The Impact of Cold Ischaemia Time on Outcomes of Living Donor Kidney Transplantation in the UK Living Kidney Sharing Scheme.

OBJECTIVE: To assess the impact of CIT on living donor kidney transplantation (LDKT) outcomes in the UKLKSS versus outside the scheme. BACKGROUND: LDKT provides the best treatment option for end-stage kidney disease patients. end-stage kidney disease patients with an incompatible living donor still have an opportunity to be transplanted through Kidney Exchange Programmes (KEP). In KEPs where kidneys travel rather than donors, cold ischaemia time (CIT) can be prolonged. METHODS: Data from all UK adult LDKT between 2007 and 2018 were analysed. RESULTS: 9969 LDKT were performed during this period, of which 1396 (14%) were transplanted through the UKLKSS, which we refer to as KEP. Median CIT was significantly different for KEP versus non-KEP (339 versus 182 minutes, P < 0.001). KEP LDKT had a higher incidence of delayed graft function (DGF) (2.91% versus 5.73%, P < 0.0001), lower 1-year (estimated Glomerular Filtration Rate (eGFR) 57.90 versus 55.25 ml/min, P = 0.04) and 5-year graft function (eGFR 55.62 versus 53.09 ml/min, P = 0.01) compared to the non-KEP group, but 1- and 5-year graft survival were similar. Within KEP, a prolonged CIT was associated with more DGF (3.47% versus 1.95%, P = 0.03), and lower graft function at 1 and 5-years (eGFR = 55 vs 50 ml/min, P = 0.02), but had no impact on graft survival. CONCLUSION: Whilst CIT was longer in KEP, associated with more DGF and lower graft function, excellent 5-year graft survival similar to non-KEP was found.

Live kidney donation: attitudes towards donor approach, motives and factors promoting donation.

BACKGROUND: There are many views regarding the initiation of the process for live donor kidney transplantation (LDKT), the motives of the donor and the appropriate ways to promote LDKT. METHODS: Health care professionals and patients were recruited in a tertiary renal and transplant centre and completed an anonymous questionnaire. They were then divided into focus groups and a structured interview was performed in order to discover the rationale behind the answers in the questionnaire. RESULTS: Four hundred and sixty-four participants completed the questionnaire. There were 168 health care professionals and 296 patients. Most of the participants (26.9%) suggested that the first approach to a potential donor should be made by the potential recipient. Participants believed that the most important motives for a kidney donor are relief as a result of the recipient's improved health after the transplant (82.5%) and altruism (80.4%). About 89.2% of participants believed that proper long-term medical follow-up of the donor is the most important factor for LDKT promotion. Fifty-five participants discussed the rationale of their answers in the focus group interview. CONCLUSIONS: In our study, participants preferred an initial approach of the donor by the recipient. The relief as a result of the recipient's improved health was suggested as a very strong motive for donation. Proper donor follow-up was considered to be paramount for the further development of LDKT.

Renal transplantation in gigantism: A case report.

BACKGROUND: Gigantism, characterized by excessive growth and height is due to increased secretion of growth hormone, most commonly from a pituitary adenoma. In addition to the surgical and anesthetic complexity, the extreme stature of these patients presents a unique challenge for kidney transplantation in deciding whether to proceed with a single or dual kidney transplantation. The lack of relevant literature further adds to the dilemma. CASE SUMMARY: A 45-year-old patient with untreated gigantism and end stage renal failure on renal replacement therapy was waitlisted for a deceased donor dual kidney transplantation due to the extreme physical stature (Height-247 cm and weight-200 kg). He was offered 2 kidneys from a 1-0-1 HLA mismatched 24-year-old DCD donor (Height-179 cm and weight-75 kg), and was planned for a bilateral retroperitoneal implantation into the recipient external iliac vessels. The immunosuppression consisted of alemtuzumab induction (50 mg) and steroid-free maintenance with tacrolimus. The donor's right kidney was uneventfully implanted extra-peritoneally into the right external iliac vessels. On contralateral exposure, the left common and external iliac arteries were ectatic and frail. A complex vascular reconstruction was not preferred in order to preserve the arterial supply to the left lower limb, to minimise the cold ischemia time and prevent additional warm ischemic insult to the second kidney. Hence, it was decided not to proceed with dual transplantation. Amidst concerns of nephron mass insufficiency, the graft function was remarkable with a serum creatinine of 120 µmol/L within a month from transplantation and 94 µmol/L at 1-year post transplantation, and without proteinuria. CONCLUSION: To our knowledge, this is the first case report on kidney transplantation in gigantism. Although it is believed that dual kidney transplantation is ideal, a single kidney transplantation from an appropriately selected donor can provide sufficient functioning nephron mass in patients with gigantism.

Attitudes toward live donor kidney transplantation and its commercialization.

Development of live donor kidney transplantation (LDKT) programs has intensified debate regarding acceptability of certain donor categories and potential commercialization. Concerning these issues, we surveyed the views of medical and nursing staff caring for patients with renal failure and renal transplant recipients and donors. Participants were recruited from a tertiary transplant unit and invited to complete an anonymous questionnaire. Four hundred and sixty-four participants completed the questionnaire (42% response). One hundred and sixty-eight (36.2%) were health care professionals and 296 (63.8%) patients; 85.6% of participants were willing to donate to their children, 80.2% to siblings, 80.8% to parents, 72% to a non-blood-related relative or friend, and 15.3% to a stranger. If participants had hypothetical renal failure, they were prepared to accept a kidney from a parent (79.5%), sibling (78.7%), child (56.3%), a non-blood-related relative or friend (79.3%), or stranger (54.1%). Regarding commercialization, responders' attitudes were that the donor should not accept financial reward (29.1%), be compensated for expenses only (60.6%), or should receive a direct financial reward (10.1%). For non-directed donation, 23.5%, 55.6%, and 20.7% were not in support of reward, compensation only, and financial reward, respectively. While live kidney donation was accepted by the majority of individuals surveyed, only the minority approved of commercialization.

New Year's greeting and overview of World Journal of Transplantation in 2021.

World Journal of Transplantation (WJT) was launched in December 2011. While we are celebrating WJT's 10-year anniversary, we are very proud to share with you that since its first issue, WJT has published 312 articles, which have been cited 2786 times (average cites per article of 9.0). Together with an excellent team effort by our authors, Editorial Board members, independent expert referees, and staff of the Editorial Office, WJT advanced in 2020. In this editorial, we summarize the journal's bibliometrics, including its citation report, published articles in 2020, peer review rate and manuscript invitation metrics, as well as its Editorial Board members and existing problems of WJT. The overall aim of this editorial is to promote the development of WJT in 2021. We appreciate the continuous support and submissions from authors and the dedicated efforts and expertise by our invited reviewers. This collective support will allow us to be even more productive in 2021. In addition, we commit to working with you all to raise the academic influence of WJT over the upcoming year. Finally, on behalf of WJT, we wish you and your families the best for the New Year.

COVID-19 pandemic: Building organisational flexibility to scale transplant programs.

The prevailing coronavirus disease 2019 pandemic has challenged our lives in an unprecedented manner. The pandemic has had a significant impact on transplantation worldwide. The logistics of travel restrictions, stretching of available resources, unclear risk of infection in immunosuppressed transplant recipients, and evolving guidelines on testing and transplantation are some of the factors that have unfavourably influenced transplant activity. We must begin to build organisational flexibility in order to restart transplantation so that we can be mindful stewards of organ donation and sincere advocates for our patients. Building a culture of honesty and transparency (with patients, families, colleagues, societies, and authorities), keeping the channels of communication open, working in collaboration with others (at local, regional, national, and international levels), and not restarting without rethinking and appraising all elements of our practice, are the main underlying principles to increase the flexibility.

Anticoagulation in simultaneous pancreas kidney transplantation - On what basis?

BACKGROUND: Despite technical refinements, early pancreas graft loss due to thrombosis continues to occur. Conventional coagulation tests (CCT) do not detect hypercoagulability and hence the hypercoagulable state due to diabetes is left untreated. Thromboelastogram (TEG) is an in-vitro diagnostic test which is used in liver transplantation, and in various intensive care settings to guide anticoagulation. TEG is better than CCT because it is dynamic and provides a global hemostatic profile including fibrinolysis. AIM: To compare the outcomes between TEG and CCT (prothrombin time, activated partial thromboplastin time and international normalized ratio) directed anticoagulation in simultaneous pancreas and kidney (SPK) transplant recipients. METHODS: A single center retrospective analysis comparing the outcomes between TEG and CCT-directed anticoagulation in SPK recipients, who were matched for donor age and graft type (donors after brainstem death and donors after circulatory death). Anticoagulation consisted of intravenous (IV) heparin titrated up to a maximum of 500 IU/h based on CCT in conjunction with various clinical parameters or directed by TEG results. Graft loss due to thrombosis, anticoagulation related bleeding, radiological incidence of partial thrombi in the pancreas graft, thrombus resolution rate after anticoagulation dose escalation, length of the hospital stays and, 1-year pancreas and kidney graft survival between the two groups were compared. RESULTS: Seventeen patients who received TEG-directed anticoagulation were compared against 51 contemporaneous SPK recipients (ratio of 1: 3) who were anticoagulated based on CCT. No graft losses occurred in the TEG group, whereas 11 grafts (7 pancreases and 4 kidneys) were lost due to thrombosis in the CCT group (P = 0.06, Fisher's exact test). The overall incidence of anticoagulation related bleeding (hematoma/ gastrointestinal bleeding/ hematuria/ nose bleeding/ re-exploration for bleeding/ post-operative blood transfusion) was 17.65% in the TEG group and 45.10% in the CCT group (P = 0.05, Fisher's exact test). The incidence of radiologically confirmed partial thrombus in pancreas allograft was 41.18% in the TEG and 25.50% in the CCT group (P = 0.23, Fisher's exact test). All recipients with partial thrombi detected in computed tomography (CT) scan had an anticoagulation dose escalation. The thrombus resolution rates in subsequent scan were 85.71% and 63.64% in the TEG group vs the CCT group (P = 0.59, Fisher's exact test). The TEG group had reduced blood product usage {10 packed red blood cell (PRBC) and 2 fresh frozen plasma (FFP)} compared to the CCT group (71 PRBC/ 10 FFP/ 2 cryoprecipitate and 2 platelets). The proportion of patients requiring transfusion in the TEG group was 17.65% vs 39.25% in the CCT group (P = 0.14, Fisher's exact test). The median length of hospital stay was 18 days in the TEG group vs 31 days in the CCT group (P = 0.03, Mann Whitney test). The 1-year pancreas graft survival was 100% in the TEG group vs 82.35% in the CCT group (P = 0.07, log rank test) and, the 1-year kidney graft survival was 100% in the TEG group vs 92.15% in the CCT group (P = 0.23, log tank test). CONCLUSION: TEG is a promising tool in guiding judicious use of anticoagulation with concomitant prevention of graft loss due to thrombosis, and reduces the length of hospital stay.

Ethical issues in live donor kidney transplant: views of medical and nursing staff.

OBJECTIVES: The ongoing development of live donor kidney transplant has generated many ethical dilemmas. It is important to be aware of the attitudes of transplant professionals involved in this practice. MATERIALS AND METHODS: An anonymous and confidential questionnaire was sent to 236 members of the medical and nursing staff of the West London Renal and Transplant Centre, to assess their views on the ethics of the current practice of live donor kidney transplant. RESULTS: Of the 236 questionnaires, 108 (45.8%) were returned. Respondents considered live donor kidney transplant ethically acceptable between blood relatives (100%), nonblood relatives and friends (92.6%), and strangers (47.2%). Most respondents were willing to donate a kidney to a blood relative (92.6%) or a nonblood relative or friend (81.5%), and 12.0% were willing to donate to a stranger. Considering themselves as potential recipients if they had end-stage renal disease, most would accept a kidney from a blood relative (91.7%) or nonblood relative or friend (85.2%),while 44.5% would accept a kidney from a stranger. The highest number of respondents (43.5%) believed that the recipient should approach the potential donor. About one-third believed there should be no financial reward, not even compensation for expenses, for donors; 8% favored direct financial rewards for donors known to recipients, and 18% favored rewards for donors not known to recipients. Slightly more than half were in favor of accepting donors with mild to moderate medical problems. CONCLUSIONS: Live related and unrelated kidney donation are considered ethically acceptable procedures, and nondirected donation is gaining support among transplant professionals. A substantial minority favored direct financial rewards for donors, especially in the case of nondirected donation.

Autogenous brachio-cephalic arterio-venousautogenous brachio-cephalic arterio-venous fistulae: effect of age, diabetes,fistulae: effect of age, diabetes, atherosclerosis, and anticoagulation on theatherosclerosis, and anticoagulation on the long-term outcomelong-term outcome.

Age, diabetes, and generalized atherosclerosis are thought to be limiting factors forAge, diabetes, and generalized atherosclerosis are thought to be limiting factors for creating an autogenous arterio-venous fistula (AVF) unlike the use of anticoagulants. Wecreating an autogenous arterio-venous fistula (AVF) unlike the use of anticoagulants. We retrospectively assessed the effect of these factors on the outcome of 75 autogenousretrospectively assessed the effect of these factors on the outcome of 75 autogenous brachio-cephalic AVFs created between January 1, 2002 and August 31, 2005. Differentbrachio-cephalic AVFs created between January 1, 2002 and August 31, 2005. Different groups of patients were compared and the longevity of the AVFs was calculated. Fifty-twogroups of patients were compared and the longevity of the AVFs was calculated. Fifty-two percent of the patients were >65 years old, 41.3% werepercent of the patients were >65 years old, 41.3% were diabetic, 48% were arteriopaths,diabetic, 48% were arteriopaths, and 41.3% were not using anticoagulants. The maximum follow-up was 35 months (mean,and 41.3% were not using anticoagulants. The maximum follow-up was 35 months (mean, 11.2 +/- 10.3 months; median, 7 months). The success rate of the operation was 93.3% (mean 11.2 +/- 10.3 months; median, 7 months). The success rate of the operation was 93.3% (70 patent AVFs); 79.3% of the AVFs were functioning at 35 months. Age >65 years old,patent AVFs); 79.3% of the AVFs were functioning at 35 months. Age >65 years old, diabetes, generalized atherosclerosis, and the lack of use of anticoagulants were notdiabetes, generalized atherosclerosis, and the lack of use of anticoagulants were not associated with an increased rate of technical failures or a decreased long-term patencyassociated with an increased rate of technical failures or a decreased long-term patency rate of the AVFs.rate of the AVFs.

Ethical issues in living donor kidney transplantation.

The ethical issues of living donor kidney transplantation, which is the treatment of choice for patients with end-stage renal failure, are the focus of intense debate. Some of those issues are related to the safety of the operation for the donor, and others are related to the motivation of the donor, the approach to and evaluation of the donor, donation by strangers, the commercialization of donation, surrogate consent for donation, and the acceptance of minors as donors. The lack of clear consensus regarding these issues results in differences in practice, not only among countries but also among transplant centers. We believe that after an open debate, agreement on certain generally accepted principles can be achieved. Such an agreement would protect potential donors and recipients and would ensure the future of living donor kidney transplantation.

Effective use of kidneys for transplantation from asystolic donors.

Severe organ shortage for transplantation is an increasing problem because the number of traditional heart-beating cadaveric donors is declining. Ways need to be found to expand the donor pool without commercializing organ transplantation, especially from unrelated live donors, and to maintain high medical standards of these procedures and their follow-up. Kidneys from asystolic or nonheart-beating donors (NHBDs) are a valuable source of organs, which can be of excellent quality, with good long-term function after transplantation. This organ source is widely underused at the moment; even so, there is increased popularity during the last few years in different countries. In addition, the rate of discarding viable kidneys from these NHBDs is still too high. Logistical and legal aspects are other important issues that need to be addressed to promote these NHBD programs more effectively. Waiting lists for renal transplantation could be significantly reduced in the future.

Hepatocyte transplantation: a review of worldwide clinical developments and experiences.

Hepatocyte transplantation is a promising treatment for several liver diseases and can also be used as a "bridge" to liver transplantation in cases of liver failure. Although the first animal experiments with this technique began in 1967, it was first applied in humans in 1992. Clearly, the most important advantage of this treatment, compared with liver transplantation, is its simplicity, since no surgery is required for implantation of the cells. Much work has been done over the years to maximize the number of viable hepatocytes that can be isolated from a liver, to prepare the cells prior to transplantation so that the outcome will be more successful, and to identify the optimal site for implantation. We review these efforts along with the worldwide clinical experience with hepatocyte transplantation during the last 13 years.

The effect of machine perfusion on the arteries of porcine kidneys.

OBJECTIVES: Machine perfusion is an excellent method of assessing the viability of a kidney graft and can also potentially improve the quality of an equivocal kidney. Several authors have expressed concerns that machine perfusion can potentially damage the vessels of the kidney but until now, no studies have been performed to clarify this issue. We aimed to examine the effect of machine perfusion on the renal arteries of porcine kidneys. MATERIALS AND METHODS: Eight pairs of kidneys were removed from pigs in the abattoir. One kidney of each pair was preserved on ice for 24 hours. The other kidney from the same animal was initially stored on ice until arrival at the laboratory when it was perfused on the RM3 machine for 4 hours and then stored again on ice for the remainder of the 24 hours. After 24 hours, since the retrieval and initial storage on ice at the abattoir, tissue samples were obtained from all renal arteries at 3 different sites. These samples were sent for histologic evaluation. RESULTS: Machine perfusion caused more damage at a statistically significant level compared with simple cold storage only for the first sample site, which was the part of the renal artery closest to the perfusion cannula. CONCLUSIONS: Our experiments suggest that machine perfusion, even when it is done lege artis, can damage the part of the renal artery closest to the adaptor, which can potentially result in a higher incidence of posttransplant arterial thrombosis. Therefore, excision of the first part of the renal artery should be considered prior to transplantation, and modifications of the perfusion technique must be developed to minimize damage to the renal arteries.

Abdominoplasty in a patient with severe obesity.

Abdominoplasty and dermolipectomy are, in some cases, the only tools that a surgeon has to treat patients with severe obesity. Although liposuction is useful in removing fatty deposits without traditional surgical incisions, its application is limited in extremely obese patients. In response to current esthetic expectations, reconstructive surgeons have to deal effectively both with the actual complaint and with the desire of the patient to have an incision as small as possible. We present a case of severe obesity with large amounts of redundant skin and fat extending to below the knees. At the time of surgery, a large area of the patient's lower abdomen had become ischemic, thus making abdominoplasty the only option for treatment. We believe it is important for the surgeon be familiar with this approach because it can occur in general practice and he should be prepared to deal with it both as a relative emergency and as an elective procedure.

Successful reversal of steal syndrome following creation of arteriovenous fistula by banding with a ringed Gore-Tex cuff: a new technique.

Steal syndrome, especially in elderly patients with peripheral vascular disease, is a serious complication following creation of an arteriovenous fistula (AVF) that, if neglected, can lead to amputation. The classic maneuver to deal with the steal syndrome is ligating the AVF and performing another procedure to gain dialysis access. We describe a simple technique of effectively reversing the steal syndrome by banding the vein of the AVF with a ringed Gore-Tex cuff that salvages the AVF and allows its immediate use for dialysis.

Laparoscopic live donor nephrectomy: a step forward in kidney transplantation?

Open donor nephrectomy for live donor kidney transplantation is a safe procedure that has been used for more than 30 years with excellent results. Laparoscopic donor nephrectomy is a relatively new technique that has the potential of decreased postoperative pain, less incisional morbidity, and shorter recovery time. Furthermore, it has been reported that this potentially less traumatic approach increases the number of potential live donors. This review article focuses on the currently used laparoscopic techniques in live kidney donation as well as the controversy regarding its efficacy, safety, and future.

Live donor kidney transplantation: attitudes of patients and health care professionals concerning the pre-surgical pathway and post-surgical follow-up.

OBJECTIVES: We surveyed the following groups of individuals concerning their attitudes towards the pathway leading up to live donor kidney transplantation (LDKT) and post-operative follow-up: kidney transplant (deceased and live donor) recipients, live kidney donors and medical and nursing staff caring for end-stage renal disease and dialysis patients. MATERIALS AND METHODS: Participants were recruited within a tertiary renal and transplant centre and invited to complete anonymized questionnaires, be involved in focus groups and undertake structured interviews. RESULTS: A total of 464 participants completed the questionnaire (36% health care professionals and 64% patients). Most perceived donor risk as small or very small (62%), and 49% stated that a potential donor should be given up to 3 months to reconsider the decision to donate. Participants were almost equally divided as to whether consensus of the donor's family is necessary (46%) or not (44%) in LDKT. Seventy-one percentage of the participants suggested that patients have a greater appreciation of a LDKT if they have been on dialysis; 58% of participants thought that donor and recipient should recuperate beside each other after surgery; 45% thought that the post-operative follow-up for the donor should last up to a year; and 83% thought that donor follow-up should include medical status and quality of life. In the interviews, participants expressed several interesting views. CONCLUSIONS: Participants believed that LDKT is safe for the donor, and the pathway to surgery and post-operative follow-up should be performed in a way that ensures lack of coercion and includes family support and an extensive post-operative follow-up.

A meta-analysis of mini-open versus standard open and laparoscopic living donor nephrectomy.

Mini-open donor nephrectomy (MODN) potentially combines advantages of standard open (SODN) and laparoscopic techniques (LDN). This article is a comparison of these techniques. A literature search was performed for studies comparing MODN with SODN or LDN. Nine studies met our selection criteria. Of the 1038 patients, 433 (42%) underwent MODN, 389 (37%) SODN and 216 (21%) LDN. MODN versus SODN: Operative time (P = 0.17), warm ischemia time (P = 0.20) and blood loss (P = 0.30) were not significantly different. Hospital stay and time to return to work were shorter for MODN by 1.67 days (P < 0.001) and 5 weeks (P = 0.03). Analgesia requirement and overall complications were less in the MODN group (P < 0.001) and (P = 0.03). Ureteric complications (P = 0.21) and 1-year graft survival (P = 0.28) were not significantly different. MODN versus LDN: Operative and warm ischemia times were significantly shorter for the MODN by 55 min (P = 0.005) and 147 s (P < 0.001). Analgesia requirement was greater for the MODN group by 9.62 mEq morphine (P = 0.04). No significant differences were found for blood loss (P = 0.8), hospital stay (P = 0.35), donor complications (P = 0.40) or ureteric complications (P = 0.83). MODN appears to provide advantages for the donor in comparison to SODN and also has a shorter operative time when compared with the LDN.