperative and short-term functional outcomes. Larger studies with longer follow-up are needed to confirm our findings. PATIENT SUMMARY In this study, we evaluated for the first time in literature the results of RAKT from living donors using kidneys with multiple arteries and veins. We found that, in experienced centers, RAKT using kidneys with multiple vessels is feasible and achieves optimal results in terms of postoperative kidney function with a low number of postoperative complications.