Prospective Analyses of Circulating B Cell Subsets in ABO-Compatible and ABO-Incompatible Kidney Transplant Recipients.

Immunosuppressive strategies applied in renal transplantation traditionally focus on T cell inhibition. B cells were mainly examined in the context of antibody-mediated rejection, whereas the impact of antibody-independent B cell functions has only recently entered the field of transplantation. Similar to T cells, distinct B cell subsets can enhance or inhibit immune responses. In this study, we prospectively analyzed the evolution of B cell subsets in the peripheral blood of AB0-compatible (n = 27) and AB0-incompatible (n = 10) renal transplant recipients. Activated B cells were transiently decreased and plasmablasts were permanently decreased in patients without signs of rejection throughout the first year. In patients with histologically confirmed renal allograft rejection, activated B cells and plasmablasts were significantly elevated on day 365. Rituximab treatment in AB0-incompatible patients resulted in long-lasting B cell depletion and in a naïve phenotype of repopulating B cells 1 year following transplantation. Acute allograft rejection was correlated with an increase of activated B cells and plasmablasts and with a significant reduction of regulatory B cell subsets. Our study demonstrates the remarkable effects of standard immunosuppression on circulating B cell subsets. Furthermore, the B cell compartment was significantly altered in rejecting patients. A specific targeting of deleterious B cell subsets could be of clinical benefit in renal transplantation.

Postoperative Continuous Infusion of Local Anesthesia in Hand-Assisted Retroperitoneoscopic Living Donor Nephrectomy.

INTRODUCTION: Postoperative pain management in living kidney donor nephrectomy plays a key role in donor comfort and is important for the further acceptance of living kidney donation in times of organ shortage. Standard pain treatment (SPT) based on opioids is limited due to related side effects. Continuous infusion of local anesthesia (CILA) into the operative field is a promising alternative. The aim of this study was to evaluate whether CILA could reduce the dose of opioids in living kidney donors operated with hand-assisted retroperitoneoscopic donor nephrectomy (HARP). METHODS: An observational study on 30 living donors was performed. The primary outcome was the difference of morphine equivalents (MEQ) administered between CILA and SPT. RESULTS: On day 0 and 1, living donors with CILA received significant less MEQ compared to the SPT group, although on day 1 this effect was not statistically significant (day 0: 6.3 mg, interquartile range [IR] 4.2-11.2 vs 16.8 mg, IR 10.5-22.1, P = .009; day 1: 5.25 mg, IR 2.1-13.3 vs 13.3 mg, IR 6.7-23.8, P = .150). On days 2 and 3 there was no difference (day 2: 13.3 mg, IR 0.0-20.0 vs 13.3 mg, IR 6.7-13.3, P = .708; day 3: 13.3 mg, IR 0.0-26.7 vs 13.3 mg, IR 6.7-20, P = .825). Overall (days 0 to3) MEQ was also less for CILA without reaching statistical significance (39.6 mg, IR 10.9-70.5 vs 59.6 mg, IR 42.4-72.9, P = .187). CONCLUSIONS: CILA seems to be an effective instrument for donor pain management in the first 24 hours after HARP. Its effect abates by 48 hours after surgery, especially if highly potent nonopioids are given.

Prognosis after "high urgent" kidney transplantation might be determined by control of preexisting septic condition.

INTRODUCTION: Dialysis is the standard bridging method for patients with end-stage renal disease. In rare cases, dialysis is impossible and immediate kidney transplantation (KT) is the only option for survival. Most allocation organizations offer an immediate allocation procedure (high urgency [HU]), which focuses on immediate allocation at the cost of immunologic matching. The impossibility of dialysis is mainly caused by multiple systemic thromboses and blood stream infections. This situation creates an ethical dilemma: Accepting the HU-KT allocation potentially saves the patient's life albeit with negatively effects on the expected patient and organ survivals. In times of organ shortage, more information is needed regarding this difficult decision; the published literature is limited to 4 papers. METHODS: We performed a retrospective analysis of patients who were transplanted by HU allocation in our center between January 1989 and October 2010. RESULTS: Of 1040 KT, 10 (0.96%) were performed in HU condition. Mean follow-up time was 37 months. The main reason for HU-KT was exhaustion of vascular access in combination with a bloodstream infection. All recipients showed severe preoperative comorbidities. Patient survival was 90% at 1, 80% at 3, and 60% at 5 years. There was 1 graft loss owing to chronic rejection. CONCLUSION: When kidney transplantation is performed as an HU procedure, it is associated with a greater morbidity and mortality compared with elective cases. Bloodstream infections that existed before transplantation contributed considerably to mortality.