Management of metabolic alterations in adult kidney transplant recipients: A joint position statement of the Italian Society of Nephrology (SIN), the Italian Society for Organ Transplantation (SITO) and the Italian Diabetes Society (SID).

Chronic metabolic alterations such as post-transplant diabetes mellitus (PTDM), dyslipidaemias and overweight/obesity significantly impact on kidney transplant (KT) outcomes. This joint position statement is based on the evidence on the management of metabolic alterations in KT recipients (KTRs) published after the release of the 2009 KDIGO clinical practice guideline for the care of KTRs. Members of the Italian Society of Nephrology (SIN), the Italian Society for Organ Transplantation (SITO) and the Italian Diabetes Society (SID) selected to represent professionals involved in the management of KTRs undertook a systematic review of the published evidence for the management of PTDM, dyslipidaemias and obesity in this setting. The aim of this work is to provide an updated review of the evidence on the prevention, diagnosis and treatment of metabolic alterations in KTRs, in order to support physicians, patients and the Healthcare System in the decision-making process when choosing among the various available options.

Are there any relations among transplant centre volume, surgical technique and anatomy for donor graft selection? Ten-year multicentric Italian experience on mini-invasive living donor nephrectomy.

BACKGROUND: Selection of the right or left living donor kidney for transplantation is influenced by many variables. In the present multi centric study including 21 Italian transplant centres, we evaluated whether centre volume or surgical technique may influence the selection process. METHODS: Intra- and perioperative donor data, donor kidney function, and recipient and graft survival were collected among 693 mini-invasive living donor nephrectomies performed from 2002 to 2014. Centre volume (LOW, 1-50 cases; HIGH, >50 cases) and surgical technique (FULL-LAP, full laparoscopic and robotic; HA-LAP, hand-assisted laparoscopy; MINI-OPEN, mini-lumbotomy) were correlated with selection of right or left donor kidney and with donor and recipient outcome. RESULTS: HIGH-volume centres retrieved a higher rate of donor right kidneys (29.3% versus 17.6%, P < 0.01) with single artery (83.1% versus 76.4%, P < 0.05) compared with LOW-volume centres. Surgical technique correlated significantly with rate of donor right kidney and presence of multiple arteries: MINI-OPEN (53% and 13%) versus HA-LAP (29% and 22%) versus FULL-LAP (11% and 23%), P < 0.001 and P < 0.05, respectively. All donors had an uneventful outcome; donor bleeding was more frequent in LOW-volume centres (4% versus 0.9%, P < 0.05). CONCLUSIONS: Centre volume and surgical technique influenced donor kidney side selection. Donor nephrectomy in LOW-volume centres was associated with higher risk of donor bleeding.

[Apheresis in ABO-incompatible kidney transplant]. / L'aferesi nel trapianto di rene ABO-incompatibile.

Living donor kidney transplantation is the preferred therapeutic option for patients with end stage renal disease. Unfortunately, about 20-30% of potential living kidney donors are rejected because of incompatible immunological barriers such as ABO incompatibility. The newest desensitization protocols based on therapeutic apheresis and perioperative immunosuppressive drugs have allowed to overcome antibody barriers. The aim of these protocols is to wash out and suppress as many anti-A or anti-B antibodies as possible and to prevent rebound phenomena after transplantation. Standard plasmapheresis, double-filtration plasmapheresis, and selective immunoadsorption are among the most common apheresis modalities applied in ABO-incompatible transplantation. Selective immunoadsorption appears to be much safer and to have markedly increased efficacy compared with plasmapheresis, as it eliminates almost exclusively blood-group antibodies, thus avoiding plasma and coagulation abnormalities. According to the literature, long-term patient and graft survival rates are similar to those achieved with ABO-compatible kidney transplants. We have used selective immunoadsorption in two ABO-incompatible kidney transplants performed at our institution. No acute rejection was observed at 12 and 32 months' follow-up and both grafts are functioning well. Despite the widespread use of ABO-incompatible kidney transplant, however, the mechanisms of accommodation, the best desensitization protocol, the upper baseline and perioperative isoagglutinin titer limit, and the most accurate isoagglutinin measurement assay are still to be defined.

[Kidney transplantation from an ABO-incompatible living donor]. / Il trapianto di rene da donatore vivente ABO-incompatibile.

Living donor kidney transplantation is the preferred therapeutic option for patients with end stage renal disease because it provides a superior immunological compatibility, it lessens the preservation-mediated graft injury and it shortens waiting time on dialysis. Unfortunately, about 30-35% of potential living kidney donors are rejected because of incompatible immunological barriers such as ABO-incompatibility or a positive crossmatch. The newest desensitization protocols based on both therapeutic apheresis and perioperative immunosuppressive drugs allowed to overcome antibodies barriers. The aim of those protocols is to wash-out and suppress as much anti-A or anti-B antibodies as possible and to prevent the rebound phenomena after transplantation. Standard plasmapheresis, double-filtration plasmapheresis and selective immunoadsorption are among the most common apheretic modalities applied in ABO-incompatible transplantation. Furthermore, selective immunoadsorption appears to be much safer and to have markedly increased efficacy comparing with plasmapheresis being able to eliminate almost exclusively blood-group antibodies avoiding plasma and coagulation abnormalities. According to literature, long-term patient and graft survival rates are similar to those achieved by ABO-compatible kidney transplants. The comparable outcome seems related to more effective desensitization protocols as well as the protective immune mechanisms of "accommodation". We have been using selective immunoadsorption in the two ABO-incompatible kidney transplants performed in our institution. No acute rejection was experienced at 6 and 26 month follow-up and both grafts are functioning well. Despite the ABO-incompatible kidney transplant widespread use, the best desensitization protocol, the upper baseline and perioperative isoagglutinin titer limit and the most accurate isoagglutinin measurement assay are still to define.

Aponeurotic-Cutaneous Tract Exeresis in Patients With Persistent Lymphorrhea After Kidney Transplantation: A Valid Approach in a Day Surgery Setting.

BACKGROUND: Lymphatic disorders (LDs) are the most common minor complications after kidney transplantation (KT), with an incidence rate between 0.6% and 33.9%, which appears to be related to both surgical and medical factors. LDs mostly resolve spontaneously, but occasionally a surgical approach may be required. MATERIALS AND METHODS: We report our experience with 7 KT recipients who developed persistent lymphorrhea (>150 mL/24 h) between October 2017 and March 2019. All cases were treated as outpatients with parietal fistulectomy (PF). The fibrotic aponeurotic-cutaneous tract was thoroughly excised, and the residual aponeurotic defect was closed by watertight suturing. Serial abdominal ultrasounds (US) were carried out after the procedure. RESULTS: A small perirenal graft lymphocele of <2 cm was detected by US in all patients after 48 to 72 hours, without any evidence of either vascular or ureteral compression. During the subsequent scheduled US follow-up, lymphoceles did not increase in size, and additional interventions were not needed. Neither superficial nor deep surgical-site infections were recorded in such patients. CONCLUSIONS: PF was found to be a safe and effective minimally invasive approach for persistent lymphorrhea after KT. It could be easily performed with local anesthesia in a day surgery setting and did not require patient hospitalization.

Laparoscopic versus open donor nephrectomy. An appraisal on surgical outcome and post-operative course.

INTRODUCTION: Laparoscopic living donor nephrectomy (LLDN) is supposed to be safe and effective and it ensures an excellent allograft function in the recipient. The use of laparoscopic technique is rapidly spreading in most transplant programs since it offers advantages over the open procedure. Aim of our study is to evaluate both surgical outcome and post-operative course in the LLDN group comparing with an historical series of open donor nephrectomies (ODN). MATERIALS AND METHODS: From January 1992 to August 2008, 37 living donor nephrectomies were performed in our center. 23 nephrectomies were carried out, laparoscopically and 14 by open technique. Donors characteristics were comparable in both groups. RESULTS: All laparoscopic nephrectomies were performed successfully without conversion. No significant differences were observed between the two groups for both surgical complication and graft and patient survival rates. Mean warm ischemia time (p < 0.04), resumption of oral intake (p < 0.03) and length of hospital stay (p < 0.0001) were shorter in the LLDN group. Mean operative time (p < 0.036) was longer in the LLDN group, whereas time to return to work and daily activities were similar (p < 0.52). CONCLUSION: Laparoscopic nephrectomy provides some post-operative advantages over the open technique without additional surgical risk ensuring comparable graft and patient outcomes. Therefore, LLDN has become the standard approach in our transplant center. However, the laparoscopic procedure should be performed only by experienced surgical staff in order to prevent serious complications in the donors.

Implementing a Ureteric Magnetic Stent in the Kidney Transplant Setting: Report of 100 Consecutive Cases.

BACKGROUND: Kidney transplantation (KT) is the treatment of choice for end-stage kidney disease. The double-J-stent has been used to prevent urological complications (UCs), but it requires cystoscopy extraction. The novel magnetic black star (MBS) stent provided with a customized retrieval device (9 or 15 Fr) has been developed to spare cystoscopy. Scope of the paper is to analyze MBS in 100 consecutive KTs. METHODS: We report a retrospective analysis of 100 consecutive KT performed between April 2015 and September 2018 using MBS (4.8 Fr, 15 cm) to protect Lich-Gregoir ureteroneocystotomy. MBS was removed 4 weeks after KT by either the 9 Fr (61 cases) or the 15 Fr (39 cases) retrieval device. RESULTS: Intraoperative MBS insertion was straightforward in all cases, and its extraction was carried out in the outpatient setting in 93 patients. Extraction time was <30 seconds in 45 out of 61 patients (73.8%) and in 38 out of 39 patients (97.4%) using the 9 Fr and the 15 Fr retrieval device, respectively. In 15 patients, MBS removal took between 30 seconds and 3 minutes. Only 2 cases required extraction by cystoscopy. We observed 2 UC (ureteric leak and stenosis), 8 urinary tract infections, and 9 stent-related symptoms. 7 patients experienced distressing pain according to Visual Analog Scale for Pain. CONCLUSIONS: In our cohort, MBS appeared to be safe and cost-effective. We advocate its routine implementation in KT because of an easy and comfortable extraction in the outpatient setting even by nondedicated staff, without detrimental impact on UC and urinary tract infection rates.

Simultaneous kidney-pancreas transplantation: the Parma Center experience.

BACKGROUND AND AIM: Diabetes mellitus is one of the major causes of end stage renal disease. After 10-15 years from the onset 30% of diabetic patients present nephropathy, and once haemodialysis is required, morbidity is particularly high and long-term survival is lower than in non-diabetic patients. Currently, it is demonstrated that simultaneous pancreas-kidney transplantation (SPK) shows beneficial effects on patient survival, on some diabetic degenerative complications and on the quality of life. Aim of the work is to report our experience in pancreas transplantation. METHODS: From June 1998 to June 2005 17 type I diabetic uremic patients underwent SPK. Donor selection considered hemodynamically stable young patients without cardiac arrest or vasopressor drug excess and with a brief Intensive Care Unit hospitalization. Average donor age was 26 years (range 16-38). The cause of death was trauma for 14 donors (82.4%) and spontaneous cerebral hemorrhage for 3 donors (17.6%). Average pancreas cold ischemic time was 716 minutes (range 320-968). RESULTS: No patient mortality was observed. No primary or delayed graft function was observed both for pancreas and kidney. Biopsy proved the occurrence of acute rejection episode in one patient (5.8%). Five surgical (29.4%) and 2 medical (11.7%) complications developed. At a median follow-up of 36.4 months (range 4.2-88) patient survival rate was 100%. Pancreas and kidney graft survival rate was 76.5% and 94.1%, respectively. All patients referred an improvement in their quality of life. CONCLUSIONS: SPK represents a well-established therapy for uremic type I diabetes mellitus since it improves patient survival in selected recipients. Our experience, as reported in literature, confirm that a successful pancreas transplantation not only brings the recipient back to normal glycemic levels, but it also improves the patient's quality of life by stabilizing some of the secondary complications of diabetes.

Pancreas procurement technique. Lessons learned from an initial experience.

BACKGROUND AND AIM OF THE STUDY: Multiorgan procurement requires good anatomical knowledge and perfect synchronization between surgeons to ensure adequate dissection of visceral vessels. The aim of this article is to assess a technique for pancreas procurement in a multiorgan donor. METHODS: starting our program of pancreas transplantation we adopted a technique for "in situ" simultaneous recovery of pancreas, liver and small bowel when indicated. We performed 3/4 of the dissection with an intact donor circulation of the organs so taht the cold ischemia time was kept to a minimum. The technique was used in 18 multiorgan cadaveric donors during a period of 74 months. Seventeen out of 18 pancreatic grafts were transplanted simultaneously with a kidney. The small intestine was transplanted in one case and the liver in 18 cases. RESULTS: None of the transplanted pancreases sustained serious ischemic or vascular injuries. One pancreatic graft was discarded due to iatrogenic vascular injury during the procurement. Vascular surgical complications included 1 portal thrombosis, 1 iliac graft thrombosis and 1 iliac graft pseudoaneurysm. Pancreas allograft removal was necessary in 4 patients. All the retrived liver and the small intestine were successfully transplanted elsewhere. CONCLUSIONS: All except one of the pancreatic grafts retrived with this technique were of excellent quality. A perfect coordination between the different surgical equipes is mandatory in order to limit the risk of vascular injury, particulary in the presence of anatomical variations.

[Surgical overview on kidney and pancreas transplantation]. / Problemi chirurgici nel trapianto di rene e di pancreas - Position paper.

The main purpose of this paper, written by a group of Italian expert transplant surgeons, is to provide clinical support and to help through the decision-making process over pre-transplant surgical procedures in potential kidney recipients, as well as selection of pancreas transplant candidates and perioperative management of kidney recipient. Current topics such as different approaches in minimally invasive donor nephrectomy, methods of graft preservation and treatment of failed allograft were addressed.

Spontaneous renal allograft rupture without acute rejection.

Renal allograft rupture (RAR) is a rare but potentially serious complication in the transplanted recipients. The most common cause is acute rejection. We report four cases (0.5%) of RAR occurred in a series of 778 consecutive kidney transplantations due to severe acute tubular necrosis and renal vein thrombosis with no evidence of acute rejection. Transplant nephrectomy was performed in three patients, whereas graft repair was achieved in one patient. These data suggest that RAR may be associated with renal vein thrombosis or severe acute tubular necrosis in absence of acute rejection. Frequently nephrectomy is necessary, but conservative surgical treatment should be attempted to preserve the allograft in selected cases.

Incidence, diagnosis, and treatment of chylous leakage after laparoscopic live donor nephrectomy.

BACKGROUND: Chylous leakage (CL) is a rare complication of laparoscopic live donor nephrectomy (LLDN). It may lead to malnutrition and immunological deficits because of protein and lymphocyte depletion. METHODS: Data from 208 consecutive LLDN performed at two institutions, between April 2000 and September 2010, were reviewed to identify the anatomical basis behind CL along with its diagnostic and therapeutic options. RESULTS: CL developed in eight donors (3.8%), as determined by high-volume drainage (range 540-800 mL/24 hr) of triglyceride-rich fluid. All donors were managed conservatively. Seven were put on total parenteral nutrition plus octreotide. One received low-fat diet, medium-chain triglyceride supplementation, and octreotide. Chylous fistulas resolved in 5 to 16 days (mean time 12.3 days). Drains were removed before hospital discharge, and no donor was readmitted and/or needed outpatient care. CONCLUSIONS: CL is a potentially insidious and perhaps misdiagnosed complication after LLDN. It occurs in nearly 4% of LLDN and it seems to be uniquely associated to left-sided kidney recovery because of distinctive lymphatics distribution around the periaortic area of dissection. Conservative therapy is effective in most donors and should be initially attempted. Surgical ligatures or fibrin sealants may be indicated in case of refractory CL before the arising of malnutrition and/or relevant immunodeficiency.

[Multiple stones in atypical heterotopic reservoir in a patient with renal transplant: endourologic resolution]. / Calcolosi multipla di reservoir atipico eterotopico in paziente con trapianto di rene: risoluzione endourologica.

BACKGROUND: Urolithiasis is a frequent complication in a heterotopic reservoir and the surgical management could be a difficult problem. Open surgery is not recommended in patients with multiple previous surgeries. A less invasive technique, such as the endourologic procedures, would allow high stone-free rate and low surgical morbidity. INTRODUCTION: Stone formation in the reservoir is a well-known complication of urinary diversion. The incidence of lithiasis in patients with continent urinary diversion is reported as 12-52.5%. Most patients will have multiple physical factors, such as immobility, need for self-catheterization and poor urine drainage, so that it is not certain that an intestinal reservoir is the cause of stones on its own. The management of urolithiasis in continent urinary diversion can be challenging and could be a difficult problem to solve. A less invasive technique, such as the endourologic procedures, is desiderable, especially in patients with kidney transplant and low immune defence. MATERIALS AND METHODS: We present the case of a 59-year-old woman with previous history of spina bifida and with neurogenic bladder. At a pediatric age, she underwent incontinent urinary diversion using a sigmo-colic conduit. For several years she had been suffering from kidney stones and recurrent urinary infections, which led to a left nephrectomy for pyonephrosis, subsequent deterioration of renal function and dialysis. In 2004, we performed an atypical continent and self-catheterizable reservoir using the previous colic conduit detubularized and ileum-cecal tract with Mitrofanoff system conduit of 14 Fr size. Finally, kidney transplant was carried out as last surgical procedure. Recently she has come to our attention for multiple and large reservoir stones. SURGICAL TECHNIQUE: preliminary exploration of the continent pouch with flexible cystoscope. Percutaneous access with Endovision° direct control through the afferent conduit with 8 Fr flexible ureteroscope. Dilation of percutaneous tract with pneumatic balloon and positioning 30 Fr Amplats sheet. Lithotripsy, with ultrasound and ballistic sources, was performed and the residual fragments were removed with grasping. At the end of the procedure, after controlling the complete clearance with flexible nephroscope and X-ray, a percutanous 12 Fr catheter and a 12 Fr Foley in the Mitrofanoff conduit were inserted. RESULTS: No fever or increase serum creatinine were observed in the post-operative time. On day 3, we removed the percutaneous foley and after 7 days we performed a cystography with a normal pouch configuration; no leakage or residual fragments were observed. The woman was discarge and returned to usual self-catheterization. The first 3-month post-operative control was regular; no infections or pain were reported. CONCLUSIONS: In special cases, like this one, the percutaneous procedure is preferred to open surgery for a best control of the pouch and a simple complete clearence of the fragments.

Percutaneous renal artery embolisation of non-functioning allograft. Preliminary experience.

PURPOSE: Percutaneous renal artery embolisation has been introduced as an alternative to nephrectomy in patients with non-functioning allograft and Graft Intolerance Syndrome (GIS). The symptoms resulting from GIS include fever, local pain, hypertension and haematuria. MATERIALS AND METHODS: From April to October 2003, five patients were treated using this technique. The intraparenchymal renal arteries were embolized by injection of calibrated tris-acryl gelatin microspheres of increasing size (from 100-300 to 700-900 microns) and occlusion was completed by the insertion of 5mm to 8mm steel coils into the renal artery. RESULTS: The procedure was well tolerated in all cases and no major complications occurred. In 3 patients GIS-related symptoms disappeared immediately. One patient required a second embolisation due to collateral circulation arising from a lumbar artery with resolution of symptoms. In the last case, the patient underwent nephrectomy because of septic fever. CONCLUSIONS: On the basis of our preliminary experience we believe that, in selected patients, percutaneous renal artery embolisation is an effective, repeatable and minimally invasive alternative to nephrectomy with no significant serious complications.