How to manage renal masses in kidney transplant recipients? A collaborative review by the EAU-YAU kidney transplantation and renal cancer working groups.

INTRODUCTION: Kidney transplant (KT) recipients have a four-times higher risk of renal malignancies compared to general population. As these patients frequently harbor bilateral or multifocal tumors, the management of renal masses is still under debate. OBJECTIVE: To explore the current management of the native kidney masses in KT patients. ACQUISITION OF EVIDENCE: We performed a literature search on MEDLINE/PubMed database. A number of 34 studies were included in the present review. SYNTHESIS OF EVIDENCE: In frail patients with renal masses below 3 cm, active surveillance is a feasible alternative. Nephron-sparing surgery is not justified for masses in the native kidney. Radical nephrectomy is the standard treatment for post-transplant renal tumors of the native kidneys in KT recipients, with laparoscopic techniques leading to significantly less perioperative complication rates as compared to the open approach. Concurrent bilateral native nephrectomy at the time of transplantation can be considered in patients with renal mass and polycystic kidney disease, especially if no residual urinary output is present. Patients with localized disease and successful radical nephrectomy do not require immunosuppression adjustment. In metastatic cases, mTOR agents can ensure efficient antitumoral response, while maintaining proper immunosuppression in order to protect the graft. CONCLUSIONS: Post-transplant renal cancer of the native kidneys is a frequent occurrence. Radical nephrectomy is most frequently performed for localized renal masses. A standardized and widely-approved screening strategy for malignancies of native renal units is yet to be implemented.

Open versus robotic-assisted kidney transplantation: A systematic review by the European Association of Urology (EAU) - Young Academic Urologists (YAU) Kidney Transplant Working Group.

INTRODUCTION: In the last 20 years, robotic assisted procedures were evaluated in the field of kidney transplantation to provide a mini-invasive approach for this particularly fragile population. As a relatively new issue, few studies compared open kidney transplantation (OKT) and robotic-assisted kidney transplantation (RAKT), mostly in small cohorts. To improve current knowledge, we wanted here to gather comparative data of OKT vs RAKT in a systematic review. METHODS: A systematic review was performed according to preferred reporting items for systematic reviews and meta-analyses. Medline, Embase, and Cochrane databases were searched to identify all studies reporting post-operative outcomes of RAKT versus OKT. RESULTS: A total of 2136 patients in 13 studies were included. Median recipient age was 42.6 years (OKT: 43.5 years and RAKT: 40.3 years). Median preemptive kidney transplantation rate was 27.1 % (OKT: 23.3 % and RAKT: 33.2 %). Median total operative time and rewarming were respectively: 235 and 49 min in OKT population; 250 and 60 min in RAKT population. Post-operative complications rates were: 26.2 % in OKT population and 17.8 % in RAKT population. Delayed graft function rates were: 4.9 % in OKT population and 2.3 in RAKT population. Mid-term functional outcomes, patient and graft survival were similar in OKT and RAKT population. CONCLUSION: This systematic review showed that RAKT may be associated with a lower incidence of delayed graft function and post-operative surgical complications and similar mid-term functional outcomes, patient and graft survival, compared to OKT for end-stage renal disease patients.

Renal transplantation in pediatric recipients: Considerations and preoperative assessment strategies.

INTRODUCTION AND OBJECTIVE: Renal transplantation in the pediatric population differs from adults in many aspects. This review will focus on the unique issues of the pediatric recipient. MATERIAL AND METHODS: A narrative review on the scarce literature regarding preoperative evaluation before kidney transplantation of the paediatric recipient with an educational focus was conducted. The literature search allowed for identification of publications in English from January 2000 to October 2022. Published studies were identified by searching the following electronic databases: PubMed (MEDLINE), WHO/UNAIDS, Google-Scholar, Semantic-Scholar and Research Gate. For efficiency and reliability, recent randomized controlled trials, meta-analyses, high quality systematic reviews and large well-designed studies were used if available. Internet searches were conducted for other relevant information (definitions, policies or guidelines). RESULTS: Management of congenital urogenital anomalies and lower urinary tract dysfunction along with optimal pediatric urological preoperative assessment for renal transplantation in children is addressed in the light of the available literature. Furthermore, particular considerations including pre-emptive transplantation, transplantation of an adult-size kidney into an infant or small child is discussed. CONCLUSIONS: Outcomes of RT in children have shown progressive improvement over the past 15 years. Transplantation with living related donor gives the best results and pre-emptive transplantation provides with benefits of avoiding dialysis. Surgical and medical considerations in both the pre-transplant and post-transplant management of the pediatric kidney recipient are extremely crucial in order to achieve better short and long-term results.

[COVID-19 Pandemic: Impact and rapid reaction of Urology]. / Pandemia COVID-19: impacto y reacción rápida de la Urología.

The COVID-19 pandemic caused by the SARS-CoV-2 virus has caused tens of thousands of deaths in Spain and has managed to breakdown the healthcare system hospitals in the Community of Madrid, largely due to its tendency to cause severe pneumonia, requiring ventilatory support. This fact has caused our center to collapse, with 130% of its beds occupied by COVID-19 patients, thus causing the absolute cessation of activity of the urology service, the practical disappearance of resident training programs, and the incorporation of a good part of the urology staff into the group of medical personnel attending these patients. In order to recover from this extraordinary level of suspended activity, we will be obliged to prioritize pathologies based on purely clinical criteria, for which tables including the relevance of each pathology within each area of urology are being proposed. Technology tools such as online training courses or surgical simulators may be convenient for the necessary reestablishment of resident education.

[COVID-19 Pandemic: Impact and rapid reaction of Urology]. / Pandemia COVID-19: impacto y reacción rápida de la Urología.

The COVID-19 pandemic caused by the SARS-CoV-2 virus has caused tens of thousands of deaths in Spain and has managed to breakdown the healthcare system hospitals in the Community of Madrid, largely due to its tendency to cause severe pneumonia, requiring ventilatory support. This fact has caused our center to collapse, with 130% of its beds occupied by COVID-19 patients, thus causing the absolute cessation of activity of the urology service, the practical disappearance of resident training programs, and the incorporation of a good part of the urology staff into the group of medical personnel attending these patients. In order to recover from this extraordinary level of suspended activity, we will be obliged to prioritize pathologies based on purely clinical criteria, for which tables including the relevance of each pathology within each area of urology are being proposed. Technology tools such as online training courses or surgical simulators may be convenient for the necessary reestablishment of resident education.

Methodology of a systematic review. / Metodología de una revisión sistemática.

CONTEXT: The objective of evidence-based medicine is to employ the best scientific information available to apply to clinical practice. Understanding and interpreting the scientific evidence involves understanding the available levels of evidence, where systematic reviews and meta-analyses of clinical trials are at the top of the levels-of-evidence pyramid. ACQUISITION OF EVIDENCE: The review process should be well developed and planned to reduce biases and eliminate irrelevant and low-quality studies. The steps for implementing a systematic review include (i) correctly formulating the clinical question to answer (PICO), (ii) developing a protocol (inclusion and exclusion criteria), (iii) performing a detailed and broad literature search and (iv) screening the abstracts of the studies identified in the search and subsequently of the selected complete texts (PRISMA). SYNTHESIS OF THE EVIDENCE: Once the studies have been selected, we need to (v) extract the necessary data into a form designed in the protocol to summarise the included studies, (vi) assess the biases of each study, identifying the quality of the available evidence, and (vii) develop tables and text that synthesise the evidence. CONCLUSIONS: A systematic review involves a critical and reproducible summary of the results of the available publications on a particular topic or clinical question. To improve scientific writing, the methodology is shown in a structured manner to implement a systematic review.

Machine perfusion: initial results in an expanded criteria donor kidney transplant program.

BACKGROUND: Delayed graft function (DGF) negatively impacts graft survival. Expanded criteria donors (ECD) show a higher rate of DGF. Hypothermic machine perfusion (HMP) has shown a DGF decrease and an increase of survival at 1 year. Several authors found that renal resistance (RR) at the end of machine perfusion was an independent risk factor for the development of DGF and poorer graft survival. The objective of this study was to analyze HMP results in the context of an ECD program and assess the impact of donor parameters and resistance index (RI) during perfusion in graft survival after kidney transplantation. METHODS: Donor age, terminal creatinine, machine perfusion time, percentage of glomerulosclerosis, and RI at the end of the perfusion were considered as risk predictors. Univariate and multivariate Cox regression analysis was constructed to find independent risk factors of DGF. Finally, diagnostic validity for RR was determined by sensitivity, specificity, and positive and negative predictive values. RESULTS: Twenty-three percent of patients developed DGF. We found no difference in the ability of flow or RI to predict the development of DGF. The predictive accuracy of RI for DGF by receiver operator characteristic curve was poor, with a c-statistic of 0.66 (95% CI, 0.50-0.81; P = .046). Our analysis did not identify risk factors that predicted graft survival at 1 year. Patient and graft survival were 98.8% and 89.7%, respectively. CONCLUSIONS: HMP has reduced the rate of DGF in our cohort of recipients of ECD grafts compared with historical data (23.3% vs 38.0%). Analysis did not identify risk pretransplant factors for graft survival at 1 year.

Resistance index determination in the pre and post kidney transplantation time points in graft dysfunction diagnosis.

BACKGROUND: Donor shortage necessitates the development of tools capable of objectively assessing kidney graft quality from expanded criteria donors and kidneys donated after cardiac death. The deteriorating donor profile is leading to a shift from cold storage toward machine perfusion preservation. Several authors found that renal resistance (RR) at the end of machine perfusion was an independent risk factor for the development of delayed graft function (DGF). In contrast, Doppler ultrasonography in the posttransplant period reveals renal hemodynamics and is useful in diagnosing renal allograft dysfunction. We sought to determine concordance between RR and the resistance index (RI) and their diagnostic value in the assessment of graft viability. METHODS: RR was determined at the end of perfusion during hypothermic machine preservation and RI was measured by Doppler ultrasonography in the early posttransplant period. Agreement between these 2 measures was established by means of the intraclass correlation coefficient (ICC). Diagnostic validity for RR and RI was determined by sensitivity, specificity and positive and negative predictive values. RESULTS: The ICC was 0.135, which indicates a slight agreement. RR and RI had limited value in the prediction of DGF for a specific kidney as reflected by a c-statistic of 0.58 and 0.66, respectively. CONCLUSIONS: There is no agreement between the RR and RI, which may be owing to the different conditions under which measurements are made. The poor predictive power of RR for DGF indicates that kidneys should not be discarded based on RR criteria alone.

Development of urologic de novo malignancies after renal transplantation.

OBJECTIVES: The incidence of neoplasms in renal transplant recipients is higher than in general population. The increasing age of donors and recipients also increases the risk of developing malignancies, including genitourinary. The aim of this study is to analyze clinical aspects and management of this complication. MATERIALS AND METHODS: We conducted a retrospective analysis of 1365 patients who underwent renal transplantation between 1977 and 2010 who were 44.6 ± 14.9 years old at the time of transplantation. The median follow-up was 95.6 months (range, 18.0-236.0). Data were analyzed for sex, age, time from transplant to diagnosis, location, clinical stage, immunosuppression, treatment, follow-up, and evolution. RESULTS: We diagnosed 25 de novo urologic neoplasms (25/1365; 1.8%) in 24 patients, with a median follow-up of 32 months (range, 12.5-51.8) from the diagnosis. Sixteen were male (66.7%) and 8 female (33.3%), with a median age at diagnosis of 59 years (range, 56.0-65.5). The median time between the transplant and the diagnosis of the malignancy was 69 months (range, 40.0-116.5). There were 11 renal cell carcinomas (RCC; 11/25; 44%), 8 in native kidney and 3 in renal allograft; 9 prostate cancers (PCa; 9/25; 36%), 8 localized and 1 metastatic; and 5 transitional cell carcinomas (TCC; 5/25; 20%), 3 in bladder and 2 in renal allograft pelvis. Treatments performed were similar to those used in the nontransplanted population. RCC were treated with radical nephrectomy when affecting the native kidney, partial nephrectomy when affecting the allograft, or immunotherapy when metastatic. Patients with localized PCa were treated with radical prostatectomy, radiotherapy, or androgenic deprivation if there were comorbidities, and those metastatic with hormonal deprivation. Bladder TCCs were treated with transurethral resection or radical cystectomy. Pelvis TCCs affecting the allograft were treated with radical nephroureterectomy of the allograft including bladder cuff and pelvic lymphadenectomy. CONCLUSIONS: There exists an increased incidence of urologic tumors in kidney transplant recipients. Conventional treatments of these tumors are technically feasible. The risk of developing these tumors remains even in the long term. Because of their suitability for curative treatments, it is advisable to perform periodic screening for urologic cancers to achieve an early diagnosis.

Renal transplantation in HIV-infected patients: experience at a tertiary hospital in Spain and review of the literature.

BACKGROUND: The use of highly active antiretroviral therapy (HAART) has decreased the morbidity and mortality in HIV-infected patients. The kidney transplantation (KT) survival rate is similar to that of HIV-negative transplant recipients. The consensus criteria for the selection of HIV patients for transplantation include: no opportunistic infections, CD4 lymphocyte count greater than 200 cells/µL, and an undetectable viral load. In Spain, HIV-infected patients present with different characteristics compared to American recipients; this could influence posttransplantation outcomes. OBJECTIVE: This study analyzed the outcome and the clinical characteristics of HIV-infected patients who received KT in Spain in the HAART era. METHODS: We retrospectively reviewed the clinical charts of seven adult HIV-infected recipients of primary renal allografts between January 2001 and June 2012. Patient inclusion criteria met the American and Spanish guidelines. The immunosuppressive protocol consisted of tacrolimus, mycophenolate mofetil, and steroids. RESULTS: The median age was 44.8 years (interquartile amplitude = 9.4). The predominant mode of transmission was intravenous drug use (71.4%) and hepatitis C virus coinfection (71.4%). The most frequent cause of end-stage renal disease was glomerulonephritis (57.1%). Six patients (85.7%) were on HAART. All patients had controlled HIV infections with undetectable viral load and a median CD4 lymphocyte count of 504 cells/µL (IQA 599). Patients were followed for a median of 16.0 months (range, 3.0 to 96.6 months). Delayed graft function and acute rejection rates were 60% and 40%, respectively. The median creatinine level at the last follow-up was 1.58 mg/dL (IQA 1.15). In one case, a high-grade Epstein-Barr virus-related B cell lymphoma was diagnosed at 83 months after renal transplantation. CONCLUSIONS: Kidney transplantation in HIV-infected patients is a safe, effective treatment for selected patients. Midterm graft survival was comparable to that of HIV-negative patients.