You have accessJournal of UrologyMisc. Benign Disease & Transplant & Renovascular (V02)1 Sep 2021V02-01 NEW TECHNOLOGIES IN ROBOT-ASSISTED KIDNEY TRANSPLANTATION: IMPROVING SURGICAL PERFORMANCES, EXPANDING THE INDICATION Alberto Piana, Angelo Territo, Andrea Gallioli, Matteo Fontana, Pietro Diana, José Maria Gaya, Oscar Rodriguez Faba, Jorge Huguet, Pavel Gavrilov, Asier Mercadé, Jose Daniel Subiela, Lluís Guirado, Carme Facundo, Andrea Bellin, Daniele Amparore, Joan Palou, Francesco Porpiglia, and Alberto Breda Alberto PianaAlberto Piana , Angelo TerritoAngelo Territo , Andrea GallioliAndrea Gallioli , Matteo FontanaMatteo Fontana , Pietro DianaPietro Diana , José Maria GayaJosé Maria Gaya , Oscar Rodriguez FabaOscar Rodriguez Faba , Jorge HuguetJorge Huguet , Pavel GavrilovPavel Gavrilov , Asier MercadéAsier Mercadé , Jose Daniel SubielaJose Daniel Subiela , Lluís GuiradoLluís Guirado , Carme FacundoCarme Facundo , Andrea BellinAndrea Bellin , Daniele AmparoreDaniele Amparore , Joan PalouJoan Palou , Francesco PorpigliaFrancesco Porpiglia , and Alberto BredaAlberto Breda View All Author Informationhttps://doi.org/10.1097/JU.0000000000001979.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Robot-assisted kidney transplantation (RAKT) has been shown promising results in grafts coming from living donation. However, this technique has two main limitations. First, grafts coming from cadaveric donors, usually reserved to patients with advanced systemic disease who often present iliac artery plaques, are excluded from RAKT because of the lack of intraoperative haptic feedback. For this reason, we introduced 3D imaging reconstruction in RAKT through the augmented reality (AR) in order to intraoperatively guide the surgeon, showing where to put the clamps and perform arteriotomy in the recipient iliac artery. Second, the regional hypothermia during rewarming time is guaranteed by intermittent ice slush insertion in the abdominal cavity, which may be suboptimal and increase the risk of ileus. To overcome this limit, we developed and tested a cold ischemia device (CID) with the aim to maintain a low and constant graft temperature while avoiding ice slush introduction. METHODS: These two projects were conducted according to IDEAL model for surgical innovation. In the first project, iliac artery anatomy together with plaques was represented in a 3D printed model. Firstly, this model was used in open kidney transplantation (OKT) setting in order to test the accuracy of the 3D reconstruction, comparing it with intraoperative tactile feedback. Subsequently, we employed this technology in the AR setting, in two cases without plaques. Finally, we tested AR in a patient with plaques. In the second project, the cooling device was developed and tested in an ex-vivo setting to assess its cooling performances. In phase 2a, the device was used in an in-vivo porcine model to evaluate the feasibility to perform both a complete OKT and RAKT. In phase 2b, CID was employed in 4 patients undergoing OKT or RAKT from living donors. Graft temperature was monitored using a thermal probe. RESULTS: The 3D-AR enabled to clamp the artery in the correct position and to find the right place to perform arteriotomy. Phase 2 demonstrated that both OKT and RAKT can be performed with the support of CID in a clinical setting, without any modification in our standard technique or perceived lengthening of the operative time. Graft temperature never exceeded 20°C. No complications related to the use of both these devices were recorded. CONCLUSIONS: These new tools were designed to overcome RAKT's main limitations, optimizing the graft cooling system and including patients with atheromatic vascular disease, paving the way to expand the indications of RAKT. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e133-e133 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Alberto Piana More articles by this author Angelo Territo More articles by this author Andrea Gallioli More articles by this author Matteo Fontana More articles by this author Pietro Diana More articles by this author José Maria Gaya More articles by this author Oscar Rodriguez Faba More articles by this author Jorge Huguet More articles by this author Pavel Gavrilov More articles by this author Asier Mercadé More articles by this author Jose Daniel Subiela More articles by this author Lluís Guirado More articles by this author Carme Facundo More articles by this author Andrea Bellin More articles by this author Daniele Amparore More articles by this author Joan Palou More articles by this author Francesco Porpiglia More articles by this author Alberto Breda More articles by this author Expand All Advertisement Loading ...

calcification. These findings demonstrate for the first time that M2 macrophagemediated IFITM3 contributes to vascular calcification through a mechanism involving transmitting Senescence signalling. CONCLUSION: Collectively, our present study demonstrated that the functional importance of M2 macrophage-IFITM3 dependent vascular calcification and provided a novel mechanistic insight to the macrophage senescence in CKD.

Kidney transplants from living donors (LDs) have a better outcome than those from deceased donors (DDs). Different factors have been suggested to justify the different outcome. In this study, we analyzed the infiltration and phenotype of monocytes/macrophages and the expression of inflammatory and fibrotic markers in renal biopsy specimens from 94 kidney recipients (60 DDs and 34 LDs) at baseline and 4 months after transplantation. We evaluated their association with medium- and long-term renal function. At baseline, inflammatory gene expression was higher in DDs than in LDs. These results were confirmed by the high number of CD68-positive cells in DD kidneys, which correlated negatively with long-term renal function. Expression of the fibrotic markers vimentin, fibronectin, and α-smooth muscle actin was more elevated in biopsy specimens from DDs at 4 months than in those from LDs. Gene expression of inflammatory and fibrotic markers at 4 months and difference between 4 months and baseline correlated negatively with medium- and long-term renal function in DDs. Multivariate analysis point to transforming growth factor-β1 as the best predictor of long-term renal function in DDs. We conclude that early macrophage infiltration, sustained inflammation, and transforming growth factor-β1 expression, at least for the first 4 months, contribute significantly to the difference in DD and LD transplant outcome.

SummaryMacrophages are involved in the development and progression of kidney fibrosis. The aim of this study was to analyse the phenotype of circulating monocytes and their ability to predict kidney allograft dysfunction in living kidney transplant recipients. Whole blood samples from 25 kidney recipients and 17 donors were collected at five time-points. Monocyte phenotype was analysed by flow cytometry, and interleukin (IL)-10 and soluble CD163 by enzyme-linked immunosorbent assay. One week after transplantation, surface CD163 and IL-10 levels increased significantly from baseline [2·99 ± 1·38 mean fluorescence intensity (MFI) to 5·18 ± 2·42 MFI for CD163; 4·5 ± 1·46 pg/ml to 6·7 ± 2·5 pg/ml for IL-10]. This CD163 increase correlated with 4-month creatinine levels (r = 0·4394, P = 0·04). However, soluble CD163 decreased significantly from baseline at 1 week (797·11 ± 340·45 ng/ml to 576·50 ± 293·60 ng/ml). CD14+CD16– monocytes increased at 4 months and correlated positively with creatinine levels at 12 and 24 months (r = 0·6348, P = 0·002 and r = 0·467, P = 0·028, respectively) and negatively with Modification of Diet in Renal Disease (MDRD) at 12 months (r = 0·6056, P = 0·003). At 4 months, IL-10 decreased significantly (P = 0·008) and correlated positively with creatinine at 2 years (r = 0·68, P = 0·010) and with CD14+ CD16– monocytes at 4 months (r = 0·732, P = 0·004). At 24 h, levels of human leucocyte antigen D-related declined from 12·12 ± 5·99 to 5·21 ± 3·84 and CD86 expression decreased from 2·76 ± 1·08 to 1·87 ± 0·95. Both markers recovered progressively until 12 months, when they decreased again. These results indicate that monitoring monocytes could be a promising new prognostic tool of graft dysfunction in renal transplant patients.

La estenosis arterial del injerto renal es una complicacion que requiere, en ocasiones, un abordaje terapeutico con cirugia o angioplastia. El objetivo del presente estudio es analizar la evolucion de 13 pacientes trasplantados renales con estenosis arterial del injerto tratados mediante angioplastia y colocacion de stent. La sospecha clinica se fundamento en un deterioro de funcion renal, acompanado de mal control de la presion arterial en algunos casos, con ecografia doppler compatible. Se realizo una arteriografia que confirmo el diagnostico y en el mismo acto se realizo una angioplastia con colocacion de stent. Se objetivo una mejoria progresiva de la funcion renal durante los 3 primeros meses que permanecio estable durante los dos primeros anos. Por otro lado, mejoraron las cifras de presion arterial en los dos primeros anos, manteniendo el mismo tratamiento antihipertensivo. En conclusion, la angioplastia con colocacion de stent es un procedimiento efectivo y seguro en el tratamiento de la estenosis de la arteria del injerto renal.

OBJECTIVE:The prevalence of traditional cardiovascular risk factors in renal transplantation is high. Studying the evolution of cardiovascular risk factors over time may help us to design better strategies to control them. The relative impact of traditional cardiovascular risk factors on allograft survival and mortality in transplant recipients is not clear. This study was performed to determine the incidence and risk factors for allograft survival and mortality among renal transplant patients.PATIENTS AND METHODS:We enrolled 250 patients who had undergone transplantation between 1980 and 2004. They were followed for various periods, and we analyzed the impact of traditional and nontraditional risk factors on renal allograft survival.RESULTS:The prevalence of hypertension was >80% during all the follow-up periods. Blood pressure diminished, antihypertensive drug prescription increased, and 15% of patients had adequate blood pressure control during follow-up. The prevalence of pretransplant diabetes mellitus was 6.8%; the incidence of posttransplant diabetes mellitus (PTDM) was 14.2%. The prevalence of PTDM increased over the course of patient evolution. The prevalence of dyslipidemia was in all cases >70%; total cholesterol and low-density lipoprotein (LDL)-cholesterol decreased; prescription of statins increased; and the percentage of patients with good lipid control also increased. The 25% prevalence of active smoking at the time of transplantation decreased to 13.6% at 10 years posttransplantation. The mean patient follow-up was 8 +/- 4.6 years. Sixty-five patients (26%) lost their grafts and 40 (16%) died during follow-up. Donor age, exercise, diastolic blood pressure, renal function, and albumin levels were independent risk factors for graft loss. Charlson comorbidity index at transplantation, recipient and donor ages, exercise, diastolic blood pressure, and LDL-cholesterol posttransplantation were independent risk factors for mortality among renal transplant recipients.CONCLUSION:Blood pressure and lipid control improved during follow-up, however, insufficiently among renal transplant patients. The prevalence of diabetes gradually increased, and the incidence of smoking cessation was low. Diastolic blood pressure, exercise, and albuminemia were the most significant modifiable cardiovascular risk factors for renal allograft survival. Diastolic blood pressure, LDL-cholesterol level, and exercise were the most relevant modifiable cardiovascular risk factors for the survival of renal transplant patients.

BACKGROUND:According to literature, patient and graft survival is better in living donor renal transplants (LRT) than in cadaver renal transplants (CRT).OBJECTIVE:To study factors that determine the best results in LRT related to those of CRT, found in univariate studies.PATIENTS AND METHODS:Renal transplants (RT) done in Catalonia during the 1990-2004 period, performed in patients over 17 years (135 LRT and 3.831 CRT), have been analyzed (retransplants were not included). The data come from the Renal Patients Transplant Registry (RMRC). Student's t-test and chi2 test have been used for mean and for proportions comparisons, respectively. To analyze univariate and multivariate survival, actuarial method and Cox regression have been used, respectively. Estimated creatinine clearance has been studied and its data have been showed through Selwood modified Analysis.RESULTS:As it happens with other great RT patients series, the RMRC analysis, globally and without any adjustment, shows that patient and graft survival in LRT is better than that obtained with CRT. When we studied which variables explain these results, we found that main factors were smaller recipient age and the short time on dialysis. The great influence of both factors has been published in a large number of papers, explaining the differences obtained on the transplanted renal patient survival.CONCLUSIONS:Once adjusted the analysis by the different factors that influence the survival of the patient and the graft, there are no differences in the obtained results, since the best outcomes of the TRV are due to factors like the smaller recipient age and the advanced TR.

When the field of transplantation was first developing, physicians worried about the teratogenicity of immunosuppressive medications and considered pregnancy ill-advised. The purpose of this study is to analyze pregnancy after kidney transplantation and their consequences on mother, graft and child. We review ten pregnant women with kidney transplantation, average of 29 years old and 44 months post-kidney transplantation. The mean glomerular filtration rate was 64 ml/min and the immunosuppression was with prednisone and tacrolimus. We analyze outcomes of different variables before and during pregnancy, and after labour. Pregnancy finished in nine of ten patients. Three patients needed cesarean section and only one patient had a miscarriage on the first term. Blood arterial pressure increased at the end of pregnancy and the creatinine level was stable with a few increase of proteinuria at the third term. We increased the tacrolimus dose to obtain the correct blood levels and any rejection was detected. We had only one patient with preeclampsia that we solved with a cesarean section. Labours were a mean of 37.2 weeks and the mean birth weight of infant was 2,809 grams. Two newborns had prematurity without structural malformations. Pregnancy after kidney transplantation is safe with prednisone and tacrolimus when the renal function is good, proteinuria doesn't exist and blood pressure is controlled.

UNLABELLED:Prophylactic and pre-emptive therapy with oral valganciclovir for cytomegalovirus infection in renal transplant recipients.BACKGROUND:Cytomegalovirus infection is a very important health problem in solid organ transplant recipients (SOT). Once-daily valganciclovir has been shown to be as clinically effective and well tolerated as oral ganciclovir tid in the prevention of CMV infection in high risk SOT recipients.METHODS:The aim of the present study was to evaluate the incidence and severity of CMV disease in 150 renal transplant recipients that received either prophylactic [high risk group (HR), N = 66] or pre-emptive [low risk group (LR), N = 84] therapy with oral valganciclovir (900 mg/day vo) for three months according to their basal risk. Patients were monitored for signs and symptoms of CMV disease and CMV plasma viral load was assessed weekly.RESULTS:A total of 31 patients (47%) of the HR and 26 patients (31%) of the LR presented a positive CMV PCR result. Twelve patients (14.3%) in the LR that had a high viral load (CMV PCR > 1,000 copies/mL) but remained asymptomatic received pre-emptive therapy. Four patients (4.7%) in the LR, after an average time of 35 days after transplant and two patients (4.5%) in the HR, after prophylactic treatment was completed, developed CMV disease. The disease was mild-moderate in most of the cases. Those patients that developed CMV disease responded to treatment with iv ganciclovir for 14 days followed by treatment with oral valganciclovir for up to three months.CONCLUSION:Prophylactic treatment with oral valganciclovir for CMV prevention is only required in high risk solid organ transplant recipients.

Introduction. We studied the renal transplantation results of living donor compared with cadaveric donor kidney transplantations.Patients and Methods. One hundred thirty-six living donor transplantations performed during, the period of 1990 to 2003 (group 1) were compared with a control group of 4304 cadaveric donor transplantations (group 2), paired 1:1. with group I patients, according to the period of transplantation, the primary renal disease, the transplant number, as well as the recipient and donor ages.Results. There were no differences regarding patient or graft survival during a 10-year follow-up.Conclusions. The benefit of performing living donor kidney transplantations is the possibility of having the donor available even before beginning dialysis treatment.

Comprehensive imaging evaluation of kidney donor anatomy is crucial for selecting candidates for living kidney transplantation and for determining the surgical technique to procure the renal graft. In 76 living renal donors we compared the results of preoperative magnetic resonance angiography (MRA) with the intraoperative findings of arterial anatomy. Donors were evaluated for the number of main renal arteries and the presence of any polar arteries. A total of 80 main renal arteries and five polar arteries were observed at MRA. At surgery, 90 main renal arteries and eight polar arteries were identified. MRA demonstrated a sensitivity, specificity, and overall accuracy of 18%, 98%, and 87%, respectively, for main arteries and 25%, 96%, and 88% for polar arteries. Eleven (14.5%) kidneys displayed more than one main artery and MRA only detected two cases. Eight kidneys had polar arteries and MRA only detected two cases. MRA is a reliable method for presurgical evaluation of renal arteries in potential donors, providing valuable information required by the surgeon. But, as the technique misses small-diameter vessels, it cannot be recommended as the sole diagnostic tool in unclear cases.

The goal of the donor evaluation is to ensure the suitability, safety and well being of the donor. In order to avoid important omissions, the evaluation of potential living kidney donors should be carried according to a protocol that includes a logical sequence of complementary explorations. Old age alone is not an absolute contraindication to donation but the evaluation should be more rigorous, because increased age may be associated with more post-operative complications after nephrectomy and renal function and long term graft survival could be shorter than the ones obtained from younger living donors. A body mass index of more than 35 kg/m2 should be an absolute contraindication to renal donation. Between 30 and 35 kg/m2 the donor evaluation should be more rigorous and it should be recommended to lose weight before nephrectomy. Hypertension is one of the most common reasons to declare a potential kidney donor unsuitable. Evidence of organ damage is an absolute contraindication to kidney donation. The donation is only reasonable when hypertension is well controlled with less than two drugs. To excluded diabetes mellitus all donors should have a fasting plasma glucose measurement. Diabetes mellitus is an absolute contraindication to living donation such as an impaired glucose tolerance or impaired fasting glucose with a family history of type 2 diabetes mellitus. Another contraindication to living donation is malignant disease, and the same standards should be adopted for cadaveric donors. The exceptions are low-grade non-melanoma skin cancer and carcinoma in situ of the uterine cervix. The presence of active infection usually precludes donation. It is very important to perform a routine test for viral infections. HIV, hepatitis B and C infection of the donor are usually a contraindication to living donor. CMV donor and recipient status should be taken into account before transplantation, and the recipients at risk for CMV disease should recieve prophylactic treatment according to the transplant unit policy.

BackgroundAt the moment, controversy has arisen about immunosuppression in aged kidney transplant recipients. We present our results on the efficacy and safety of induction treatment based on tacrolimus (FK506) and mycophenolate mofetil (MMF).Material and methodWe performed 72 transplants in patients of 60 years or older. Induction treatment consisted on (FK 506) 0.1 mg/kg/day and MMF 2 gr/day. Antilymphocyte serum was administered with delayed graft function. A total of 54 patients received kidneys from donors over 60 years old.ResultsCold ischemia time was 16.4 h (S=5.7). Delayed graft function occurred in 35 patients (48.6%). Acute rejection was observed in nine patients (12.5%). Opportunistic infections were found in 19 patients (26.4%). Seven patients died due to sudden death (1), acute myocardial infarction (1), stroke (1), infection (3), and neoplasm (1). At 1, 2, and 3 years, serum creatinine was 145, 163, and 156 mmol/l; patient survival 93%, 90%, and 90%; graft survival 93%, 90%, and 87%; and death-censored graft survival 100%, 100%, and 97%, respectively.ConclusionThese immunosuppressive guidelines appear to be efficacious and safe in kidney transplant in elderly recipients.