Yoshihiro Itabashi

Successful Kidney Transplantation in Children With a Compromised Inferior Vena Cava

Background Children with a compromised inferior vena cava (IVC) were previously considered unsuitable for kidney transplantation because of the technical difficulties and the increased risk of graft thrombosis secondary to inadequate renal venous outflow. Methods We conducted a retrospective study of 11 transplants in 9 patients with end-stage renal disease and thrombosed IVCs who received adult kidney allografts between 2000 and 2015. The mean age at transplantation was 7.5 ± 3.5 years. A pretransplant diagnosis of the IVC thrombosis was made in 7 patients by magnetic resonance imaging and computerized tomography, whereas there were 2 instances of intraoperative discovery of the IVC thrombosis. Results In the early cases, a kidney was placed intraperitoneally at the right iliac fossa with a venous anastomosis to the patent segment of the suprarenal IVC. After 2008, however, 6 adult-sized kidneys were subsequently placed in the left orthotopic position. Venous drainage was attained to the infrahepatic IVC (n = 3), left native renal vein (n = 2), and ascending lumbar vein (n = 1). Moreover, a venous bypass was created between the graft and the splenic vein in 2 children who showed high return pressure after the vessel was declamped. The mean glomerular filtration rate of the functioning 8 grafts 1 year posttransplant was 73.4 ± 20.4 mL/min per 1.73 m2. Of note, 6 of the grafts have been functioning well, with a mean follow-up of 66 months. Both 1- and 5-year graft survival were 81.8%. Conclusions Transplantation into the left orthotopic position and the revascularization methods are an effective set of surgical techniques that could potentially be adopted as safe and reliable transplant approaches in children with IVC thrombosis.

Successful third renal transplantation in a child with an occluded inferior vena cava: A novel technique to use the venous interposition between the transplant renal vein and the infrahepatic inferior vena cava

A girl aged 11 years and 3 months with occlusion of the inferior vena cava had experienced two renal transplant graft failures since birth. The third renal transplant from a live donor was carried out. Preoperative evaluation showed that the arteries from the right common to the right external iliac artery were absent, and the ilio‐caval vein was occluded below the level of the renal vein. The donors renal artery was anastomosed to the aorta. The donors ovarian and large saphenous veins were used to extend the transplant renal vein to the recipients patent inferior vena cava. The present report concludes that the extension of a short donor renal vein using other donor veins is a viable therapeutic option for pediatric patients with vascular occlusions.

BK virus nephropathy in a patient with ABO-incompatible renal transplantation.

Abstract:  A 43‐year‐old woman with end‐stage renal disease originating from IgA nephropathy entered chronic haemodialysis therapy. She then received an ABO‐incompatible living related renal transplantation. Initial immunosuppression consisted of azathioprine, methylprednisolone and tacrolimus. At 155 days after transplantation, the azathioprine was changed to mycophenolate mofetil for continuous graft dysfunction. Furthermore, a total of three courses of anti‐rejection therapy was given. At 665 days after transplantation, diagnosis of BK‐virus nephropathy was made by immunohistochemical analysis and viral DNA assay. Therefore the immunosuppression therapy was reduced for graft dysfunction. All five renal biopsy specimens were examined retrospectively in order to determine when the BK virus nephropathy had developed. The expressions of SV40 large T antigens were detected from the third (117 days) to the fifth (665 days) biopsies, with increasing numbers of SV40 large T antigen positive cells. In addition, many cells contained inclusion bodies which were already present in the urinary sediment for 3 months post‐transplantation. Although it is difficult to make a diagnosis of early stage of BKVN, we have to consider with caution if urinary cells with inclusion body are seen. Awareness of BKVN at the earliest opportunity is important in order to avoid over‐immunosuppression.

The New Desensitization Porotocol for ABO Incompatible Living Donor Kidney Transplantation Using Low Dose Rituximab without Plasmapheresis

Purpose We have demonstrated that the long-term outcome of ABO incompatible living donor kidney transplantation (ABOiKT) was comparable to those of ABO compatible KT(ABOcKT). Since 2010, new protocol using low dose rituximab (RIT) without plasmapheresis(PP) was administered to recipients with low titer anti-donor blood group antibody titer (ABGAb) was less than x64. The purpose of this study was to evaluate the efficacy of this new protocol for ABOiKTx. Method 279 recipients underwent kidney transplantation between September 2010 and August 2017. 43 patients who received PP before kidney transplantation because of positivity of donor specific antibody, high titer ABGAb or a recurrence prevention of original disease were excluded. Consequently, 236 recipients were enrolled in this study. The patients were divided into two groups: ABOiKT (n=41) and ABOcKT (n=195). No recipient received splenectomy before kidney transplantation. As a standard protocol, all patients received quadruple immunosuppressive therapy including calcineurin inhibitor, methylprednisolone and mycophenolate mofetil. In addition, as a desentization protocol for ABOiKT, RIT was administered twice on day -10 and -1 day before transplantation at a dose of 100 mg/body. To evaluate the efficacy and safety of this new protocol for ABOiKT, graft survival, clinical acute rejection rate, late-onset neutropenia (LON) and infectious complication were compared between the two groups. Results Median baseline titers of ABGAb in ABOiKT was x16 (0-x64). Overall 1-,3- and 5-year graft survival rates were 98.3%, 96.8% and 96.8% in ABOcKT and 97.1%, 97.1% and 97.1% in ABOiKT, respectively (p=0.950). There was no significant difference in the clinical T cell mediated acute rejection rates (17 (8.7%) in ABOcKT vs. 3 (7.3%) in ABOiKT (p=0.770)) nor antibody mediated acute rejection rates (3 (1.5%) in ABOcKT vs. o (0%) in ABOiKT (p=0.424)). Ocurrence rates of LON were significantly higher in ABOiKT (18 (43.9%)) than in ABOcKT (11 (5.6%)) (p<0.0001). However, the rates of infectious complication that needed inpatient hospital care or modification of immunosuppression were no significantly different between two groups (p=0.256). Conclusion Our current desensitization protocol using low dose RIT without splenectomy was safe and effective for ABOiKTx. Though infectious complication did not increase, we had to pay attention to LON after ABOiKT. Moreover, pretransplant antibody removal would not be prerequisite for ABOiKTx with low titer ABGAb.

Significant Survival Improvement in Recipients with Lupus Nephritis on Kidney Transplantation: Single Center Experience

Objectives To examine the incidence for recurrent lupus nephritis, allograft loss, and survival among systemic lupus erythematosus (SLE) kidney transplant patients comparing before and after year of 2000. Methods The retrospective corhort of all SLE kidney transplant recipients in this institution from June 1989 to June 2016 were reviewed. Patients under 18 yrs. old were excluded. Time-to-event (above outcomes) was examined by Kaplan Meier method and Wilcoxon analysis. Results Nearly 800 renal transplantations were performed in this institution, 16 SLE recipients were identified. All recipients except one were female transplanted at age of 34.6±10.1yrs. old. 8 patients transplanted before 2000, and rest of 8 patients transplanted after 2000. All 16 but one recipients have no recurrence of lupus nephritis by protocol biopsy. Just one recipient had recurrent lupus nephritis (WHO III) without graft dysfunction. Before 2000, 4pts were died from 1 for cancer, 1 for severe liver disease, and 2 for infection, 50% of mortality was noted. After 2000, all 8 recipients have survived, however 1 for hepatic cancer, 1 for pancreatic cancer, 1 for cellebelar infarction, one for systemic amyloidosis and 1 for chronic rejection. No recipients failed graft except death with functioning graft. 5 recipients married and 3 having baby among them. Conclusion While recurrent lupus nephritis is known around only 10%, mortality is rather high in 20% especially in African American ethnicity. This retrospective Asian analysis was found to be less mortality after a year of 2000. Contemporary immunosuppression (introduction of MMF, tacrolimus, basiliximab and reduced dosage of steroid) might lead to favorable outcome. SLE patients have already suffered from taking so much dose of steroid before transplant, such like young female patients should be cared with caution at minimum dose of immunosuppression.

Interlobular hyaline arteriopathy reflects severe arteriolopathy in renal allografts: Interlobular hyaline arteriopathy

The present study was performed to examine the clinicopathological significance of hyaline deposits in the smooth muscle of the interlobular artery (interlobular hyaline arteriopathy [IHA]) in renal allografts.

Management of patients with severe Epstein syndrome: A review of four patients who received living-donor renal transplantation: Management of severe Epstein syndrome

Epstein syndrome is a hereditary disease characterized by macrothrombocytopaenia and progressive nephritis. The abnormality of the MYH9 gene has a strong relationship to the severity of the disease. Severe Epstein syndrome progresses to end‐stage renal disease rapidly after adolescence. There is no established therapy. We sought to clarify appropriate management of Epstein syndrome nephropathy.

Pharmacokinetic Profile of Twice- and Once-daily Tacrolimus in Pediatric Kidney Transplant Recipients

BACKGROUND The aim of this study was to assess the differences in pharmacokinetic (PK) profiles after the 1:1 ratio-based conversion from a twice-daily to a once-daily tacrolimus formulation (TD-TAC and OD-TAC, respectively) in pediatric recipients of kidney transplants. METHODS TD-TAC was initially administered to 29 pediatric patients who underwent kidney transplantations between April 2010 and September 2015 and were then subsequently switched to OD-TAC. The switch dose ratio was 1:1, and the 24-hour complete PK parameter assessment was performed before and after the regimen was changed from TD-TAC to OD-TAC. RESULTS The mean total daily dose at baseline was 5.5 ± 2.9 mg (0.18 ± 0.10 mg/kg body weight). Consecutive PK studies revealed no significant difference in the mean time to achieve maximum concentrations and the area under the concentration-time curve from 0 to 24 hours (AUC0-24) of both drug formulations. However, the mean trough concentration (Cmin) and the maximum concentration of OD-TAC were 22% and 6% lower and higher, respectively, than those of TD-TAC. Therefore, a better correlation was observed between the AUC0-24 and Cmin of OD-TAC than between those of TD-TAC. CONCLUSIONS After the change from TD-TAC to OD-TAC, the AUC0-24 values were equivalent despite a 22% reduction in Cmin. Cmin may therefore be an excellent predictor in the therapeutic drug monitoring of OD-TAC because of its superior correlation with AUC0-24.