Hendrikus J.A.N. Kimenai

A randomized controlled trial comparing intravesical to extravesical ureteroneocystostomy in living donor kidney transplantation recipients

Urological complications after kidney transplantation are mostly related to the ureteroneocystostomy leading to significant morbidity, mortality, and high costs. The most commonly used techniques for the ureteroneocystostomy are the intravesical and the extravesical anastomosis. No evidence in favor of one of these two anastomoses exists. Our aim was to determine the technique with the best outcome regarding urological complications in a prospective randomized controlled trial (Netherlands Trial Register NTR2320). We randomized 200 consecutive recipients of a living donor kidney for either an intravesical or an extravesical anastomosis. The primary outcome was defined as placement of a percutaneous nephrostomy. No significant differences were found in the number of percutaneous nephrostomy placements or ureter reinterventions between both groups. Nevertheless, significantly fewer urinary tract infections occurred in the group with an extravesical anastomosis. In addition, this anastomosis was performed significantly faster compared with the intravesical anastomosis. Thus, extravesical ureteroneocystostomy was associated with significantly fewer urinary tract infections and might be preferable because of its surgical simplicity.

Kidney Retransplantation in the Ipsilateral Iliac Fossa: A Surgical Challenge

The aim of this study is to review the surgical outcome of kidney retransplantation in the ipsilateral iliac fossa in comparison to first kidney transplants. The database was screened for retransplantations between 1995 and 2013. Each study patient was matched with 3 patients with a first kidney transplantation. Just for graft and patient survival analyses, we added an extra control group including all patients receiving a second transplantation in the contralateral iliac fossa. We identified 99 patients who received a retransplantation in the ipsilateral iliac fossa. There was significantly more blood loss and longer operative time in the retransplantation group. The rate of vascular complications and graft nephrectomies within 1 year was significantly higher in the study group. The graft survival rates at 1 year and 3, 5, and 10 years were 76%, 67%, 61%, and 47% in the study group versus 94%, 88%, 77%, and 67% (pu2009<u20090.001) in the first control group versus 91%, 86%, 78%, and 57% (pu2009=u20090.008) in the second control group. Patient survival did not differ significantly between the groups. Kidney retransplantation in ipsilateral iliac fossa is surgically challenging and associated with more vascular complications and graft loss within the first year after transplantation. Whenever feasible, the second renal transplant (first retransplant) should be performed contralateral to the prior failed one.

Successful Use of Ectopic Pelvic Kidney for Living Related Donation Technical Aspects and Literature Review

Ectopic pelvic kidneys can provide an additional source of organs for transplantation. They are often excluded from donation in living donation programs mainly due to aberrant vascular and urinary anatomies. We present a donor with an ectopic left kidney, who successfully donated his kidney. The use of ectopic pelvic kidney for living kidney transplantation is a highly demanding surgical procedure but after extensive preoperative investigation in high volume centers with surgical expertise in vascular reconstruction and access surgery, ectopic pelvic kidneys should not be a contraindication for donation and should be considered as a viable option.

Vascular Multiplicity Should Not Be a Contra-Indication for Live Kidney Donation and Transplantation

Background Whether vascular multiplicity should be considered as contraindication and therefore ‘extended donor criterion’ is still under debate. Methods Data from all live kidney donors from 2006–2013 (n = 951) was retrospectively reviewed. Vascular anatomy as imaged by MRA, CTA or other modalities was compared with intraoperative findings. Furthermore, the influence of vascular multiplicity on outcome of donors and recipients was studied. Results In 237 out of 951 donors (25%), vascular multiplicity was present. CTA had the highest accuracy levels regarding vascular anatomy assessment. Regarding outcome of donors with vascular multiplicity, warm ischemia time (WIT) and skin-to-skin time were significantly longer if arterial multiplicity (AM) was present (5.1 vs. 4.0 mins and 202 vs. 178 mins). Skin-to-skin time was significantly longer, and complication rates were higher in donors with venous multiplicity (203 vs. 180 mins and 17.2% vs. 8.4%). Outcome of renal transplant recipients showed a significantly increased WIT (30 vs. 26.7 minutes), higher rate of DGF (13.9% vs. 6.9%) and lower rate of BPAR (6.9% vs. 13.9%) in patients receiving a kidney with AM compared to kidneys with singular anatomy. Conclusions We conclude that vascular multiplicity should not be a contra-indication, since it has little impact on clinical outcome in the donor as well as in renal transplant recipients.

Ureteral length in live donor kidney transplantation; Does size matter?

The aim of this study was to evaluate the role of ureteral length on urological complications. Data were retrospective collected from the INEX‐trial database, a RCT to compare the intravesical to the extravesical ureteroneocystostomy. Ureteral length was measured in 198 recipients and used to divide recipients into three categories based on interquartile ranges: short (≤8.5 cm), medium (8.6–10.9 cm) and long ureters (≥11 cm). Urological complications were defined as the number of percutaneous nephrostomy placements (PCN). Fifty recipients fell into the short, 98 into the medium and 50 recipients into the long ureter category. Median follow‐up was 26 (range 2–45) months. There was no significant difference in number of PCN placements between the categories. There were 9 (18%) PCN placements in the short ureter category, 21 (20%) in medium ureter category and 10 (21%) in the long ureter category, P = 0.886. Risk factor analysis for gender, arterial multiplicity and type of ureteroneocystostomy showed no differences in PCN placements between the three ureteral length categories. We conclude that ureteral length alone does not seem to influence the number of urological complications.

Tissue-Resident Memory T Cells of Donor Origin are Short-Lived in Renal Allografts after Transplantation

Introduction Tissue-resident memory T (TRM) cells provide protective immunity to infection by rapidly responding to antigen in non-lymphoid tissues. These non-migrating memory T cells are characterized by surface expression of CD69 and CD103. In transplanted kidneys the existence, origin and properties of TRM cells are unclear. In this study, we used the unique tissue resource of transplant nephrectomies to determine whether TRM cells reside in rejected kidney allografts and whether these cells are of donor or recipient origin. Materials and Methods Thirteen transplant nephrectomy specimens were studied. These grafts failed because of acute (n=4) or chronic (n=9) rejection and were removed after a mean time of 6.7 years (range: 8 days – 26 years). Half of the explanted renal allograft (cortex and medulla) was processed into a single cell suspension. Isolated cells were stained and analyzed by flow cytometry to determine their phenotype. The origin of the cells was measured by mAb directed against HLA epitopes of the donor or acceptor. Results Functional CD3+ T cells were isolated from all explanted kidney allografts as 57.8 ± 16.5% (mean ± SD) of the cells had the capacity to produce IFN&ggr;; 16.1 ± 6.8% produced IL-2; 1.8 ± 1.2% IL-17, and 4.6 ± 5.2% IL-4 after PMA/ionomycin stimulation. The isolated T cells consisted of 43.2 ± 19.1% CD4+ T cells and 45.3 ± 20.6% CD8+ T cells.Of the CD8+ T cells, 27.9 ± 15.5% expressed CD69 and CD103, reflecting CD8+ TRM cells. The majority of these TRM cells did not express CD28 (61.6 ± 18.2%), indicating a phenotype associated with highly-reactive effector functions. The isolated CD4+ T cells also included a population of TRM cells, though this fraction was relatively small (1.9 ± 2.2%). We confirmed that CD69+CD103+ TRM cells were exclusively present in the renal allografts and not in the circulation of healthy controls (p=0.002). No differences in proportions of TRM cells were found between acute and chronically rejecting kidney allografts. High proportions of donor CD4+ and CD8+ T cells were present in the renal allografts removed within the first month after transplantation (6.8 ± 5.7% CD4+ T cells; 9.8 ± 9.2% CD8+ T cells) compared to low proportions in the renal allografts removed after one month (0.4 ± 0.3% CD4+ T cells; 0.3 ± 0.3% CD8+ T cells). Remarkably, within the CD8+ TRM cells the ratio between donor versus recipient cells was 3.6 times higher compared to this ratio within the total CD8+ T cells. Conclusion Our results demonstrate that both donor and patient CD4+ and CD8+ TRM cells reside in the rejecting transplanted kidney. Over time, the donor TRM cells disappear from the allograft.

Estimated skeletal muscle mass and density values measured on computed tomography examinations in over 1000 living kidney donors

Background/ObjectivesCurrently, there are no widely accepted cut-off points to categorize patients as sarcopenic (low skeletal muscle mass) or myosteatotic based on computed tomography (CT) measurements. Moreover, little is known about skeletal muscle mass in healthy subjects, particularly in a Western-European population.Subjects/MethodsSkeletal muscle mass (skeletal muscle index, cm2/m2) and density (Hounsfield units, HU) at the level of the third lumbar vertebra were measured on contrast-enhanced CT images in live kidney donors with an age range of 18–86 years, who may be considered as healthy subjects, from 2010 to 2015. Differences between sex, body mass index (BMI), age groups, and American Society of Anesthesiologists (ASA) classification were assessed. Mann−Whitney U and Kruskal−Wallis tests were used to compare groups.ResultsOf the 1073 included patients, 499 (46.5%) were male and the median age and BMI were 51 years and 25.4u2009kg/m2, respectively. Male gender, increased age, and increased BMI were significantly associated with both skeletal muscle mass and density. Nomograms including these parameters were developed to calculate the estimated skeletal muscle mass and density of a healthy subject and the lower bound of the 90% prediction interval (p5) values were provided.ConclusionsSkeletal muscle density and mass were significantly associated with sex, age, and BMI in a large cohort of healthy Western-European subjects. The newly developed nomograms may be used to calculate the estimated healthy skeletal muscle mass for individuals in patient populations.

Algorithm for Bosniak 2F Cyst in Kidney Donation

Patient: Female, 54 Final Diagnosis: Multilocular cystic renal cell carcinoma with clear cells Symptoms: None Medication: — Clinical Procedure: Hand-assisted retroperitoneal donor nephrectomy Specialty: Transplantology Objective: Unusual setting of medical care Background: The Bosniak system for radiological classification of renal cysts offers a tool for surgical decision-making in clinical practice. Although 95% of Bosniak 2F cysts remain benign, a consensus on the management of Bosniak 2F cysts in kidney donation has not been developed. Case Report: We present a donor with a Bosniak 2F cyst, who successfully donated her kidney after partial resection of the Bosniak 2F cyst. Postoperative pathology examination of the partially resected cystic wall revealed a multilocular cystic renal cell carcinoma. Postoperative pathology examination revealed a multilocular cystic renal cell carcinoma. Resection of the Bosniak 2F cyst provides 2 advantages: the recipient receives a new donor kidney and will be free of dialysis, and the donor will be free of surveillance. Conclusions: We present a practical guideline for kidney donors with Bosniak 2F cysts, balancing the risk of tumor transmission or recurrence with the benefit associated with organ transplantation, without compromising the risk of the donor and recipient. Further evaluation of this algorithm by longer follow-up and more studies is needed to prove its safety.