Early experience with COVID-19 in kidney transplantation recipients: update and review

ABSTRACT Introduction: little is known on the risk factors, clinical presentation, therapeutic protocols, and outcomes of kidney transplantation recipients (KTRs) who become infected by SARS-CoV-2. Purpose: to provide an updated view regarding the early experience obtained from the management of KTRs with COVID-19. Materials and Methods: A narrative review was conducted using PubMed database to identify relevant articles written in English/Spanish, and published through May 15, 2020. Search terms included: "coronavirus", "severe acute respiratory syndrome coronavirus 2", "SARS-CoV-2", "COVID-19", "COVID", "renal transplantation", and "kidney transplantation". Case series were considered eligible, and case reports excluded. Thirty-four articles were included in the review. Results: KTRs should be considered immunocompromised hosts: potential risk for infection, non-negligible comorbidity, and exposure to long-term immunosuppression. Only single center small retrospective experiences are still available regarding KTRs with COVID-19. SARS-CoV-2 symptoms in KTRs are similar to that observed for the general population, being fever and cough the most frequently observed. Mild-to-moderate symptomatic KTRs can be managed in an outpatient setting, while patients exhibiting severe symptoms must be addmited to hospital. More rapid clinical progression, and higher complication and death rates have been observed for hospitalized KTRs, requiring hemodyalisis or ventilatory support. Lymphopenia, elevated serum markers (C-reactive protein, procalcitonin, IL-6, D-dimer), and chest-X-ray findings consistent with pneumonia are linked to worse prognosis. A number of antiviral therapies have been used. However, it is difficult to draw meaningful conclusions regarding their efficacy at this point. Baseline immunosupression regimen should be adjusted in a case-by-case manner. However, it poses a significant challenge.

Early experience with COVID-19 in kidney transplantation recipients: update and review.

INTRODUCTION: little is known on the risk factors, clinical presentation, therapeutic protocols, and outcomes of kidney transplantation recipients (KTRs) who become infected by SARS-CoV-2. PURPOSE: to provide an updated view regarding the early experience obtained from the management of KTRs with COVID-19. MATERIALS AND METHODS: A narrative review was conducted using PubMed database to identify relevant articles written in English/Spanish, and published through May 15, 2020. Search terms included: "coronavirus", "severe acute respiratory syndrome coronavirus 2", "SARS-CoV-2", "COVID-19", "COVID", "renal transplantation", and "kidney transplantation". Case series were considered eligible, and case reports excluded. Thirty-four articles were included in the review. RESULTS: KTRs should be considered immunocompromised hosts: potential risk for infection, non-negligible comorbidity, and exposure to long-term immunosuppression. Only single center small retrospective experiences are still available regarding KTRs with COVID-19. SARS-CoV-2 symptoms in KTRs are similar to that observed for the general population, being fever and cough the most frequently observed. Mild-to-moderate symptomatic KTRs can be managed in an outpatient setting, while patients exhibiting severe symptoms must be addmited to hospital. More rapid clinical progression, and higher complication and death rates have been observed for hospitalized KTRs, requiring hemodyalisis or ventilatory support. Lymphopenia, elevated serum markers (C-reactive protein, procalcitonin, IL-6, D-dimer), and chest-X-ray findings consistent with pneumonia are linked to worse prognosis. A number of antiviral therapies have been used. However, it is difficult to draw meaningful conclusions regarding their efficacy at this point. Baseline immunosupression regimen should be adjusted in a case-by-case manner. However, it poses a significant challenge.

Renal Transplantation in a Patient With Unsuspected Inferior Vena Cava Obliteration.

Vena cava thrombosis can represent a surgical challenge in the context of kidney transplantation. Selection of venous drainage in this setting should provide adequate venous outflow and minimize the risk of thrombosis and subsequent graft failure. We report the case of an adult female patient who presented for a deceased donor kidney transplant with incidental finding of complete inferior vena cava (IVC) and obliteration. After exploration of the retroperitoneal space up to the level of the obliterated IVC, a collateral venous branch was identified at the confluence of the right and left iliac veins. This was utilized as the site of the renal vein venous anastomosis. The patient recovered with immediate graft function. Follow-up ultrasound demonstrated patent vasculature without evidence of thrombosis or outflow obstruction. This report offers a surgical alternative to proceed in the case of an adult with unsuspected caval system obliteration.

Tumor thrombus involving the inferior vena cava in renal malignancy: is there a difference in clinical presentation and outcome among right and left side tumors?

PURPOSE: Renal cell carcinoma (RCC) has a propensity to propagate into the renal vein and inferior vena cava (IVC). Due to inherent differences in the venous anatomy of the right and left kidneys, tumor thrombus involvement of IVC may vary. The aim of this study is to compare clinical presentation and outcome of right vs. left RCC with IVC thrombus. MATERIALS AND METHODS: Patients who underwent radical nephrectomy and IVC thrombectomy between 1997 and 2008 were identified. All relevant data were collected and analyzed. RESULTS: Eight-seven patients were included. Sixty patients (69%) had a right sided tumor. Mean tumor size was 10.2 (+/- 4) cm and was not significantly different on either side. Fifty-six percent of right sided tumors had level-III (intra-hepatic) or higher tumor thrombus, while 22% of left sided tumors had similar level thrombus extension (p < 0.0001). Nearly 50% of left sided tumors showed level-I thrombus compared to 10% of right side tumors. A comparison of age, estimated blood loss and transfusion rate was not significantly different. The recurrence free (p = 0.9) and disease specific survival (p = 0.4) were not significantly different between the right and left side tumors with IVC thrombus. CONCLUSION: A level-III IVC tumor thrombus is more frequently seen with a right side tumor. However, clinical and operative characteristics among the left and right sided tumors with IVC thrombus were not different. More significantly, recurrence rate and survival did not differ with the laterality of the tumor.

Tumor thrombus involving the inferior vena cava in renal malignancy: is there a difference in clinical presentation and outcome among right and left side tumors?

PURPOSE: Renal cell carcinoma (RCC) has a propensity to propagate into the renal vein and inferior vena cava (IVC). Due to inherent differences in the venous anatomy of the right and left kidneys, tumor thrombus involvement of IVC may vary. The aim of this study is to compare clinical presentation and outcome of right vs. left RCC with IVC thrombus. MATERIALS AND METHODS: Patients who underwent radical nephrectomy and IVC thrombectomy between 1997 and 2008 were identified. All relevant data were collected and analyzed. Results: Eight-seven patients were included. Sixty patients (69 percent) had a right sided tumor. Mean tumor size was 10.2 (± 4) cm and was not significantly different on either side. Fifty-six percent of right sided tumors had level-III (intra-hepatic) or higher tumor thrombus, while 22 percent of left sided tumors had similar level thrombus extension (p < 0.0001). Nearly 50 percent of left sided tumors showed level-I thrombus compared to 10 percent of right side tumors. A comparison of age, estimated blood loss and transfusion rate was not significantly different. The recurrence free (p = 0.9) and disease specific survival (p = 0.4) were not significantly different between the right and left side tumors with IVC thrombus. Conclusion: A level-III IVC tumor thrombus is more frequently seen with a right side tumor. However, clinical and operative characteristics among the left and right sided tumors with IVC thrombus were not different. More significantly, recurrence rate and survival did not differ with the laterality of the tumor.

The role of liver transplantation techniques in the surgical management of advanced renal urothelial carcinoma with or without inferior vena cava thrombus.

PURPOSE: Standard radical nephrectomy for large masses is significantly facilitated by liver transplantation techniques, which have been successfully employed over the last ten years at our institution. Large and locally-advanced urothelial carcinoma of the kidney with or without extension into the inferior vena cava is rare. The purpose of this study was to present the surgical management of large and locally-advanced urothelial tumors arising from the renal pelvis using liver transplantation techniques and to evaluate patient outcome. MATERIALS AND METHODS: Diagnostic work-up and surgical management of 4 patients with large and locally-advanced renal urothelial carcinoma were retrospectively reviewed. Two out of four patients with urothelial carcinoma presented with inferior vena cava thrombus. Mean tumor size was 11.6 cm. All patients underwent surgery, 2 patients with the presumed diagnosis of renal cell cancer. Liver transplantation techniques were an integral part in all radical nephrectomies. RESULTS: No intraoperative complications and postoperative mortality occurred. Mean operative time was 7.5 hours, estimated blood loss was 1.5 L, and an average of 4.8 units of blood was transfused intraoperatively. Three patients succumbed to cancer recurrence at a mean postoperative time of 6.3 months; 1 patient is still alive 24 months after surgery. CONCLUSIONS: Large and locally-advanced renal masses of urothelial origin can be successfully removed by a combination of radical nephrectomy with liver transplantation techniques. Since long-term outcome of such patients has been poor, accurate preoperative diagnosis is essential to consider neoadjuvant treatment and to plan nephroureterectomy.

The role of liver transplantation techniques in the surgical management of advanced renal urothelial carcinoma with or without inferior vena cava thrombus

Purpose: Standard radical nephrectomy for large masses is significantly facilitated by liver transplantation techniques, which have been successfully employed over the last ten years at our institution. Large and locally-advanced urothelial carcinoma of the kidney with or without extension into the inferior vena cava is rare. The purpose of this study was to present the surgical management of large and locally-advanced urothelial tumors arising from the renal pelvis using liver transplantation techniques and to evaluate patient outcome. Materials and Methods: Diagnostic work-up and surgical management of 4 patients with large and locally-advanced renal urothelial carcinoma were retrospectively reviewed. Two out of four patients with urothelial carcinoma presented with inferior vena cava thrombus. Mean tumor size was 11.6 cm. All patients underwent surgery, 2 patients with the presumed diagnosis of renal cell cancer. Liver transplantation techniques were an integral part in all radical nephrectomies. Results: No intraoperative complications and postoperative mortality occurred. Mean operative time was 7.5 hours, estimated blood loss was 1.5 L, and an average of 4.8 units of blood was transfused intraoperatively. Three patients succumbed to cancer recurrence at a mean postoperative time of 6.3 months; 1 patient is still alive 24 months after surgery. Conclusions: Large and locally-advanced renal masses of urothelial origin can be successfully removed by a combination of radical nephrectomy with liver transplantation techniques. Since long-term outcome of such patients has been poor, accurate preoperative diagnosis is essential to consider neoadjuvant treatment and to plan nephroureterectomy.