Clinical outcome of living donor kidney transplantation across simultaneous ABO and HLA incompatibility: Single center experience of first ten cases.

BACKGROUND AND AIMS: Preconditioning using different protocols has been tested to prevent antibody mediated rejection (ABMR) individually for ABO and HLA incompatibility. However, simultaneous presence of both barriers is still less explored. The aim of this study was to report outcomes of institutional desensitization protocol in renal transplant recipients with simultaneous ABO and HLA incompatibility. MATERIALS AND METHODS: This was a retrospective study conducted from October 2015 to December 2018. All patients with a clinical diagnosis of dialysis dependent chronic kidney disease (CKD), who were prospective coexistent HLA and ABO incompatible renal transplant recipients were included in the study. Patients were followed up and graft function and patient survival was assessed at 1 y from the date of transplant. RESULTS: Median and mode baseline anti-A titers were 64, while median and mode baseline anti-B titers were 256. All recipients were discharged by tenth postoperative day. None of the patients had any bleeding complications. Post transplant infection rate was found to be 20 %. A total of 54 therapeutic plasma exchange (TPE) procedures were performed before transplant and 8 were performed after transplant. Graft survival and patient survival was 100 % at 3, 6, 9, and 12 months. Range and mean follow-up period was 15-42 months and 23 months respectively. Mean glomerular filtration rate (GFR) at 1 y using the CKD-EPI equation was 85.25 ± 13.76 mL/min. Biopsy proven ABMR was observed in one case only which was managed with TPE and immunosuppression. CONCLUSION: Simultaneous ABO and HLA incompatibility in renal transplant recipients can be managed successfully with adequate preconditioning and careful monitoring.

Outcome of desensitization in human leukocyte antigen and ABO incompatible living donor kidney transplantation: Single center experience of first 200 incompatible transplants.

BACKGROUND AND AIMS: Although desensitization is well established, concerns about graft outcome, patient survival and rejection still exist. The present study aims at comparing outcomes of renal transplant recipients across simultaneous ABO and human leukocyte antigen (HLA) incompatibility barriers to those with ABO or HLA incompatibility alone. MATERIALS AND METHODS: This was a retrospective study conducted from October 2015 to December 2018. All patients with a clinical diagnosis of chronic kidney disease, who were prospective HLA incompatible (HLAi) and/or ABO incompatible (ABOi) renal transplant recipients were included. A total of 400 cases including 36 ABOi transplants, 154 HLAi transplants, 10 simultaneously ABO and HLA incompatible transplants, and 200 ABO (ABOc) and HLA (HLAc) compatible kidney transplants from living donors were included. RESULTS: There were significantly more number of blood transfusions, previous transplants and pregnancies in HLAi transplant recipients relative to the ABOi or the control group. Mean number of therapeutic plasma exchange procedures per patient and mean plasma volume processed per procedure were slightly higher in the ABOi + HLAi category. The incidence of graft dysfunction due to suspected antibody-mediated rejection during first year was highest in the ABOi + HLAi group, followed by ABOc + HLAi and ABOi + HLAc, lowest in the ABOc + HLAc category. Mean time to first episode of graft dysfunction was significantly shorter with incompatible transplants. There were no kidney transplant recipient deaths in the study. CONCLUSION: Patient outcome and graft outcomes observed with incompatible transplants were not worse than those observed with compatible transplants.

Histopathological changes of radial artery wall in patients of chronic kidney disease stage 5 undergoing AV fistula formation and their correlation with serum iPTH levels.

Vascular complications arise in uremic patients in the absence of clinically significant atherosclerotic disease. Elevated serum parathyroid hormone (PTH) and abnormal calcium (Ca) and phosphorus (P) balance have been implicated in vascular damage in chronic kidney disease (CKD) patients, but there is lack of histo-pathological studies. Patients with CKD stage 5 and 5D who underwent arterio-venous fistula were included in this study. Baseline and laboratory parameters including assessment of total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, triglycerides, uric acid, albumin, calcium, phosphorus, intact PTH (iPTH) and vitamin D level were documented. The specimens of the arterial wall were obtained during the procedure and were analyzed. Patients were divided into two groups iPTH <400 (Group A) and iPTH >400 (Group B). Mean intimal thickness (IT) was significantly high in patients of Group B (60.4 ± 24.1 µ m) as compared with patients of Group A (37.8 ± 14.9 µm) (P = 0.003). Vascular calcification was comparable in both groups. The iPTH level was found to be an independent risk factor for high intima thickness (correlation coefficient 0.653) (P-value <0.01). Patients with high (≥ 400 pg/mL) iPTH have 8.93 times the risk of developing intimal thickness of ≥ 60 µ m as compared with patients with low (<400 pg/mL) iPTH (P-value <0.05), with 95% confidence interval of 1.27, 62.61. The mean IT of the radial artery significantly correlated with the iPTH level, while vascular calcification was independent of the iPTH level. Hyperparathyroidism is an important cause of ongoing vascular damage and may contribute to higher vascular events in CKD patients.

Laparoscopic right donor nephrectomy: endo TA stapler is safe and effective.

Although laparoscopic donor nephrectomy is now a well-accepted alternative to traditional open donor nephrectomy at many transplantation centers, there are always concerns regarding quality of graft and vessels after laparoscopic harvest, especially with right donor nephrectomy. Several methods of graft retrieval have been explored to achieve acceptable graft outcome. We share our initial experience at the Institute of Kidney Diseases and Research Center, Amedabad, India of laparoscopic right donor nephrectomy performed by subcostal open, and pure laparoscopic approach with the use of Endo TA stapler. Nine laparoscopic right donor nephrectomies were performed by the trans-peritoneal approach at our centre from January 2006 to March 2007. In the first five cases, the grafts were retrieved through subcostal incision (Group A) and the last four cases were performed purely laparoscopically by using Endo TA stapler device (Group B). None of the patients needed open conversion. The mean operative time and hospital stay were comparable in each group. The warm ischemia time was longer in pure laparoscopic group (415 seconds) than the subcostal open approach group (176 seconds). The serum creatinine of the recipients on day seven was comparable in both the groups. The recipient surgery was effectively performed with graft retrieved using Endo TA stapler device (Group B) without any compromise to the renal vein length. Our study suggests that the Endo TA stapler device is safe and provides all the benefits of minimally invasive surgery to the donor.