Medium-Term Outcomes of COVID-19 Infection After Kidney Transplantation for Ongoing Living and Deceased Kidney Transplantations within the COVID-19 Pandemic.

OBJECTIVES: To present the early to midterm experience of two referral kidney transplantation centers with living and deceased kidney transplantations that were performed within the COVID-19 pandemic. MATERIALS AND METHODS: All cases performed in two referral centers in Iran within the COVID-19 pandemic were investigated. Transplantations were performed from May 2020 to February 2021. The protocol for screening included nasopharyngeal RT-PCR with chest CT scan for living and deceased transplantations in center A and RTPCR for living transplantations and chest CT scan for deceased transplantations in center B. Patients were followed for 14-26 months after transplantation regarding COVID-19 infection and its outcomes in case of infection. RESULTS: 103 kidney transplantations were performed during the study period including 54 (52.4%) living and 49 (47.6%) deceased kidney transplantations. Twenty-four recipients (23.3%) and a living donor (1%) were infected with COVID-19. The severity of COVID-19 infection was mild, moderate, severe, and critical in 16 (66.6%), 4 (16.6%), 2 (8.4%), and 2 patients (8.4%), respectively. Two mortalities were observed within transplantation recipients with COVID-19 infection (1.9%). 87.5% (7/8) COVID-19 infections in center B were observed in recipients of deceased transplantations who were screened only by chest CT scan. CONCLUSION: The results of this study indicate a low frequency of COVID-19 mortality (1.9% for the whole cohort and 8.3% within COVID-19 infected patients) for recipients of living and deceased kidney transplantation that were performed within the COVID-19 pandemic. The above findings highlight for the first time in a large study the probability of living kidney transplantation during the COVID-19 pandemic in case strict screening of donors and recipients and close supervision of operating rooms and wards are implemented. We further hypothesize the inadequacy of chest CT scan for screening of COVID-19 in kidney transplantation surgery candidates.

Incidence of malignancy after living kidney transplantation: a multicenter study from iran.

Malignancy is a common complication after renal transplantation. However, limited data are available on post-transplant malignancy in living kidney transplantation. Therefore, we made a plan to evaluate the incidence and types of malignancies, association with the main risk factors and patient survival in a large population of living kidney transplantation. We conducted a large retrospective multicenter study on 12525 renal recipients, accounting for up to 59% of all kidney transplantation in Iran during 22 years follow up period. All information was collected from observation of individual notes or computerized records for transplant patients. Two hundred and sixty-six biopsy-proven malignancies were collected from 16 Transplant Centers in Iran; 26 different type of malignancy categorized in 5 groups were detected. The mean age of patients was 46.2±12.9 years, mean age at tumor diagnosis was 50.8±13.2 years and average time between transplantation and detection of malignancy was 50.0±48.4 months. Overall tumor incidence in recipients was 2%. Kaposis' sarcoma was the most common type of tumor. The overall mean survival time was 117.1 months (95% CI: 104.9-129.3). In multivariate analysis, the only independent risk factor associated with mortality was type of malignancy. This study revealed the lowest malignancy incidence in living unrelated kidney transplantation.

Skin cancer after renal transplantation: Results of a multicenter study in Iran.

BACKGROUND: Incidence and risk factors for skin tumors following renal transplantation can vary geographically; therefore, a retrospective study was performed to determine the incidence of and potential risk factors for skin cancer at 14 Transplant Centers in Iran between 1984 and 2008. MATERIAL/METHODS: We enrolled 11,255 kidney transplant recipients who were examined for all skin tumors. All skin cancers were established by histological examination. The data collection included the patient's age and sex, immunosuppressive regimen before and after diagnosis of tumor, rejection episodes, post-transplant latency period, other concurrent neoplastic problems, renal allograft function and outcome. RESULTS: One hundred and twenty-eight (1.14%) renal recipients had skin tumor, representing half of all post-transplant malignancies (128 out of 245 cases). Kaposi's sarcoma was the most common post-transplant cancer compared with other skin tumors. Male recipients had more tumors than did females (P=0.04); the male-to-female ratio in the affected patients was 2.5:1. The age at transplantation of patients with skin tumor was higher compared to RTRs without skin tumor (47±11 vs. 38±15 years, P=0.000), and individuals older than 45 years were at higher risk (odds ratio=3.8, 95%CI 2.6-5.5) of skin cancers. Patients consuming azathioprine were at risk more of skin cancer compared with those were on MMF (odds ratio =2.9, 95%, CI 2.0-4.2). The overall mortality was low (7.8%) in cases with skin cancer. CONCLUSIONS: This study showed that male sex, increased age, prolonged immunosuppression and azathioprine increased the risk of skin tumors after renal transplantation.

Short-term and long-term effects of slow graft function on graft survival in pediatric live donor renal transplantation.

SGF generally has early and long-term consequences for allograft survival. Limited studies have been performed on SGF and its complications in pediatric renal transplantation. Therefore, 230 children who received transplants between 1985 and 2005 in Labafi Nejad hospital were included in this study. SGF was defined if the serum creatinine level increased, remained unchanged, or decreased by <10% per day immediately after surgery during three consecutive days in the first week after transplantation. The children were divided into two groups: 183 children in group A (non-SGF) and 47 patients in group B (SGF). The impact of SGF on renal function within the first year, long-term graft survival and post-transplantation complications were analyzed and compared using logistic regression model and Kaplan-Meier survival analysis. The incidence of graft failure at the end of follow-up period was significantly more common in SGF group (53.2% vs. 22.4%, p < 0.001). The median survival time was 140.25 (s.e.m. = 19.35) months in group A (non-SGF) and 60 (s.e.m. = 17.90) months in group B (SGF) (p < 0.001). The graft survival rate was 94.9%, 91.9%, 83.9%, 79.2%, and 72% at one, three, five, seven, and twelve yr after transplantation in children without SGF vs. 75.6%, 53.2%, 47.2%, 40% at one, three, five, and seven yr after transplantation in patients with SGF. The results of our study showed that slow graft function could remarkably affect graft survival and worsen both short-term and long-term transplantation outcomes. Thus, the prevention of SGF is one of the most important issues in graft survival improvement.

Kaposi's sarcoma following living donor kidney transplantation: review of 7,939 recipients.

INTRODUCTION: Kaposi's sarcoma (KS) is one of the most common tumors to occur in kidney recipients, especially in the Middle East countries. Limited data with adequate sample size exist about the development of KS in living kidney recipients. METHODS: Therefore, we made a plan for a multicenter study, accounting for up to 36% (n = 7,939) of all kidney transplantation in Iran, to determine the incidence of KS after kidney transplantation between 1984 and 2007. RESULTS: Fifty-five (0.69%) recipients who developed KS after kidney transplantation were retrospectively evaluated with a median follow-up of 24 (1-180) months. KS occurred more often in older age when compared to patients without KS (49 +/- 12 vs. 38 +/- 15 years, P = 0.000). KS was frequently found during the first 2 years after transplantation (72.7%). Skin involvement was universal. Furthermore, overall mortality rate was 18%, and it was higher in patients with visceral involvement compared to those with mucocutaneous lesions (P = 0.01). However, KS had no adverse affect on patient and graft survival rates compared to those without KS. Forty-four patients with limited mucocutaneous disease and four with visceral disease responded to withdrawal or reduction of immunosuppression with or without other treatment modalities. Renal function was preserved when immunosuppression was reduced instead of withdrawn in patients with and without visceral involvement (P = 0.001 and 0.008, respectively). CONCLUSION: The high incidence of KS in this large population studied, as compared to that reported in other transplant patient groups, suggests that genetic predisposition may play a pathogenetic role.

Lymphoma after living donor kidney transplantation: an Iranian multicenter experience.

INTRODUCTION: Post-transplant lymphoproliferative disorders (PTLD) are well-recognized complications in solid organ recipients. Limited data exist about the development of PTLDs in living kidney recipients. This study deals with a multicenter nationwide experience with kidney recipients from living donors. METHODS: We reviewed data of PTLD patients from a total population of 6,500 patients transplanted at three different transplant centers in Iran from 1984 to 2006. We also compared their data with 2,250 normal kidney recipients of Baqiyatallah Transplant Center. Data were analyzed to determine potential correlates with the occurrence of PTLD and patient outcome. RESULTS: Overall, 31 patients were diagnosed as having post-transplant lymphomas. The incidence of PTLD in our kidney transplant population comprised 0.47%. Sixteen (53%) PTLD patients were females, whereas 15 (47%) were males. The mean ages at transplantation and diagnosis were 37.1 and 41.9, respectively. Twelve (63%) patients died, and seven are alive. All deaths occurred within the 1st year after PTLD diagnosis. The mean time period from transplantation to diagnosis of PTLD was 64 (0.7-173) months. Localization of PTLD in the brain associated the worst outcome. Compared to non-PTLD patients, PTLD patients were significantly female predominated (51.6% vs. 32.2%; P = 0.03) and had lower age at transplantation (36.9 years vs. 42.9 years, respectively; P = 0.01). Patients under immunosuppressive regimens containing azathioprine were at higher risk for acquiring PTLDs compared to those with a MMF-containing regimen. CONCLUSION: PTLD is a major threat to kidney transplant recipients. Immunosuppressive agents have a significant role in developing the disease. Early detection of the disease and using more safe immunosuppresants may have beneficial effects on patient outcomes and incidence of the disease.

Laparoscopic management of ureteral calculi: a report of 123 cases.

INTRODUCTION: Our aim was to evaluate the efficacy and safety of laparoscopic surgery for the management of ureteral calculi. MATERIALS AND METHODS: We performed 123 laparoscopic calculus removal in 103 men and 31 women. Indications for the procedure were extracorporeal shockwave lithotripsy or transureteral lithotomy failure and large calculus. The mean age of the patients was 39.6 +/- 13.8 years. The calculi were between 1 and 5.6 cm and located in the upper, middle, and lower ureter in 90 (73.2%), 20 (16.3%), and 13 (10.5%) patients, respectively. Ureteral stent was used in 52 (42.3%) patients. We used 3 ports for camera and instruments. Intraperitoneal approach was used in 104 (84.6%) and extraperitoneal in 19 (15.4%). RESULTS: The mean operative time was 143.2 +/- 60.5 minutes. One hundred and nineteen patients (96.7%) became stone free. Minor complications occurred in 14 (11.4%) patients. Conversion to open surgery was required in 1 patient due to migration of the calculus to the peritoneum after removal from the ureter. Intra-abdominal hematoma led to reoperation 1 day after the surgery in 1 patient. Operative time was different significantly between extraperitoneal and intraperitoneal approaches (171.3 +/- 91.3 minutes and 137.3 +/- 52.2 minutes, respectively; P = .02). CONCLUSION: Our results confirm the efficacy and safety of laparoscopic removal of ureteral calculi in selected groups of patients, taking the advantage of this minimally invasive procedure such as better cosmetic results and patient's satisfaction.

Is preemptive kidney transplantation preferred? Updated study.

INTRODUCTION: For eligible patients with end-stage renal disease, the dialysis stage could be bypassed by preemptive kidney transplantation (PKT), when the organ is available. We compared this treatment option with kidney transplantation in patients with pretransplant dialysis (PTD). MATERIALS AND METHODS: We retrospectively studied on 300 patients who received PKT between 1992 and 2006 from living donors. They were compared with 300 kidney recipients with PTD matched for the time of transplantation that had been on hemodialysis for at least 6 months. Episodes of rejection, graft function, and graft and patient survivals were compared between the two groups. RESULTS: No significant differences were noted in the sex of the recipients, age and sex of the donors, donor source, and posttransplant immunosuppressive therapy, but posttransplant follow-up was longer (P < .001) and the recipients were older (P < .001) in the PTD group. Seventy-one patients (23.7%) in the PKT group and 64 (21.3%) in the PTD had at least 1 rejection (P = .49). The kidney allografts were functional in 272 (90.7%) kidney recipients in the PKT group and 278 (92.7%) in the PTD group during their follow-ups (P = .30). Five-year graft and patient survival rates were slightly higher in the PTD group, which were not statistically significant (P = .06 and P = .07, respectively). CONCLUSION: In addition to comparable patient and grretroper aft survivals with the PKT and kidney transplantations after a period of dialysis, PKT eliminates hemodialysis costs and complications. We recommend PKT as a better choice for transplantation whenever possible.

Role of laparoscopic nephrectomy for management of symptomatic nephrogenic hypertension.

OBJECTIVES: To investigate the efficacy of laparoscopic nephrectomy for the management of hypertension associated with a unilateral poorly functioning kidney in adults and the role of some variables in the prediction of its outcome in the management of nephrogenic hypertension. METHODS: We conducted this study on 22 hypertensive patients with a unilateral, minimally functioning kidney. We included patients with a well-functioned contralateral kidney, no renal tumors, no renovascular hypertension, and no diagnosis of end-stage renal disease. All patients had poorly controlled hypertension or preferred to discontinue medical therapy. Their age at the onset of hypertension, gender, age at laparoscopic nephrectomy, and the interval from diagnosis to intervention were evaluated. A complete response was defined as blood pressure normalization without medical treatment. A partial response was defined as a decrease in the medication requirements and/or a 10-mm Hg decrease in diastolic blood pressure after surgery. Measurement of plasma renin activity was not available in our country at the time of the study. RESULTS: After nephrectomy, 12 (54.5%), 2 (9.1%), and 8 (36.4%) patients had a complete, partial, or no response to the surgery, respectively. No significant association was found between the response to laparoscopic nephrectomy and age, gender, and mean blood pressure. Only the hypertension-related signs and symptoms before surgery were significantly associated with the response to laparoscopic nephrectomy (P = 0.01) on both univariate and multivariate analysis. CONCLUSIONS: Nephrectomy seems effective for the management of nephrogenic hypertension in patients who wish to discontinue medical therapy. We suggest paying attention to the preoperative hypertension-related symptoms for the prediction of the response to nephrectomy.

Deceased-donor kidney transplantation in Iran: trends, barriers and opportunities.

Having enjoyed considerable success in kidney transplantation in recent years, Iran has been named the most active country in the Middle East Society for Organ Transplantation region in providing equitable quick, and intermediary-free access to affordable kidney transplantation for everyone regardless of gender and economic circumstances. We are, however, of the opinion that the Iranian model can benefit further from improving deceased-donor kidney transplantation, especially after a fatwa (Islamic edict) in the early 1980s lifted many religious and legal barriers. Deceased-donor kidney transplantation in Iran should be bolstered by establishing a transplantation model, increasing government funds, and encouraging participation of the general public in the Iranian Network for Transplant Organ Procurement. We recommend that an intensive media campaign be launched to heighten public awareness and more transplantation centres be involved in cadaveric transplantation with streamlined systems of cadaveric donations registration so as to facilitate the process of finding and relating the donors with potential recipients.

Laparoscopic ureteropelvic junction decompression for the management of obstruction.

INTRODUCTION: We reported the outcome and complications of laparoscopic aberrant vessels transposition without performing pyeloplasty in patients with ureteropelvic stenosis. MATERIALS AND METHODS: A total of 10 patients with ureteropelvic stenosis accompanying with aberrant vessels underwent laparoscopic transposition of vessels between June 2001 and March 2003. 4 of the cases were male and 6 were female, and 4 out of 10 had right side and 6 had left side involvement. The mean age was 31.9 (14 - 59). Reaction of aberrant vessels was performed by cutting the vain and fixing the artery to the lipid layer around the kidney and renal pelvis. RESULTS: The procedure was successful in all the cases without any perioperative complications. The operative time was 2.20 hours (1.45 - 2.50) including cystoscopy, DJ placement, and transposition. Mean hospital stay was 2.9 (2-5) days, and patients were followed up an average of 9.1 (3-22) months. Except one case of rehospitalization due to pain, no complication occurred. The rate of clinical and radiological improvement was 100% and IVP showed a decrease in the degree of hydronephrosis as well as the resolution of obstruction observed in renogram. CONCLUSION: With regard to our findings, it seems, at least in a proportion of patients with UPJ stenosis accompanied with crossing vessels, that mechanical compression is the mere cause of obstruction and primary stenosis does not coexist. As a result, treatment is achieved by transposition of the crossing vessels without entering the renal unit.

The role of ureteroscopy in the treatment of renal transplantation complications.

INTRODUCTION: To determine the feasibility, safety, and efficacy of diagnostic and therapeutic ureteroscopy in renal allograft ureters. MATERIALS AND METHODS: We reviewed 1560 consecutive renal allografts have been preformed between June 1989 and February 2002.Twenty-eight patients (1.8%) had indication for endoscopic procedure on allograft ureter. Six patients had obstructive ureteral calculi with a history of failed ESWL, 3 had suspected ureteral stricture, 9 had upward migrated ureteral stents and 10 had ureteral stricture at ureteroneocystostomy site. Ureters were anastomosed to bladder using Leadbetter- Politano and Lich-GreGoire methods in 6 and 22 cases, respectively. Ureteroscopies were performed with semi rigid 9.8F wolf ureteroscope. RESULTS: Identifying and introducing the ureteral orifice was successful in 19(68%) cases. If we exclude 10 patients with ureteral stricture, ureteroscopy was successful in 13 out of 18 (72%). Four ureteral calculi (67%) were removed with ureteroscope.Seven out of nine migrated stents (78%) were retrieved. Four patients with ureteral stricture at ureteroneocystostomy site (40%) had successful ureteral dilatation and double J ureteral catheters were also inserted. Diagnostic ureteroscopy was successful in all cases. Two complications including one urinary leakage and one symptomatic urinary tract infection occurred that were managed conservatively. CONCLUSION: Ureteral endoscopy was safe and effective method for management of urological complications after RT (renal transplantation). This procedure can be considered as the first choice compared with percutaneous and antegrade modalities.

A comparison of augmentation cystoplasty before and after renal transplantation with the control group.

INTRODUCTION: We compared two surgical methods of augmentation cystoplasty (AC), before and after renal transplantation, and the outcomes of both methods with transplant patients with normal bladder function. MATERIALS AND METHODS: 1520 kidney transplantations were performed at Shahid Labbafinejad Center between March 1988 and February 2002 of which 36 cases was accompanied with AC. In 20 patients (group A) AC was performed before transplantation. This group consisted of 14 males and 6 females with a mean age of 26.1 (13-39) at the time of transplantation. Sixteen patients consisting of 11 males and 5 females (mean age 27.3, 12-44) underwent AC after transplantation. Eventually 40 transplant patients with normal bladder function were assigned in the control group including 18 males and 22 females with a mean age of 31.2 (11-55) (group C). RESULTS: Normal graft function was achieved in 16, 13, and 33 patients of groups A, B, and C respectively over the mean follow-up of 70, 59, and 76 months (p<0.7). Mean serum creatinine during the follow-up was 1.48+/-0.4, 1.7+/-1, and 1.4+/-0.55 for groups A, B, and C respectively. 9, 12, and 17 patients (26, 64, and 34 cases) with UTI requiring hospital admission were observed in the 3 groups respectively. The incident of UTI and the resultant hospitalization in group B was more than the one in group C (p<0.03), but it did not differ significantly from group A to group C. CONCLUSION: AC is a safe and effective method to improve the lower urinary system function and with the exception of increased risk of UTI following AC after transplantation (group B), there is no considerable difference in the complication rates between AC before and after renal transplantation. As a result, we can perform AC before or after kidney transplantation in patients with dysfunctional lower urinary tract system up to their specific conditions.