Concomitant Polyoma BK Virus and West Nile Virus in Renal Allografts.

Surveillance of the renal allograft recipient is essential when monitoring renal function to detect the early onset of rejection and alter therapeutic treatments to treat acute rejection or other causes and improve long-term graft function. If renal function begins to deteriorate, a renal biopsy is often indicated to assess the Banff grade of potential rejection or other causes, especially in the setting of polyoma BK viral load elevation. Although BK infection in the allograft is asymptomatic, reactivation of the virus is known to be associated with the acceleration of pathologic change and a poor outcome in the allograft. BK reactivation in a transplant kidney is not uncommon, and determining inflammation related to the virus versus acute rejection is paramount for appropriate immunosuppressive therapy management. We identified a concomitant polyoma BK virus and West Nile Virus (WNV) infection in two renal transplant patients which, to our knowledge, has not previously been reported. However, other concomitant infections have been reported in renal allografts including BK virus and cytomegalovirus (CMV), CMV and hepatitis C (HCV), and HCV and human immunodeficiency virus (HIV). As WNV has become endemic in many regions of the United States, and since the transmission of the virus via transplanted organs is associated with significant morbidity and mortality, it may be prudent to consider serologic screening for WNV in living donors prior to organ procurement. Regardless, the observation we made and report here should underscore the potential for concomitant viral infections that may be masked when a renal allograft has a significant inflammatory response to BK virus.

Quantifying mortality burden in patients with cancer due to COVID-19 in the US: A national cross-sectional analysis.

INTRODUCTION: There is limited information on the impact of certain social factors on mortality outcomes in patients with cancer and COVID-19 on a national scale. This study aims to characterize excess mortality and analyze a subset of sociodemographic trends in COVID-19 and cancer mortality. METHODS: Patients with cancer listed on their death certificates from 2018 to 2021 and patients with COVID-19 and cancer listed on multiple cause of death certificates from the CDC Wide-Ranging Online Data for Epidemiologic Research database from March 2020 to December 2021 were included. Age-adjusted mortality rates (AAMR) per 1,000,000 population were compared across race/ethnicity groups, sex, and census regions. Crude mortality rates were compared across different age groups and regions based on urbanization status. RESULTS: Average AAMR in patients with COVID-19 and cancer was 41.7 in 2020 and 56.7 in 2021. CONCLUSIONS: Mortality rates in patients with cancer and COVID-19 were significantly higher in certain populations. Targeted interventions are necessary to improve outcomes.

Electronic Patient Portal Use After Kidney Transplant: A Single-Center Retrospective Study.

INTRODUCTION: Online patient portals have become a core component of patient-centered care. Limited research exists on such portal use in patients after kidney transplantation. The aim of this study was to examine preoperative, perioperative, and postoperative factors associated with post-transplantation portal use. METHODS: This cross-sectional study included all patients who underwent kidney transplantation from April 2016 to May 2019 at the University of Toledo Medical Center. Exclusion criteria included international travel for transplantation and those without available postoperative lab or follow-up records. Data were collected for 2 y post-transplantation. Univariable and multivariable linear regression was performed to determine associations with portal use. RESULTS: Two hundred and forty-seven kidney transplant recipients were included in the study; 35.6% (n = 88) used the portal versus 64.4% (n = 159) did not. Preoperative factors associated with increased use included income >$40,000 (odds ratio [OR], 2.95; P = 0.006) and cancer history (OR, 2.46; P = 0.007), whereas diabetes history had reduced use (OR, 0.51; P = 0.021). The Black race had the least use. Perioperatively, reduced use was associated with dialysis before transplant (OR, 0.25; P < 0.001) and hospital stay ≥4 d (OR, 0.49; P = 0.009). Postoperatively, associations with increased use included average eGFR >30 (P = 0.04) and hospital readmissions (n = 102), whereas those with ER (n = 138) visits had decreased use. Multivariable analysis revealed increased use with income >$40,000 (OR, 2.51; P = 0.033). CONCLUSIONS: There was no observed difference in clinical outcomes for portal users and nonusers undergoing kidney transplantation, although portal use may decrease the likelihood of ER visits. Socioeconomic status and ethnicity may play a role on who utilizes the patient portals.

Patient-reported disruptions to cancer care during the COVID-19 pandemic: A national cross-sectional study.

BACKGROUND: The aim of this study is to evaluate the extent and associations with patient-reported disruptions to cancer treatment and cancer-related care during the COVID-19 pandemic utilizing nationally representative data. METHODS: This analysis uses data from the 2020 National Health Interview Survey (NHIS), an annual, cross-sectional survey of US adults. Adults (age >18) who reported requiring current cancer treatment or other cancer-related medical care in the second half of 2020 were included. Estimated proportions of patients with self-reported changes, delays, or cancelations to cancer treatment or other cancer care due to the COVID-19 pandemic were calculated using sampling weights and associations with sociodemographic and other health-related variables were analyzed. RESULTS: In total, 574 (sample-weighted estimate of 2,867,326) adults reported requiring cancer treatment and/or other cancer care since the start of the COVID-19 pandemic. An estimated 32.1% reported any change, delay, or cancelation. On sample-weighted univariable analysis, patients who were younger, female, had one or fewer comorbidities, and uninsured were significantly more likely to report disruptions. On sample-weighted, multivariable analysis, patients who were younger and female remained significant predictors. Nearly 90% of patients included in the study reported virtual appointment use. Patients reporting disruptions were also significantly more likely to report feelings of anxiety. CONCLUSIONS: An estimated 1/3 of patients experienced disruptions to cancer care due to the COVID-19 pandemic. Patients experiencing disruptions in care were more likely to be female or younger which may reflect risk stratification strategies in the early stages of the pandemic, and also had higher rates of anxiety. The longitudinal impact of these disruptions on outcomes merits further study.

False Positive Pregnancy Test Before Kidney Transplant: Case Report and Review of Literature.

Pregnancy tests are routinely done before any surgery under general anesthesia including kidney transplantation. Positive test usually leads to more investigations to detect a possible pregnancy or malignancy and the surgery gets canceled or postponed. Because a kidney transplant from a deceased donor is not elective, it usually gets canceled in this scenario. Some groups have reported on normally elevated human chorionic gonadotrophin (hCG) levels in perimenopausal women and in patients with chronic kidney disease. This is thought to be from the pituitary. We present a highly sensitized prospective kidney transplant recipient with a positive pregnancy test with low levels of serum human chorionic gonadotrophin. She underwent additional preoperative testing after which we proceeded with the kidney transplant. Herein, we discuss the management of patients who have an unexpected positive pregnancy test before transplant.

Conservative Management of Muscle Invasive Bladder Cancer in Kidney-Pancreas Transplant Patient.

Introduction. Solid organ transplant increases the risk for muscle-invasive bladder cancer (MIBC). Although a common tumor, urothelial cell carcinoma (UCC) of the bladder in patients with kidney-pancreas transplants is scarcely reported. Case Presentation. A 65-year-old male with history of type 1 diabetes and a 14-year status post deceased donor pancreas-kidney transplant presented with 3 weeks of gross hematuria. CT scan showed multiple bladder masses. Transurethral resection of bladder tumor (TURBT) showed papillary UCC. 5 months later, the patient reported new-onset gross hematuria. TURBT showed MIBC. The patient elected for bladder-preserving TMT. On cystoscopy there was no gross evidence of carcinoma at 3.5 years of follow up. Discussion. Currently, no specific management guidelines target this population with MIBC. The first-line treatment for MIBC is radical cystectomy (RC) with neoadjuvant chemotherapy. For patients that are medically unfit or unwilling to undergo RC, trimodal therapy (TMT) is an alternative. TMT for bladder cancer consists of complete tumor resection with chemotherapy and radiation. This report demonstrates a unique case of a patient with kidney-pancreas transplant diagnosed with MIBC treated with TMT that has no evidence of gross tumorigenesis at 3.5 years after diagnosis. Our findings suggest that trimodal therapy should be considered for treatment of MIBC in patients with kidney-pancreatic transplants to preserve the donated allografts.

Robotic stapler use: Is it safe?-FDA database analysis across multiple surgical specialties.

INTRODUCTION: Robotic-assisted techniques are common across many surgical subspecialties. While robotic stapling offers increased surgeon control, there is limited information on surgical complications related to robotic stapler use. METHODS: We reviewed the FDA's MAUDE database for adverse events related to robotic stapler use. RESULTS: Upon review of the FDA database, the most frequently reported robotic stapler complications were malfunction, failure to form staple line, device fragmentation, and misfire. 31 Clavien-Dindo grade II or higher complications were attributed to stapler use since 2014. CONCLUSIONS: Further research on prevalence of robotic stapler use is needed to quantity the associated complication rate.

Role of Synthetic Mesh Renorrhaphy and Neocapsule Reconstruction to Salvage Posttransplant Severely Damaged Renal Allografts.

OBJECTIVES: As the recipient pool continues to rise, it is vital to conserve donor organs whenever possible. Injured renal allografts continue to be discarded for a variety of reasons, and salvaging potentially useable grafts is of utmost importance. Little information is available on outcomes of salvaged allografts. Here, we present an easily replicable technique to salvage damaged renal allografts using polyglactin mesh. MATERIALS AND METHODS: Polyglactin woven mesh was used to salvage 4 otherwise irreparably injured allografts. In the first case, unidentified extracorporeal shockwave lithotripsy-induced microfractures 2 months before procurement of a deceased-donor kidney led to significant capsular injury. In the second case, rapid recovery of a deceased-donor kidney limited evaluation, and severe capsular rupture was diagnosed after perfusion. In the third case, an anticoagulated pediatric recipient received a living related-donor kidney from his mother, and a biopsy-induced hematoma 2 months posttransplant led to severe capsular denudation. In the fourth case, a pumped kidney from a donor after cardiac death developed severe focal capsular denudation. In each case, a keyhole hilar-sparing incision was made in an industry-standard 12 × 12-inch polyglactin mesh sheet, which was then fitted and sutured in a vest-over-pants method to provide a scaffold for hemostasis and capsular healing. Topical hemostatic agents were added in the first and fourth cases. Patients were followed longitudinally. RESULTS: All allografts were successfully salvaged using our technique, and none developed Page kidney, hydronephrosis, urinoma, or hemorrhage. At last follow-up, recipient 1 had kidney loss 7 years postrepair secondary to chronic allograft nephropathy, recipient 2 was lost to follow-up at 1 year with normal renal function, and recipients 3 and 4 had normal renal function at years 3 and 7 posttransplant. CONCLUSIONS: This simple technique using readily available materials can salvage allografts that would have been potentially explanted or discarded.

Underrepresented minority representation trends in gynecologic oncology fellowships in the United States.

OBJECTIVE: To evaluate representation trends of historically underrepresented minority (URM) groups in gynecologic oncology fellowships in the United States using a nationwide database collected by the Accreditation Council for Graduate Medical Education (ACGME). METHODS: Data on self-reported ethnicity/race of filled residency positions was collected from ACGME Database Books across three academic years from 2016 to 2019. Primary chi-square analysis compared URM representation in gynecologic oncology to obstetrics and gynecology, other surgical specialties, and other medical specialties. Secondary analysis examined representation of two URM subgroups: 1) Asian/Pacific Islander, and 2) Hispanic, Black, Native American, Other (HBNO), across specialty groups. RESULTS: A total of 528 gynecologic oncology positions, 12,559 obstetrics and gynecology positions, 52,733 other surgical positions, and 240,690 other medical positions from ACGME accredited medical specialties were included in analysis. Primary comparative analysis showed a statistically significant lower proportion (P < 0.05) of URM trainees in gynecologic oncology in comparison to each of obstetrics and gynecology, other surgical fields, and other medical fields. Secondary analysis also demonstrated a significantly lower proportion (P < 0.05) of HBNO physicians in gynecologic oncology in comparison to obstetrics and gynecology, as well as all other medical and surgical specialties. CONCLUSIONS: This study illustrates the disparities in URM representation, especially those who identify as HBNO, in gynecologic oncology fellowship training in comparison to obstetrics and gynecology as well as other medical and surgical fields. Improvements to the current recruitment and selection practices in gynecologic oncology fellowships in the United States are necessary in order to ensure a diverse and representative workforce.

Robotic-assisted Donor Nephrectomy: As Safe as Laparoscopic Donor Nephrectomy.

OBJECTIVES: Robotic-assisted donor nephrectomy has become increasingly popular in recent years. We sought to compare robotic-assisted outcomes to operative outcomes in a historical cohort of laparoscopic donor nephrectomies. MATERIALS AND METHODS: A retrospective review of 58 consecutive donor nephrectomies at a single center by two surgeons from 2015 to 2019 was performed. RESULTS: Robotic-assisted (n = 32) and laparoscopic (n =26) donors were comparable in terms of estimated blood loss (66.4 vs. 62.5 mL; p=0.81) and length of stay (1.6 vs. 1.5 days; p=0.37). The post-operative change in creatinine was not significantly different between the groups (-0.45 vs. -0.45; p=0.97). Warm ischemia time was longer in the robotic group (7.36 vs. 5.15 minutes; p < 0.01). Case duration was significantly longer for robotic-assisted cases (306 vs. 247 minutes; p < 0.01). However, robotic cases were more likely to be right-sided (6/32 (18.8%) vs. 1/26 (3.8%)) and have vascular multiplicity (7/32 (21.9%) vs. 0/26 (0%)). There was one Clavien II or greater complication in the robotic group, and none in the laparoscopic group. CONCLUSIONS: Our data agree with previous reports that robotic-assisted donor nephrectomy is safe and has similar outcomes to a laparoscopic approach. Moreover, cases with multiple renal arteries or veins and right-sided cases were completed safely using the robotic approach. The longer case duration in the robotic group was attributed to the learning curve associated with implementing a new technique, and later robotic operative times approached laparoscopic operative times.

Initial Experience with the Use of a Robotic Stapler for Robot-Assisted Donor Nephrectomy.

INTRODUCTION: Since the first description of robot-assisted laparoscopic donor nephrectomy for living donor renal transplantation, additional studies have noted outcomes comparable to traditional laparoscopic surgery. Urologists have embraced the technical advantages of the robotic approach, including improved dissection and more accurate graft preservation. With the advent of robotic stapling, we aim to demonstrate the feasibility of the use of robotic stapling for living-donor nephrectomies. MATERIALS AND METHODS: Ten cases of da Vinci® EndoWrist® Stapler use during robot-assisted donor nephrectomy by a single surgeon are reported. Variables examined included patient anatomy, estimated blood loss (EBL), warm ischemia time (WIT), postoperative complications, and graft function at follow-up. The costs of the laparoscopic and robotic staplers at our institution are reported. RESULTS: One right and nine left nephrectomies were performed by a single surgeon. Eight living donors had a single renal artery and vein, while two had multiple renal arteries and renal veins. A single vascular stapler load (45-mm, white cartridge) was used for vessels in all cases. WIT was <6 minutes in each case, and EBL ranged from 13 to 100 mL. Sufficient length on the renal artery and vein was obtained to execute anastomoses in all cases. Only one patient had postoperative complications that were related to anesthesia. Graft function of recipients and postoperative renal function has been adequate to date. The cost of using the robotic stapler was $705 (EndoWrist Stapler), and the cost of the laparoscopic stapler (Endo GIA™ Stapler; Medtronic, Dublin, Ireland) was $494.06. CONCLUSIONS: The use of robotic stapler is feasible in terms of patient safety, technique, postoperative outcomes, and cost in both left- and right-sided living-donor robotic nephrectomies. Further research is needed to confirm the benefit and safety of EndoWrist stapler use in robotic donor nephrectomies compared to laparoscopic stapler use.

Pediatric liver transplantation: predictors of survival and resource utilization.

PURPOSE: We sought to identify factors associated with increased resource utilization and in-hospital mortality for pediatric liver transplantation (LT). METHODS: Kids' Inpatient Database (1997-2009) was used to identify cases of LT in patients <20 years old. RESULTS: Overall, 2905 cases were identified, with an in-hospital survival of 91 %. LT was performed most frequently in < 5 year olds (61 %), females (51 %), and Caucasians (56 %). LT was performed at urban teaching hospitals (97 %) and facilities with children's units (51 %). Indications included pathologic conditions of the biliary tract (44 %) and inborn errors of metabolism (34 %), though unspecified end stage liver disease was the most common (75 %). Logistic regression found higher mortality in children undergoing LT for malignant conditions (odds ratio: 4.8) and acute hepatic failure (OR 3.4). Cases complicated by renal failure (OR 7.7) and complications of LT (OR 2.7) had higher mortality rates. Resource utilization increased for children with renal failure and those with hemorrhage as a complication of LT, p < 0.05. CONCLUSION: Hospital survival is predicted by indication and complications associated with LT. Resource utilization increased with renal failure and complications related to LT. Admission length was sensitive to payer status, hospital characteristics, and UNOS region, whereas total costs were unaffected by payer status or hospital type.

Feasibility of renal transplantation after unroofing of a large renal cyst in an expanded criteria donor.

We present a case in which a deceased donor kidney with a large simple cyst was successfully unroofed and transplanted to a 61-year-old male. The donor was a 62-year-old male with a history of hypertension for 2 years; cerebral vascular accident was the cause of death. A large 8-cm cyst distorting the renal hilum was identified upon the procurement of the deceased donor kidney. Prior to transplantation, the large cyst was unroofed from the allograft; the frozen section confirmed a benign cyst and the transplant was performed. Postoperatively, the serum creatinine level was 1.4 mg/ml at 22-month follow-up and the patient was normotensive. Deceased donor kidneys with giant cysts distorting the renal hilum can be effectively transplanted.

C-X-C chemokine receptor 7: a functionally associated molecular marker for bladder cancer.

BACKGROUND: C-X-C chemokine receptor 4 (CXCR4) and CXCR7 are 7-transmembrane chemokine receptors of the stroma-derived factor (SDF-1). CXCR4, but not CXCR7, has been examined in bladder cancer (BCa). This study examined the functional and clinical significance of CXCR7 in BCa. METHODS: CXCR4 and CXCR7 levels were measured in BCa cell lines, tissues (normal = 25; BCa = 44), and urine specimens (n = 186) by quantitative polymerase chain reaction and/or immunohistochemistry. CXCR7 function in BCa cells were examined by transient transfections using a CXCR7 expression vector or small interfering RNA. RESULTS: In BCa cell lines, CXCR7 messenger RNA levels were 5- to 37-fold higher than those for CXCR4. Transient overexpression of CXCR7 in BCa cell lines promoted growth and chemotactic motility. CXCR7 colocalized and formed a functional complex with epidermal growth factor receptor, phosphoinositide 3-kinase/Akt, Erk, and src and induced their phosphorylation. CXCR7 also induced up-regulation of cyclin-D1 and bcl-2. Suppression of CXCR7 expression reversed these effects and induced apoptosis. CXCR7 messenger RNA levels and CXCR7 staining scores were significantly (5- to 10-fold) higher in BCa tissues than in normal tissues (P < .001). CXCR7 expression independently associated with metastasis (P = .019) and disease-specific mortality (P = .03). CXCR7 was highly expressed in endothelial cells in high-grade BCa tissues when compared to low-grade BCa and normal bladder. CXCR7 levels were elevated in exfoliated urothelial cells from high-grade BCa patients (P = .0001; 90% sensitivity; 75% specificity); CXCR4 levels were unaltered. CONCLUSIONS: CXCR7 promotes BCa cell proliferation and motility plausibly through epidermal growth factor receptor receptor and Akt signaling. CXCR7 expression is elevated in BCa tissues and exfoliated cells and is associated with high-grade and metastasis.

Dramatic reduction in tumor burden with neoadjuvant sunitinib prior to bilateral nephron-sparing surgery.

Neoadjuvant sunitinib has recently been described for the management of renal cell carcinoma. We present the pre and posttreatment images of a 49-year-old male with bilateral biopsy-proven clear cell renal cell carcinoma who underwent treatment with sunitinib prior to nephron-sparing surgery. After four four-week cycles of daily 50 mg sunitinib, the patient demonstrated a dramatic reduction in tumor burden allowing for successful bilateral partial nephrectomy.

Radiofrequency ablation (RFA) therapy for renal angiomyolipoma (AML): an alternative to angio-embolization and nephron-sparing surgery.

OBJECTIVES: To show that radiofrequency ablation (RFA) is safe and effective treatment for renal angiomyolipoma (AML). Current treatments to reduce the risk of haemorrhage include tumour extirpation, angio-embolization, or ablative therapy. PATIENTS AND METHODS: Review of our prospective database revealed 15 patients with intraoperative biopsy confirmed renal AML undergoing RFA from February 2002 to March 2010. Patients underwent either laparoscopic or computed tomography (CT)-guided percutaneous RFA using either the Cool-tip™ (Covidien, Inc. Boulder, CO, USA) or RITA™ (Angiodynamics(®), Latham, NY, USA) RFA probe. CT at 1 month, 6 months, 1 year, and annually thereafter. RESULTS: In all, two male and 13 female patients with seven left-sided and eight right-sided tumours with a mean (range) size of 2.6 (1.0-3.7) cm underwent laparoscopic (five) or CT-guided (10) RFA. No intraoperative complications occurred. Minor complications included transient haematuria and intercostals nerve transection. Surgical complications included pneumonia and myocardial infarction. There was no radiographic evidence of persistent AML (CT enhancement) at a mean follow-up of 21 months. CONCLUSIONS: The haemostatic effect of RFA allows renal lesions suspicious for AML to be treated without bleeding complications. Avoids surgical risk of extirpation or embolization. RFA for renal AML is safe and effective.

Molecular characterization of kidney cancer: association of hyaluronic acid family with histological subtypes and metastasis.

BACKGROUND: Molecular profiling of renal cell carcinomas (RCCs) may improve the distinction between oncocytoma and malignant RCC subtypes and aid in early detection of metastasis. The hyaluronic acid (HA) family includes HA synthases (HAS1, HAS2, HAS3), hyaluronidases (HYAL-1, HYAL-2, HYAL-3, HYAL-4, PH20, HYAL-P1), and HA receptors (CD44s, CD44v, RHAMM). HA family members promote tumor growth and metastasis. The authors evaluated the expression of HA family members in kidney specimens. METHODS: By using quantitative polymerase chain reaction, mRNA levels of 12 HA family members were measured in tumor specimens obtained from 86 consecutive patients undergoing nephrectomy; 80 of them also provided normal specimens. Mean and median follow-up were 15.2 ± 8.8 and 13.8 months. RCC specimens included clear cell RCC: 65; papillary: 10; chromophobe: 5; oncocytoma: 6; metastasis positive: 17. RESULTS: Median HAS1, CD44s, and RHAMM transcript levels were elevated 3- to 25-fold in clear cell RCC and papillary and chromophobe tumors when compared with normal tissues. HYAL-4, CD44s, and RHAMM levels were elevated 4- to 12-fold in clear cell RCC and papillary tumors when compared with oncocytomas; only HYAL-4 levels distinguished between chromophobe and oncocytoma (P = .009). CD44s and RHAMM levels were significantly higher in tumors <4 cm (510 ± 611 and 19.6 ± 20.8, respectively) when compared with oncocytoma (46.4 ± 20 and 3.8 ± 2.5; P ≤ .006). In univariate and multivariate analyses, CD44s (P < .0001), RHAMM (P < .0001), stage, tumor size, and/or renal vein involvement were significantly associated with metastasis. The combined CD44s + RHAMM marker had 82% sensitivity and 86% specificity to predict metastasis. CONCLUSIONS: CD44s and RHAMM levels distinguish between oncocytoma and RCC subtypes regardless of tumor size and are potential predictors of RCC metastasis.

Laparoscopic and image-guided radiofrequency ablation of renal tumors: patient selection and outcomes.

Multiple modalities exist for the management of small renal tumors, including active surveillance, extirpation (radical nephrectomy and partial nephrectomy), and ablative therapies. Radiofrequency ablation (RFA) is an alternative to extirpative surgery for renal tumors. This article presents the current literature on RFA for renal tumors. We reviewed 28 RFA series in the English literature from 2003 to 2010 to assess patient selection, biopsy, renal outcomes, and oncologic outcomes.