Preoperative autologous blood donation for kidney transplant and end-stage renal disease patients: A single-center study.

Although preoperative autologous blood donation (PABD) has many advantages, there has been a decrease in the performance due to a decrease in the residual risk of allogeneic blood transfusion. In allogeneic blood transfusion, anti HLA antibodies and donor-specific antibodies mediate antibody-mediated rejection, which results in graft failure. PABD for anemic patients such as those with end-stage renal disease (ESRD) and a kidney transplant is relatively contraindicated. In this study, we aimed to investigate the characteristics of patients who underwent PABD and elucidate the safety and feasibility of PABD. We performed PABD safely in ten ESRD patients and nine kidney transplant patients and retrospectively analyzed medical records of the hospital. All kidney transplant patients avoided allogeneic blood transfusion, but 4 out of 10 ESRD patients had allogeneic blood transfusion, even if their blood donation volume was larger than those of the kidney transplant patients. It depends on the type of operation; cardiovascular surgery was more common in ESRD patients, and orthopedic surgery was more common in kidney transplant patients. There was profuse bleeding in cardiovascular surgery compared to orthopedic surgery because of longer operation time of the former. Completely avoiding allogeneic blood transfusion in major surgery was rather difficult even if PABD was performed. To prevent the formation of anti- HLA antibodies, PABD would be considered for ESRD patients undergoing kidney transplantation and kidney transplant patients that are potential candidates for secondary kidney transplantation.

Early unclamping might reduce the risk of renal artery pseudoaneurysm after robot-assisted laparoscopic partial nephrectomy.

OBJECTIVES: To determine the influence of the early unclamping technique on the risk of renal artery pseudoaneurysm during robot-assisted laparoscopic partial nephrectomy. METHODS: From January 2013 to October 2014, 96 patients underwent robot-assisted laparoscopic partial nephrectomy for renal masses at Tokyo Women's Medical University Hospital, Tokyo, Japan. Computed tomography angiography was carried out 3-4 days after surgery. Early in the series, renal hilum was left unclamped and renorrhaphy was subsequently carried out (conventional unclamping technique). An early unclamping technique has been used since November 2013. RESULTS: A total of 61 patients underwent robot-assisted laparoscopic partial nephrectomy with early unclamping, and 35 patients underwent robot-assisted laparoscopic partial nephrectomy with conventional unclamping. Ischemia time was significantly shorter in the early unclamping group (16.5 vs. 23.1 min; P < 0.01). The early unclamping group showed a significantly lower incidence of asymptomatic renal artery pseudoaneurysm relative to the conventional unclamping group (11.4% vs. 28.6%; P = 0.03). Multivariate analysis showed that the early unclamping technique was a significant independent factor in reducing the risk of renal artery pseudoaneurysm (hazard ratio 0.27; P = 0.01). CONCLUSIONS: The present findings suggest that an early unclamping technique might reduce ischemic time and risk of renal artery pseudoaneurysm. The absence of arterial bleeding before renorrhaphy is likely to be a key step in preventing renal artery pseudoaneurysm during robot-assisted laparoscopic partial nephrectomy.

Imaging findings from a case of bilharziasis in a patient with gross hematuria of several years' duration.

A 31-year-old man came to the hospital complaining of gross hematuria. Pelvic computed tomography (CT) showed mild thickening of the anterior wall of the urinary bladder. After injection of contrast material, the inner part of the anterior wall of the urinary bladder was mildly enhanced. Magnetic resonance imaging (MRI) showed that the anterior wall of the urinary bladder had localized thickening. There was a discrete area of hyper-intensity in the lesion on T2-weighted images. Differentiation of the lesion from malignancy was difficult based on the CT and MRI findings. The urologists decided to perform transurethral resection of this lesion. The pathological findings showed inflammatory granulation tissues in the peculiar muscle plate and Schistosoma haematobium eggs. His travel history showed that he had traveled to about 30 nations and had been swimming in a lake in Africa several years ago. He began therapy with praziquantel. MRI has better contrast resolution than CT and so detects findings of inflammatory change better than CT. Although it is difficult to distinguish a tumor from the inflammatory change, MRI nevertheless plays an important role in the diagnosis of patients with continuous hematuria, especially those with a history of travel to Africa and/or the Middle East.

Treatment of Posttransplantation Anemia.

Kidney transplantation represents a renal replacement therapy for end-stage renal failure, with outcomes improving from year to year. With the improved survival prognosis, treatment of complications of chronic kidney disease after transplantation is becoming increasingly important. In particular, posttransplantation anemia (PTA) is often protracted, which could be related to a variety of factors, including the renal function status, graft rejection episodes, and infectious causes. PTA occurs in about 30-40% of transplant recipients, and is known to affect the function of the transplanted kidney as well as patient survival. Early PTA is associated with a risk of death and cardiovascular disorders, however, during this phase, priority is given to the appropriate maintenance of immunosuppression rather than to the treatment of anemia. Maintenance-phase PTA exerts a strong influence on the survival, prognosis of the transplanted kidney, quality of life, etc. Unlike the disease state and treatment of usual renal anemia, it has been suggested that PTA may possibly reflect the functional state of the transplanted kidney. Therefore, it has been suggested that proper renal function may be maintained by ensuring a normal hemoglobin level in kidney transplant recipients. Proper management of PTA could be expected to be associated with an improved prognosis of the transplanted kidney and improved patient survival in kidney transplant recipients. It is advisable to provide appropriate treatment by setting target levels in accordance with the dialysis vintage, primary disease, cardiovascular complications, and kidney transplant function and delineation of the transplant recipient characteristics.

Bilateral and multiple mixed epithelial and stromal tumors of the kidney: A case report.

Mixed epithelial and stromal tumor (MEST) of the kidney is a benign tumor occurring predominantly in older women. Histologically, MEST comprises tubuloglandular and cystic structures in an ovarian-like stroma. Bilateral and multiple cases are rare. We herein present a case of bilateral and multiple MEST in a 43-year-old woman. The patient presented with gross hematuria and was referred to a primary care physician. A computed tomography scan revealed 5 tumors in the right and 2 in the left kidney. Renal cell carcinoma was suspected, and left partial nephrectomy followed by right radical nephrectomy was planned. After the left partial nephrectomy, the histopathological diagnosis was MEST, which was consistent with the results obtained following needle biopsy. Therefore, the contralateral tumor was also suspected to be MEST, and needle biopsy was performed. The histopathological diagnosis was identical and the right kidney was spared. The patient is currently periodically monitored. As MEST is a benign tumor, preoperative diagnosis is crucial for avoiding overtreatment.

KDIGO clinical practice guideline on the evaluation and care of living kidney donors

The 2017 Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors is intended to assist medical professionals who evaluate living kidney donor candidates and provide care before, during and after donation. The guideline development process followed the Grades of Recommendation Assessment, Development, and Evaluation (GRADE) approach and guideline recommendations are based on systematic reviews of relevant studies that included critical appraisal of the quality of the evidence and the strength of recommendations. However, many recommendations, for which there was no evidence or no systematic search for evidence was undertaken by the Evidence Review Team, were issued as ungraded expert opinion recommendations. The guideline work group concluded that a comprehensive approach to risk assessment should replace decisions based on assessments of single risk factors in isolation. Original data analyses were undertaken to produce a "proof-in-concept" risk-prediction model for kidney failure to support a framework for quantitative risk assessment in the donor candidate evaluation and defensible shared decision making. This framework is grounded in the simultaneous consideration of each candidate's profile of demographic and health characteristics. The processes and framework for the donor candidate evaluation are presented, along with recommendations for optimal care before, during, and after donation. Limitations of the evidence are discussed, especially regarding the lack of definitive prospective studies and clinical outcome trials. Suggestions for future research, including the need for continued refinement of long-term risk prediction and novel approaches to estimating donation-attributable risks, are also provided.

Excellent long-term outcome of ABO-incompatible living donor kidney transplantation in Japan.

Owing to the severe shortage of cadaveric grafts in Japan, we have performed ABO-incompatible living donor kidney transplantation since 1989. This study assessed short- and long-term outcomes in 441 patients who received ABO-incompatible living donor kidney transplants between January 1989 and December 2001. We compared our results with historical data from 1055 recipients of living kidney transplantation. Overall patient survival rates 1, 3, 5, 7, and 9 years after ABO-incompatible transplantation were 93%, 89%, 87%, 85%, and 84%, respectively. Corresponding overall graft survival rates were 84%, 80%, 71%, 65%, and 59%. After ABO-incompatible transplantation, graft survival rates were significantly higher in patients 29 years or younger than in those 30 years or older and in patients who received anticoagulation therapy than in those who did not receive such therapy. There were no significant differences between A-incompatible and B-incompatible recipients with respect to clinical outcomes. The graft survival rate at 1 year in the historical controls was slightly but not significantly higher than that in our recipients of ABO-incompatible transplants. We conclude that long-term outcome in recipients of ABO-incompatible living kidneys is excellent. Transplantation of ABO-incompatible kidneys from living donors is a radical, but effective treatment for end-stage renal disease.