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.

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.

ABO antigens play an important role in solid organ transplantation. Desensitization for ABO incompatibility offers patients awaiting transplant a larger donor pool. The aim of this study was to assess outcome of desensitization using the institutional preconditioning protocol in ABO-incompatible solid organ transplants. A retrospective analysis of ABO-incompatible solid organ transplants between October 2015 and June 2018, at a tertiary healthcare center was performed. The preconditioning regimen consisted of immunosuppression and therapeutic apheresis (TA). Pre- and post-TA titers were performed, until a target titer of 8 or below was achieved, at which transplant was performed. Follow-up data till 1 year was analyzed. A total of 50 ABO-incompatible solid organ transplantations, including 14 liver transplants and 36 renal transplants were analyzed. The median baseline anti-A and anti-B titers were 192 and 256, respectively. A total of 150 therapeutic plasma exchange (TPE) procedures were performed for renal transplant recipients; 19 TPE and eight immunoadsorption procedures (five preoperative and three intraoperative) were performed for liver transplant recipients. Five (10%) patients experienced minor adverse events. Biopsy revealed antibody-mediated rejection was observed in three cases in the immediate posttransplant phase and in three (6.67%) cases over 1 year. There was one death due to transplant-associated thrombotic microangiopathy. Graft survival for renal transplant was 100% and death-censored graft survival for liver transplant was 100%. Despite difficulties, ABO-incompatible transplants can be performed without antibody-mediated rejection with the use of an appropriate protocol.

Successful renal transplantation across HLA barrier in sensitized individuals has been on the rise during the past decade, primarily due to improved desensitization regimes. The aim of this study was to share outcome of desensitization in renal transplant recipients with donor-specific anti-HLA antibodies (DSA). This was a retrospective analysis of all HLA immunized individuals who were prospective renal transplant recipients. All such patients underwent preconditioning as per the institutional desensitization protocol. Complement-dependent cytoxicity-based crossmatch (CDC-XM), luminex-based crossmatch (LM-XM) and flowcytometry-based crossmatch (FC-XM) were done in all cases. If any of these tests turned out positive, single antigen bead assay (SAB) was performed. Desensitization for DSA was performed in 55 patients and all patients were followed-up for 1 year to assess graft function and patient outcome. CDC-XM being a less sensitive assay, could not detect incompatibility in 29 (52.73%) cases. After desensitization, even though SAB and LM-XM results revealed an MFI within acceptable range, FC-XM being an extremely sensitive assay, continued to give a positive result in eight (14.55%) cases. The mean ± SD number of pretransplant TPE were 3.44 ± 0.98 (2-11). Out of 55, there were 10 patients who were lost to follow up. Patient and graft survival of 45 patients at 1 year was found to be 100%. Preconditioning for renal transplants in the form of immunosuppression with TPE is an extremely useful auxiliary for transplantation in HLA sensitized renal transplant recipients.

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.

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.

Objectives To determine the feasibility of obtaining an adequate cuff of the inferior vena cava (IVC) for vascular anastomosis during retroperitoneoscopic donor nephrectomy.Methods Between September 2004 and May 2005, a total 100 retroperitoneoscopic donor nephrectomies were performed. Fifteen cases were performed on the right side. The Endo-TA stapler was used to obtain the cuff of IVC in all cases of right-side donor nephrectomy.Results Mean warm ischemia time was 4.9 minutes (range, 2.96 to 8.0 minutes). Mean length of the cuff of IVC was 4 mm (range, 3 to 6 mm) at the upper end and 6 mm (range, 4 to 8 mm) at the lower end of the vein. All grafts functioned immediately, and there was one graft loss due to vascular rejection.Conclusions Control of the renal vein by use of the Endo-TA stapler during retroperitoneoscopic donor nephrectomy helps in obtaining a good vascular cuff of the IVC.

A Boari flap may be required to bridge long defects of the middle and lower ureter to the bladder. Laparoscopic construction of a Boari flap was performed in a patient with a ureteral stricture secondary to iatrogenic injury. The salient steps performed were spatulation of the transected ureteral end, fashioning of a Boari flap from the bladder, end-to-side anastomosis of the ureter to the flap, placement of a stent with the aid of a suction cannula, and closure of the flap over the stent. A Boari flap can be accomplished laparoscopically with minimal morbidity.