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.

Retrospective evaluation of LCP-tacrolimus (Envarsus XR) dosing in de novo kidney transplant.

INTRODUCTION: Tacrolimus is known to exhibit significant inter- and intra-patient pharmacokinetic (PK) and pharmacodynamic (PD) variability regarding therapeutic response. LCP-tacrolimus (LCPT-Envarsus XR) was approved in 2018 for use as a de novo immunosuppressive agent in kidney transplants, but there is limited evidence to guide de novo dosing of LCPT in patients with obesity. The primary objective of this study was to evaluate the impact of different calculated weight-based de novo LCPT dosing on early transplant outcomes. METHODS: This was a retrospective study of patients with obesity (BMI ≥ 30 kg/m2 ) who received a kidney transplant at the University of Illinois Hospital and Health System (UIH), between March 2019 and March 2021. Subjects were included if were age 18 years or older and received de novo LCPT throughout index hospitalization. The primary endpoint of this study was to compare correlations between the first tacrolimus trough level and dosing weight strategy (e.g., TBW, AdjBW, IBW). RESULTS: There was a statistically significant, though modest, correlation between all three dosing strategies and the first tacrolimus trough level (TBW correlation coefficient = .431, p < .001; AdjBW correlation coefficient = .455, p < .001; IBW correlation coefficient = .465; p < .001). In regression modeling for supratherapeutic levels each additional .01 mg/kg increase in dose by TBW, AdjBW, and IBW increased the odds of a supratherapeutic level by 1.46, 1.34, and 1.24, respectively (p < .001). CONCLUSIONS: The use of LCPT in kidney transplant recipients with obesity dosed using TBW demonstrated the strongest correlation with initial supratherapeutic tacrolimus levels. Larger prospective studies are needed to investigate the further impact of body weight on dosing regimens in the obese population.

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.

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.

Heterogeneity in the nonplanarity and arterial curvature of arteriovenous fistulas in vivo.

OBJECTIVE: Native arteriovenous fistulas (AVFs) for hemodialysis are susceptible to nonmaturation. Adverse features of local blood flow have been implicated in the formation of perianastomotic neointimal hyperplasia that may underpin nonmaturation. Whereas computational fluid dynamic simulations of idealized models highlight the importance of geometry on fluid and vessel wall interactions, little is known in vivo about AVF geometry and its role in adverse clinical outcomes. This study set out to examine the three-dimensional geometry of native AVFs and the geometric correlates of AVF failure. METHODS: As part of an observational study between 2013 and 2016, patients underwent creation of an upper limb AVF according to current surgical best practice. Phase-contrast magnetic resonance imaging was performed on the day of surgery to obtain luminal geometry along with ultrasound measurements of flow. Magnetic resonance imaging data sets were segmented and reconstructed for quantitative and qualitative analysis of local geometry. Clinical maturation was evaluated at 6 weeks. RESULTS: There were 60 patients who were successfully imaged on the day of surgery. Radiocephalic (n = 17), brachiocephalic (n = 40), and brachiobasilic (n = 3) fistulas were included in the study. Centerlines extracted from segmented vessel lumen exhibited significant heterogeneity in arterial nonplanarity and curvature. Furthermore, these features are more marked in brachiocephalic than in radiocephalic fistulas. Across the cohort, the projected bifurcation angle was 73 ± 16 degrees (mean ± standard deviation). Geometry was preserved at 2 weeks in 20 patients who underwent repeated imaging. A greater degree of arterial nonplanarity (log odds ratio [logOR], 0.95 per 0.1/vessel diameter; 95% confidence interval [CI], 0.22-1.90; P = .03) and a larger bifurcation angle (logOR, 0.05 per degree; 95% CI, 0.01-0.09; P = .02) are associated with a greater rate of maturation, as is fistula location (upper vs lower arm; logOR, -1.9; 95% CI, -3.2 to 0.7; P = .002). CONCLUSIONS: There is significant heterogeneity in the three-dimensional geometry of AVFs, in particular, arterial nonplanarity and curvature. In this largest cohort of AVF geometry to date, the effect of individual geometric correlates on maturation is uncertain but supports the premise that future modeling studies will need to acknowledge the complex geometry of AVFs.

Novel non-invasive biomarkers diagnostic of acute rejection in renal transplant recipients: A systematic review.

BACKGROUND AND OBJECTIVES: Acute rejection is a significant complication detrimental to kidney transplant function. Current accepted means of diagnosis is percutaneous renal biopsy, a costly and invasive procedure. There is an urgent need to detect and validate non-invasive biomarkers capable of replacing the biopsy. DESIGN, SETTING, PARTICIPANTS AND MEASUREMENTS: Comprehensive literature searches of Medline, EMBASE and Cochrane Central Register of Controlled Trials databases were performed. Eligible studies were included as per inclusion criteria and assessed for quality using the GRADE quality of evidence tool. Outcomes evaluated included biomarker diagnostic performance, number of patients/samples, mean age and gender ratio, immunosuppression regime, in addition to clinical applications of the biomarker(s) tested. PRISMA guidelines were followed. Where possible, statistical analysis of comparative performance data was performed. RESULTS: 23 studies were included in this review, including 19 adult, 3 paediatric and 1 mixed studies. A total of 2858 participants and 50 candidate non-invasive tests were identified. Sensitivity, specificity and area under the curve performance values ranged 36%-100%, 30%-100% and 0.55-0.98, respectively. CONCLUSIONS: Although larger, more robust multi-centre validation studies are needed before non-invasive biomarkers can replace the biopsy, numerous candidate tests have demonstrated significant promise for various facets of postoperative management. Suggested uses include: ruling out patients with a low risk of acute rejection to avoid the need for biopsy, non-invasive testing where the biopsy is contraindicated and a prompt diagnosis is needed, and integration into a serial blood monitoring protocol in conjunction with serum creatinine.

Living Donor Intestinal Transplantation.

This study explores intestinal transplantation (ITx) as a viable treatment option for intestinal failure (IF). Historical development, donor and recipient considerations, surgical techniques, immunosuppression, and outcomes, are reviewed with particular emphasis to the value of living donor ITx. The review highlights the evolution of ITx and emphasizes the ongoing need for patient-specific selection processes. In the realm of pediatric ITx, the article underlines the significance of early intervention to mitigate IF-related liver disease. Overall, it provides a comprehensive overview of this life-saving procedure.

Indications for Multivisceral Transplantation: A Systematic Review.

Consensus remains elusive in the definition and indications of multivisceral transplantation (MVT) within the transplant community. MVT encompasses transplantation of all organs reliant on the celiac artery axis and the superior mesenteric artery in different combinations. Some institutions classify MVT as involving the grafting of the stomach or ascending colon in addition to the jejunoileal complex. MVT indications span a wide spectrum of conditions, including tumors, intestinal dysmotility disorders, and trauma. This systematic review aims to consolidate existing literature on MVT cases and their indications, providing an organizational framework to comprehend the current criteria for MVT.

The Role of Colon in Isolated Intestinal Transplantation: Description of 4 Cases.

Intra-abdominal desmoid tumors are a rare and complex clinical problem. These tumors are locally invasive, and surgical ablation represents the mainstay of treatment. When localized at the root of the mesentery, their resection may require extensive excision of the intestine resulting in intestinal failure and life-long total parenteral nutrition. Intestinal transplantation, either autotransplantation or allotransplantation, has been used as a viable option to treat this group of patients. Herein, we describe a series of 4 patients with unresectable intra-abdominal desmoid tumor who underwent cadaveric isolated intestinal and ascending colon transplantation.

Clinical outcomes of intestinal transplant recipients receiving maintenance basiliximab, sublingual tacrolimus and prednisone: A case series.

INTRODUCTION: Intestinal transplantation poses a unique challenge in the field of solid organ transplantation. The combination of tacrolimus and prednisone stands as the foundational cornerstone of maintenance immunosuppression in the field of intestinal transplantation. This case series aims to describe 1-year clinical outcomes of 5 intestinal transplant recipients who received a novel immunosuppression regimen consisting of monthly basiliximab, sublingual tacrolimus, and prednisone. METHODS: A retrospective analysis of patients who underwent intestinal transplantation in our center between January 01, 2020, and January 31, 2022, was conducted. Each recipient was followed for at least 1-year post-transplant. Recipient baseline demographics, clinical characteristics, and follow-up data were obtained from the electronic health records. Data collection included recipient demographics (age, sex, race/ethnicity, BMI), cause of intestinal failure, immunological data, infectiology data and treatment information. RESULTS: A total of five patients underwent intestinal transplantation, of which two males (40 %) and three females (60 %), with a median age of 20.1 years (17.4-28.8). The median (IQR) tacrolimus trough by month 1 was 10.4 (8.4-13.2) ng/mL. Subsequently, the median (IQR) tacrolimus troughs at specified periods are as follows, respectively: month 3: 10.2 (8.2-13.2) ng/mL; month 6: 8.4 (7.6-9.6) ng/mL; and month 12: 8.8 (6.2-9.8) ng/mL. Three patients (60.0 %) had biopsy proven rejection, but all of them had resolution after the optimization of immunosuppression. All patients were alive and had a functioning intestinal allograft at 1-year. CONCLUSION: The combination of monthly basiliximab, sublingual tacrolimus, and prednisone is an effective novel maintenance immunosuppression in intestinal transplantation. A larger and more extended study duration would be necessary to thoroughly assess the safety and sustained benefits of the novel maintenance immunosuppression regimen.

Obesity and Kidney Transplantation-How to Evaluate, What to Do, and Outcomes.

Obesity is a growing issue that is spreading worldwide; its prevalence is ever increasing in patients with end-stage renal disease and represents a potential barrier to transplantation. The lack of unanimous guidelines exacerbates the current disparity in treatment, which can affect outcomes, leading to a significantly longer time on the waiting list. Multidisciplinary and multimodal management (encompassing several healthcare professionals such as nephrologists, transplant physicians and surgeons, primary care providers, and nurses) is of paramount importance for the optimal management of this patient population in a continuum from waitlisting to transplantation. Development of this guideline followed a standardized protocol for evidence review. In this review, we report on our clinical experience in transplantation of obese patients; strategies to manage this condition, including bariatric surgery, suitable timing for transplantation among this patient population, and clinical experience in robotic sleeve gastrectomy; and simultaneous robotic kidney transplantation to achieve optimal outcomes.