Single-center retrospective assessment of robotic-assisted simultaneous pancreas-kidney transplants: Exploring clinical utility.

The diabetic population is witnessing a rise in obesity rates, creating specific hurdles for individuals seeking pancreas transplantation because they are frequently disqualified due to their elevated body weight. Introducing a robotic-assisted approach to transplantation has been proven to yield improved outcomes, particularly in patients with obesity. A retrospective analysis was conducted between January 2015 and September 2023. The study included a total of 140 patients, with 16 receiving robotic-assisted simultaneous pancreas-kidney transplantation (RSPK) and 124 undergoing open approach simultaneous pancreas-kidney transplantation (OSPK) during the study period. The median age was 45 (36.8-52.7) and 44.5 years (36.8-51.8) (RSPK vs OSPK, P = .487). There were no significant differences in demographics except body mass index (RSPK vs OSPK, 34.9 vs 28.1, P < .001) and a higher percentage of patients with high cardiac risk in the RSPK group. The robotic approach has a lengthier overall operative time and warm ischemia time. Surgical and nonsurgical complications at 30-days and 1-year grafts and patient survival (93.8% vs 96.8%, RSPK vs OSPK, P = .521) were similar. Our findings suggest that employing robotic assistance in simultaneous pancreas-kidney transplantation is safe. Wider adoption and utilization of this technique could potentially improve transplant accessibility for individuals with obesity and diabetes.

Timing Considerations for Sleeve Gastrectomy in Kidney Transplant Patients: A Single Center Evaluation.

Current scientific literature is deficient in detailing the optimal timing for conducting bariatric surgery in relation to kidney transplantation. In this study, we performed a retrospective evaluation of kidney transplant recipients with BMI >35 kg/m2. It aimed to provide data on those who received both sleeve gastrectomy (SG) and kidney transplantation (KT) simultaneously, as well as on patients who underwent SG and KT at different times, either before or after. In addition, the acceptance levels of the bariatric surgery among different scenarios were assessed. Our findings demonstrated that combined KT and SG led to successful weight loss, in contrast to undergoing kidney transplant alone, while maintaining comparable rates of graft and patient survival. Weight loss was similar between recipients who had a combined operation and those who underwent SG following the transplant. Additionally, over a median time frame of 1.7 years, patients who underwent SG before KT exhibited a statistically significant reduction in BMI at the time of the transplant. Notably, our study highlights that patients offered the combined procedure were significantly more likely to undergo SG compared to those for whom SG was presented at a different operative time than the transplant.

Robotic kidney transplantation from deceased donors: A single-center experience.

Robotic-assisted kidney transplant (RAKT) has proven to be a successful approach for patients with elevated body mass index (BMI). To date, a paucity of studies comprehensively analyzing the clinical outcomes of RAKT by using the grafts from deceased donors exists. This was a single-center retrospective analysis of RAKT from deceased donor kidneys (n = 93) from 2009 to 2021. The cohort was divided into 3 groups on the basis of recipient BMI (BMI ≤ 41.2 vs BMI 41.2-44.5 vs BMI ≥ 44.5 kg/m2, n = 31). Delayed graft function was significantly higher in the group with the highest BMI (BMI ≤ 41.2 vs BMI 41.2-44.5 vs BMI ≥ 44.5 kg/m2, 12.5% vs 10% vs 45.16%, P = .001). Graft survival after 12 months of follow-up was significantly lower in the group with BMI of ≥44.5 kg/m2 (BMI ≤ 41.2 vs BMI 41.2-44.5 vs BMI ≥ 44.5 kg/m2, 93.7% vs 100% vs 83.9%. P = .05). For BMI, the relative risk of patient survival was 1.10 for each increase in a BMI in the range of 5 (CI 95%, 0.98-1.21). Death-censored graft survival after 5 years was significantly better than the UNOS-matched cohort (dRAKT vs match, 86.2% vs 68.9%, P = .03). This single-center analysis shows that RAKT can be performed safely; however, caution should be used when matching marginal kidneys with patients with high BMI.

Impact of early corticosteroid withdrawal on simultaneous pancreas-kidney transplant long-term outcomes: Single center experience and comparison to the International Pancreas Transplant Registry.

BACKGROUND: There remains a paucity of modern data comparing early steroid withdrawal (ESW) versus chronic corticosteroid (CCS) immunosuppression in simultaneous pancreas kidney (SPK) transplant recipients with long-term follow-up. Therefore, the purpose of this study is to assess the effectiveness and tolerability of ESW compared to CCS post-SPK. METHODS: This was a retrospective single-center matched comparison with the International Pancreas Transplant Registry (IPTR). Patients from University of Illinois Hospital (UIH) represented the ESW group and were compared to those matched CCS patients from the IPTR. Included patients were adult recipients of a primary SPK transplant between 2003 and 2018 within the US receiving rabbit anti-thymocyte globulin induction. Patients were excluded if they had early technical failures, missing IPTR data, graft thrombosis, re-transplant, or positive crossmatch SPK. RESULTS: A total of 156 patients were matched and included in the analysis. Patients were predominantly African American (46.15%) males (64.1%) with Type 1 diabetes etiology (92.31%). Overall pancreas allograft survival (hazard ratio [HR] = .89, 95% confidence interval [CI] .34-2.30, p = .81) and kidney allograft survival (HR = .80, 95%CI .32-2.03, p = .64) were similar between the two groups. Immunologic pancreas allograft loss was statistically similar at 1-year (ESW 1.3% vs. CCS 0%, p = .16), 5-year (ESW 1.3% vs. CCS 7.7%, p = .16), and 10-year (ESW 11.0% vs. CCS 7.7%, p = .99). The 1-year (ESW 2.6% vs. CCS 0%, p > .05), 5-year (ESW 8.3% vs. CCS 7.0%, p > .05), and 10-year (ESW 22.7% vs. CCS 9.9%, p = .2575) immunologic kidney allograft loss were also statistically similar. There was no difference in 10-year overall patient survival (ESW 76.2% vs. CCS 65.6%, p = .63). CONCLUSIONS: No differences were found between allograft or patient survival post-SPK when comparing an ESW or CCS protocol. Future assessment is needed to determine differences in metabolic outcomes.

Robotic Assisted Living Donor Nephrectomies: A Safe Alternative to Laparoscopic Technique for Kidney Transplant Donation.

OBJECTIVE: To review outcomes after laparoscopic, robotic-assisted living donor nephrectomy (RLDN) in the first, and largest series reported to date. SUMMARY OF BACKGROUND DATA: Introduction of minimal invasive, laparoscopic donor nephrectomy has increased live kidney donation, paving the way for further innovation to expand the donor pool with RLDN. METHODS: Retrospective chart review of 1084 consecutive RLDNs performed between 2000 and 2017. Patient demographics, surgical data, and complications were collected. RESULTS: Six patients underwent conversion to open procedures between 2002 and 2005, whereas the remainder were successfully completed robotically. Median donor age was 35.7 (17.4) years, with a median BMI of 28.6 (7.7) kg/m2. Nephrectomies were preferentially performed on the left side (95.2%). Multiple renal arteries were present in 24.1%. Median operative time was 159 (54) minutes, warm ischemia time 180 (90) seconds, estimated blood loss 50 (32) mL, and length of stay 3 (1) days. The median follow-up was 15 (28) months. Complications were reported in 216 patients (19.9%), of which 176 patients (81.5%) were minor (Clavien-Dindo class I and II). Duration of surgery, warm ischemia time, operative blood loss, conversion, and complication rates were not associated with increase in body mass index. CONCLUSION: RLDN is a safe technique and offers a reasonable alternative to conventional laparoscopic surgery, in particular in donors with higher body mass index and multiple arteries. It offers transplant surgeons a platform to develop skills in robotic-assisted surgery needed in the more advanced setting of minimal invasive recipient operations.

Corrigendum: Donor Size Doesn't Impact En Bloc Kidney Transplant Outcomes: A Single-Center Experience and Review of Literature.

[This corrects the article DOI: 10.3389/ti.2022.10731.].

Donor Size Doesn't Impact En Bloc Kidney Transplant Outcomes: A Single-Center Experience and Review of Literature.

Few transplant programs use kidneys from donors with body weight (BW)<10 kg due to higher incidence of vascular and urological complications, and DGF. The purpose of this study was to investigate the non-inferiority of pediatric en bloc kidneys from donors with BW<10 kg. We performed a single-center retrospective analysis of en bloc kidney transplants from pediatric donor cohort (n = 46) from 2003 to 2021 and stratified the outcomes by donor BW (small group, donor BW<10 kg, n = 30; standard group, donor BW<10 kg, n = 16). Graft function, rate of early post-transplant complications, graft and patient survival were analyzed. Complication rates were similar between both groups with 1 case of arterial thrombosis in the smaller group. Overall graft and patient survival rates were similar between the small and the standard group (graft survival-90% vs. 100%, p = 0.09; patient survival-96.7 vs. 100%, p = 0.48). Serum creatinine at 1, 3, 5 years was no different between groups. Reoperation rate was higher in the small group (23.3% vs. 6.25%, p = 0.03). The allograft from small donors could be related to higher reoperation rate in the early post-transplant period, but not associated with lower long-term graft and patient survival.

Simultaneous robotic kidney transplantation and bariatric surgery for morbidly obese patients with end-stage renal failure.

Patients with obesity have limited access to kidney transplantation, mainly due to an increased incidence of surgical complications, which could be reduced with selective use of robotic-assisted surgery. This prospective randomized controlled trial compares the safety and efficacy of combining robotic sleeve gastrectomy and robotic-assisted kidney transplant to robotic kidney transplant alone in candidates with class II or III obesity. Twenty candidates were recruited, 11 were randomized to the robotic sleeve gastrectomy and robotic-assisted kidney transplant group and 9 to the robotic kidney transplant group. At 12-month follow-up, change in body mass index was -8.76 ± 1.82 in the robotic sleeve gastrectomy and robotic-assisted kidney transplant group compared to 1.70 ± 2.30 in the robotic kidney transplant group (P = .0041). Estimated glomerular filtration rate, serum creatinine, readmission rates, and graft failure rates up to 12 months were not different between the two groups. Length of surgery was longer in the robotic sleeve gastrectomy and robotic-assisted kidney transplant group (405 minutes vs. 269 minutes, p = .00304) without increase in estimated blood loss (120 ml vs. 117 ml, p = .908) or incidence of surgical complications. Combined robotic-assisted kidney transplant and sleeve gastrectomy is safe and effective compared to robotic-assisted kidney transplant alone.

Personalized physical rehabilitation program and employment in kidney transplant recipients: a randomized trial.

Kidney transplantation is the preferred treatment for kidney failure; however after transplant, reduced physical function, poor self-perceptions, and unemployment are common concerns that remain. This randomized controlled trial compared the effects of a 12-month exercise rehabilitation program (intervention) to standard care alone (control) in kidney transplant recipients. The exercise intervention consisted of a 2 day/week, 60-minute personalized, one-on-one, resistance-based exercise trainings. Eighty participants completed the study (52 intervention vs. 28 control). For individuals unemployed at baseline, there was a 52.3% increase in employment compared to 13.3 % increase in the control group after 12 months (P = <0.0001). For those already employed at baseline, 100% of individuals maintained employment in both groups after 12 months (P = 0.4742). For all comers, there was a positive trend for Global Physical Health (P = 0.0034), Global Mental Health (P = 0.0064), and Physical Function (P = 0.0075), with the intervention group showing greater improvements. These findings suggest the implementation of an exercise rehabilitation program postkidney transplant can be beneficial to increase employment for individuals previously unemployed, improve self-perceived health, physical function, and mental health, overall contributing to better health outcomes in kidney transplant recipients. (Clinicaltrials.gov number: NCT02409901).

Robotic kidney transplantation in the obese patient: 10-year experience from a single center.

Despite increasing obesity rates in the dialysis population, obese kidney transplant candidates are still denied transplantation by many centers. We performed a single-center retrospective analysis of a robotic-assisted kidney transplant (RAKT) cohort from January 2009 to December 2018. A total of 239 patients were included in this analysis. The median BMI was 41.4 kg/m2 , with the majority (53.1%) of patients being African American and 69.4% of organs sourced from living donors. The median surgery duration and warm ischemia times were 4.8 hours and 45 minutes respectively. Wound complications (mostly seromas and hematomas) occurred in 3.8% of patients, with 1 patient developing a surgical site infection (SSI). Seventeen (7.1%) graft failures, mostly due to acute rejection, were reported during follow-up. Patient survival was 98% and 95%, whereas graft survival was 98% and 93%, at 1 and 3 years respectively. Similar survival statistics were obtained from patients undergoing open transplant over the same time period from the UNOS database. In conclusion, RAKT can be safely performed in obese patients with minimal SSI risk, excellent graft function, and patient outcomes comparable to national data. RAKT could improve access to kidney transplantation in obese patients due to the low surgical complication rate.

Obesity in kidney transplantation.

The prevalence of obesity among patients with chronic kidney disease continues to increase as a reflection of the trend observed in the general population. Factors affecting the access to the waiting list and the transplantability of this specific population will be analysed. From observational studies, kidney transplantation in obese patients carries an increased risk of surgical complications compared to the nonobese population; therefore, many centres have been reluctant to proceed with transplantation, despite this treatment modality confers a survival advantage over dialysis. As a consequence, obese patients continue to face decreased access to the waiting list, with a lower likelihood of being transplanted and higher waiting times when compared to the nonobese candidates. In this review will be described the current strategies for treatment of obesity in different settings (pretransplant, at transplant and post-transplant). Obesity represents a risk factor for surgical complications but not a contraindication for kidney transplantation; outcomes could be greatly improved with its multidisciplinary and multimodal treatment. The modern technology with minimally invasive techniques, mainly using robotic platform, allows a reduction in the surgical complications rate, with graft and patient survival rates comparable to the nonobese counterpart.

Simultaneous recipient external iliac endarterectomy and renal transplant - a propensity score matched analysis.

Patients with end-stage renal disease and severe iliac atherosclerosis are frequently denied renal transplant due to technical challenges, and risk of potential steal syndrome in the allograft, or ipsilateral limb. Few studies have evaluated the safety and efficacy of performing an endarterectomy in this setting. A single-center retrospective review of renal transplant patients from 1/2013 to 12/2017 was performed. Patients requiring endarterectomy at the time of transplant were matched to a nonendarterectomized cohort in a 1:2 fashion using propensity score matching. Patients were followed for a minimum of 12 months. Simultaneous endarterectomy and renal transplant were performed in 23 patients and subsequently matched to 42 controls. Ankle-brachial index was lower in the endarterectomized group (P = 0.04). Delayed graft function (26.1% vs. 19%, P = 0.54), graft loss (8.7% vs. 7.1%, P = 0.53), 1-year mortality (8.7% vs. 4.8%, P = 0.53), and renal function at 12 months were comparable in both groups. There were no incidents of ipsilateral limb loss in the endarterectomized population. This is the first matched study investigating endarterectomy and renal transplant. Long-term follow-up of limb and graft function is indicated. Despite the small sample size, our findings suggest that a combined procedure can safely provide renal transplantation access to a previously underserved population.

The utility of robotic assisted pancreas transplants - a single center retrospective study.

The prevalence of obesity within the diabetic population is on the rise. This development poses unique challenges for pancreas transplantation candidates as obese individuals are often denied access to transplant. The introduction of robotic approach to transplant has been shown to improve outcomes in obese patients. A single center retrospective review of pancreas transplant cases over a 4-year period ending December 2018 was performed. Patients undergoing robotic surgery were compared to their counterparts undergoing open transplant. 49 patients (10 robot, 39 open) received pancreas transplants over the study period. Mean age was 43.1 ± 7.5 vs. 42.8 ± 9.7 years. There were no significant differences in demographics except body mass index (33.7 ± 5.2 vs. 27.1 ± 6.6, P = 0.005). Operative duration (7.6 ± 1.6 vs. 5.3 ± 1.4, P < 0.001), and warm ischemia times [45.5 (IQR: 13.7) vs. 33 (7), P < 0.001] were longer in the robotic arm. There were no wound complications in the robotic approach patients. Graft (100% vs. 88%, P = 0.37) and patient survival (100% vs. 100%, P = 0.72) after 1 year were similar. Our findings suggest that robotic pancreas is both safe and effective in obese diabetic patients, without added risk of wound complications. Wide adoption of the technique is encouraged while long term follow-up of our recipients is awaited.

Minimally invasive, robot-assisted procedure for kidney transplantation among morbidly obese: Positive outcomes at 5 years post-transplant.

The pre-transplant weight loss required of end-stage renal disease patients is often unachievable. Though robot-assisted procedures among extremely obese have shown minimal complication, long-term outcomes are understudied. Previously, we reported no difference in 6-month patient and graft survival among 28 robot-assisted transplant cases (2009-2013) and 28 open controls (2004-2010). Groups were frequency-matched on age, sex, race, donor compatibility, disease, and dialysis history. Cases had greater median pre-transplant body mass index (BMI; 42.3 (31.1-64.3) vs 36.8 (30.0-51.1)). Here, we compared patient and graft survival through 5 years post-transplant. Infection, wound complications, and significant re-hospitalizations were collected. One-, three-, and five-year graft survival were 100%, 100%, and 89.3% among cases, and 96.4%, 85.7%, and 78.6% among controls. Rejection within 1 year was greater among cases (11 vs 8). Five-year rates were similar (P = 0.54). Post-transplant BMI remained comparable. No cases and eight controls experienced surgical site infection (SSI). Two cases and one control experienced hernias. Post-transplant diabetes was documented among five cases and six controls. Three deaths occurred among cases, two among controls. This is the most extensive known follow-up of such obese recipients of robot-assisted transplant. Our procedure is a promising pathway to transplant and decreased mortality for those deemed too high risk for conventional surgery.

Long-term outcomes of living-related small intestinal transplantation in children: A single-center experience.

Pediatric patients with irreversible intestinal failure present a significant challenge to meet the nutritional needs that promote growth. From 2002 to 2013, 13 living-related small intestinal transplantations were performed in 10 children, with a median age of 18 months. Grafts included isolated living-related intestinal transplantation (n=7), and living-related liver and small intestine (n=6). The immunosuppression protocol consisted of induction with thymoglobulin and maintenance therapy with tacrolimus and steroids. Seven of 10 children are currently alive with a functioning graft and good quality of life. Six of the seven children who are alive have a follow-up longer than 10 years. The average time to initiation of oral diet was 32 days (range, 13-202 days). The median day for ileostomy takedown was 77 (range, 18-224 days). Seven children are on an oral diet, and one of them is on supplements at night through a g-tube. We observed an improvement in growth during the first 3 years post-transplant and progressive weight gain throughout the first year post-transplantation. Growth catch-up and weight gain plateaued after these time periods. We concluded that living donor intestinal transplantation potentially offers a feasible, alternative strategy for long-term treatment of irreversible intestinal failure in children.

Obesity Increases the Risk of Primary Nonfunction and Early Access Loss, and Decreases Overall Patency in Patients Who Underwent Hemodialysis Reliable Outflow Device Placement.

BACKGROUND: Hemodialysis reliable outflow (HeRO) catheters were introduced in 2008, and have been since providing a reliable alternative for hemodialysis patients who are deemed "access challenged." However, its outcomes have not been extensively investigated due to its relatively young age. Here, we report our 6-year single institution experience, and demonstrate the significant impact of obesity on HeRO graft outcomes, an aspect not previously studied in the literature. METHODS: Patients who underwent HeRO graft placement at the University of Illinois Hospital between April 2009 and August 2015 were included retrospectively. Data were collected from patients' electronic medical records and analyzed using SPSS software. RESULTS: Thirty-three patients who underwent 34 HeRO catheter placements were included. Mean age was 47 ± 12 years, and mean body mass index (BMI) was 30.75 ± 10.22. Median follow-up was 635 days. Overall catheter-related complications were thrombosis (70.59%), infection (20.59%), arterial steal (8.82%), and pseudoaneurysms requiring intervention (8.82%). Overall primary and secondary patency rates after 6 and 12 months were 31.25%, 25%, 78.13%, and 71.86%, respectively. Primary nonfunction rate was 14.7%. Obese patients had significantly higher rate of primary nonfunction (38.46% vs. 0%, P = 0.0046), and relative risk 3.62 (95% confidence interval [CI] 2.01-6.52). They also had a significantly decreased rate of graft patency after 12 months (10.53% vs. 53.85%, P = 0.0227), leading to a relative risk of "early" graft loss within 1 year of 5.12 (95% CI 1.26-20.83). Overall median graft patency in obese patients was significantly shorter than that of nonobese patients (311 vs. 1295 days, P = 0.014). BMI, as a continuous variable, was a significant predictor of primary nonfunction (P = 0.046) and early graft loss (0.020) when tested against age, sex, race, and diabetes in a multivariate logistic regression analysis. CONCLUSIONS: HeRO catheters offer a reliable, and possibly the last, alternative in hemodialysis access-challenged patients. In our population, obesity was a significant risk factor for primary nonfunction, early graft loss, and a shorter overall graft patency. BMI, as a continuous variable, can serve as a predictor of primary nonfunction and early graft loss after adjustment for age, race, sex, and diabetes. Obesity's effect on HeRO catheters has not been amply addressed; therefore further prospective studies are warranted.