ABSTRACTBackgroundWe aimed to investigate the outcome of patients after RDN at different time points.MethodsWe studied the outcomes of 77 living robotic living donor nephrectomies (RDN). Donors were separated into three groups: learning curve period (LCP), stabilisation period (SP), and teaching period (TP).ResultsThere were significant differences in blood loss and hospitalisation times between the three groups. Operative time was significantly shorter in the LCP group compared with the SP and TP groups (282 ± 51.6 min vs. 308 ± 38.7 min vs. 314 ± 28.7, p = 0.02). However, warm ischaemia time was shorter in the TP group compared with the LCP and SP groups (5.0 ± 3.6 min vs. 3.4 ± 3.2 min vs. 1.5 ± 1.3 min, p < 0.01). Complication rates were higher in the LCP group compared with the SP and TP groups (p = 0.04).ConclusionThis study demonstrated that RDN outcomes improve after the learning period.

ABSTRACT Glucagon-like peptide 1 (GLP-1) analogs are used to treat type 2 diabetes, and they can regulate insulin secretion, energy homeostasis, inflammation, and immune cell function. This study sought to determine whether the GLP-1 analog liraglutide exerts a beneficial action in an acute lung injury model of pneumonia-induced sepsis. Methods: Wild-type FVB/NJ mice (n = 114) were infected by intratracheal injection with Pseudomonas aeruginosa Xen5 (4 × 104 CFU/mouse) or an equal volume (50 μL) of saline (control) with or without a subcutaneous injection of liraglutide (2 mg/kg, 30 min after infection). Mice were killed 24 h after infection. Lung tissues and BALF were analyzed. In separate experiments, the dynamic growth of bacteria and animal mortality was monitored using in vivo imaging system within 48 h after infection. In addition, primary lung alveolar type II cells isolated from mice were used to study the mechanism of liraglutide action. Result: Liraglutide improved survival (P < 0.05), decreased bacterial loads in vivo, and reduced lung injury scores (P < 0.01) in septic mice. Liraglutide-treated mice showed decreased levels of inflammatory cells (P < 0.01) and proinflammatory cytokines (TNF-α and IL-6) (P < 0.01) in the lung compared with septic controls. Liraglutide significantly increased pulmonary surfactant proteins (SP-A and SP-B) expression/secretion (P < 0.01) and phospholipid secretion (P < 0.01) in vivo. Primary alveolar type II cells pretreated with liraglutide improved SP-A and SP-B expression after LPS exposure (P < 0.01). Conclusion: Liraglutide attenuates mortality and lung inflammation/injury in pneumonia-induced sepsis. The increased surfactant expression/secretion and anti-inflammatory effects of liraglutide represent potential mechanisms by GLP-1 agonists potentiate host defense and maintain alveolar respiratory function in acute lung injury.

OBJECTIVES:Ureteral strictures after kidney transplant are an uncommon but significant cause of morbidity. This systematic literature review investigated risk factors for ureteral stricture formation after renal transplant and overall rate of strictures after renal transplant. MATERIALS AND METHODS:We used PubMed, Medline, and Cochrane Library to search for relevant articles concerning renal transplant and posttransplant complications (ureteral stricture). We included the key words "kidney transplant" OR "renal transplant" AND "ureteral stenosis/stricture" AND "adults." We selected (1) clinical studies involving ureteral strictures following renal transplant; (2) studies with outcomes that included ureteral stricture rate; and (3) studies that had preoperative data on mean donor patient age, sex, and donor type (living or deceased). Case reports, case series, letters to the editors, and nonEnglish articles were excluded. RESULTS:We identified 455 articles initially; 356 articles were screened, and 13 original articles were included in the study. Together, the studies reported on 292 posttransplant ureteral strictures. Kidney graft multiplicity (P = .02), donor age (P < .001), stentless procedures (P = .04), recipient age (P < .001), donation after circulatory death (P = .04), cold ischemia time (P = .027), warm ischemia time (P = .05), history of nephrolithiasis (P = .001), history of prostate conditions (P = .024), history of bladder recatheterization (P = .006), history of bladder outlet obstruction (P = .007), double kidney transplant (P = .037), and panel reactive antibodies were associated with posttransplant ureteral stricture formation. Mean ureteral stricture rate was 0.08 ± 0.04 (range, 0.34%-65%). Mean period from transplant to stricture formation was 17 ± 24 months. Mean followup was 36 ± 16 months. CONCLUSIONS:Ureteral stricture can potentially affect graft function and patient outcomes. Understanding and managing the risk factors associated with ureteral stricture are crucial for improving posttransplant prognosis.

INTRODUCTION:This study examines the effect of belatacept based salvage regimens on kidney transplant outcomes. METHODS:This single-center retrospective study included all adult kidney transplant recipients between 2011 and 2022 who were converted to belatacept salvage therapy during their follow up. eGFR, graft survival, incidence of infections and neoplasia, histology and DSA data were collected through systematic review of the medical record. RESULTS:Patients were divided into 3 groups based on salvage regimen: Mycophenolate mofetil/belatacept (MMF/Bela) (n = 28), low-dose Calcineurin inhibitors/belatacept (CNI/Bela) (n = 22), and low-dose Calcineurin inhibitors/ Mycophenolate mofetil /belatacept (CNI/MMF/Bela) (n = 13). Patients with antibody-mediated rejection were more likely to receive CNIs in addition to belatacept (low-dose CNI/MMF/Bela 54%, low-dose CNI/Bela 45%, MMF/Bela 3.6%, p < 0.001). DSA decreased in all groups after transition to belatacept by 15.67% (p = 0.15). No difference in Glomerular filtration rate (eGFR) over time was observed between the groups, and eGFR remained stable over the first year after transition to belatacept. The incidence of death and allograft failure was similar between the groups (low- dose CNI/MMF/Bela n = 3, low-dose CNI/Bela n = 7, MMF/Bela n = 4; p = 0.41). Patients in the low-dose CNI/Bela cohort who were transitioned to belatacept within 6 months from transplant showed a decline in eGFR over the first year after transition, while the other treatment cohorts demonstrated stable or slight increase in eGFR. CONCLUSIONS:The present study demonstrates comparable transplant outcomes in terms of eGFR, graft survival, incidence of infections and neoplasia, rejection rate and donor specific antibody (DSA) in three belatacept-based maintenance immunosuppression regimens supporting the safety and efficacy of these therapeutic options.

Abstract Background: We aimed to investigate how surgeon experience in different time points impact donors’ outcome. Methods: This is a retrospective study comparing outcome of 77 living kidney donors who had robotic living donor nephrectomies (RDN) performed at a single institution. Donors separated into three groups: 25 patients constituting the learning curve period (LCP), 25 patients constituting the stabilization period (SP), and the 27 patients constituting the teaching period (TP). The groups were compared by collecting data on pre-, intra- and postoperative parameters and costs. Results: Among the three RDN groups, there were significant differences in blood loss (102 mL vs 39 mL vs 41 mL, p=0.01), intra-operative fluids administration (3.2 L vs 3.1 L vs 2.7 L, p=0.45), hospitalization times (2.96 days vs 1.92 days vs 1.85 days, p<0.01), and morphine milligram equivalents (MME) (2068 vs 375 vs 222, p<0.01). Operative time was significantly shorter in the LCP group compared to the TP group (282 min vs 308 min vs 314, p=0.02). However, warm ischemia time was shorter in the TP group compared to the LCP group (5.0 min vs 3.4 min vs 1.5 min, p<0.01). Complication rates were significantly higher in the LCP group compared to the SP and TP groups (p=0.04), but readmission within 30 days was similar at all surgical time points(p=0.58). Surgical costs ($73,756 vs $82,949 vs $91783, p<0.01) were higher in both the SP and TP groups. Conclusion: This study has demonstrated that RDN outcomes improve significantly after the initial learning curve of the technique.

OBJECTIVES:Transplant of kidneys from donors with acute kidney injury has shown favorable outcomes. We investigated the outcomes of kidney transplant recipients with deceased donors who developed acute kidney injury before organ procurement.MATERIALS AND METHODS:We retrospectively reviewed the medical records of recipients from January 2016 to December 2021 in a single center. Outcomes in recipients of kidney grafts from donors with and without acute kidney injury were compared.RESULTS:The mean follow-up time was 40 months. Our study included 129 (34%) kidneys transplanted from donors with acute kidney injury and 251 (66%) kidneys from donors without acute kidney injury. Delayed graft function rate in recipients was 33% in the acute kidney injury group and 25.5% in the group without acute kidney injury (P = .099). Readmission rate at 30 days was significantly higher among recipients of kidneys with acute kidney injury compared with recipients of kidneys without acute kidney injury (45% vs 33.5%; P = .02). The mean overall costs of transplant in the acute kidney injury group were comparable to the group without acute kidney injury ($253 865 vs $253 611; P = .97). The acute rejection rate was comparable between the 2 groups (4% in both groups; P = .96). Delayed graft function rate was increased with increased stage of acute kidney injury (18% stage 1, 45% stage 2, 36% stage 3; P = .03). However, the overall length of hospital stay and costs were comparable among recipients of different stages of acute kidney injury.CONCLUSIONS:Our study showed that kidney transplants from donors with acute kidney injury have early and late outcomes comparable to kidney transplants from donors without acute kidney injury. Allografts from donors with acute kidney injury can be used safely and can expand the donor pool in kidney transplant without increasing perioperative resource utilization.

Hyperacute rejection is a rare complication of renal transplantation. It is mainly caused by preformed human leukocyte antigen antibodies and can lead to the loss of the transplanted kidney. Renal transplantation is a highly beneficial treatment for people with end-stage renal disease, greatly improving their quality of life. However, antibody-mediated rejection is a significant challenge for the long-term survival of transplanted kidneys. An 18-year-old male with nephrotic syndrome, who underwent bilateral renal nephrectomy due to severe proteinuria, received a living donor kidney. Pretransplant panel reactive antibodies were low. Cytotoxic T- and B-cell and non-HLA cross-match was negative. The graft became cyanotic and mottled within half an hour of transplantation. Allograft was quickly extracted, and a biopsy showed hyperacute rejection. The patient was treated with plasmapheresis, intravenous immunoglobulin, and eculizumab. The graft was successfully re-implanted after 18 hours. Further treatment included additional sessions of plasmapheresis, intravenous immunoglobulin, eculizumab, T-cell-depleting agent, and immunosuppressive therapy. Serum creatinine became stable, and renal biopsy after one month demonstrated intact parenchyma with no inflammation or fibrosis. This case highlights the critical importance of promptly removing the transplanted kidney and using aggressive immunotherapy to save renal allografts in cases of hyperacute rejection.

Background: The deceased donor kidney allocation system (KAS) aims to optimize and equalize organ access for candidates nationwide and facilitate organ matching for candidates who are harder to match due to biological reasons. In March 2021, UNOS implanted a new allocation of KT based on distance from the donor hospitals. A distance within 250 nautical miles will receive additional proximity points to access KT. Material and Method: This retrospective single-center study assessed the Cold ischemic time (CIT) and Delayed graft function (DGF) in allograft kidneys from January 2014 to December 2020. We studied 221 import KT, compared the outcomes to locally procured KT (n = 160), and finally compared the patients and graft survival rates in 1-year and 5-years. Results: Donor and recipient demographics were similar in both groups. Induction and maintenance immunosuppression was similar in both groups. CIT was significantly higher in the imported group (27.6 vs. 15.9 h, p< 0.0001). However, distance did not impact CIT significantly (R2= 0.07) in the imported KTs. Distance also did not impact the rate of DGF in both groups (imported 21% vs. 22%, p = 0.74). Patient and graft survivals were similar in the imported vs. local group. Conclusions: We conclude that distance alone does not correlate with CIT and DGF and it is not a great single predictable factor for the outcomes. There are many logistical factors and OPO factors that have a significant impact on CIT and DGF occurrence, which should be considered, and the new UNOS allocation changes can help in terms of equal distribution of available allografts.

BACKGROUND:Belatacept has been demonstrated as an effective alternative immunosuppressant in kidney transplant recipients. This study focuses on outcomes of early and late conversion to Belatacept-based immunosuppression after kidney transplant. MATERIALS AND METHODS:This retrospective analysis of a prospectively collected database included all adult kidney transplants patients at SUNY Upstate Medical Hospital from 1 January 2014 to 30 December 2022. Early conversion was defined as all conversions done at <6 months after kidney transplantation, and late conversion to belatacept was defined as conversion at >6 months after kidney transplantation. RESULTS:Out of 61 patients included in this study, 33 patients (54%) were in the early conversion group, and 28 patients (46%) were in the late conversion group. The mean eGFR in the early conversion group was 26.73 ± 16.26 ml/min/1.73 m2 before conversion to belatacept, which improved to 45.3 ± 21.01 ml/min/1.73 m2 at one-year post-conversion (p = 0.0006). Furthermore, eGFR changes in the late conversion group were insignificant, with 46.30 ± 15.65 ml/min/1.73 m2 before conversion to belatacept, and 44.76 ± 22.91 ml/min/1.73 m2 after one year of follow-up (p = 0.72). All four biopsy-proven allograft rejections in the early conversion group were acute T-cell-mediated rejections (ATMR). In the late conversion group, out of three biopsy-proven rejections, one was chronic antibody-mediated rejection (CAMR), one was ATMR, and one was mixed ATMR/CAMR. All four patients with ATMR rejection received mycophenolic acid (MPA) as part of their immunosuppressive regimen, and none received tacrolimus. The one-year post-conversion allograft survival rate in early and late conversion groups was 100%. However, the one-year post-conversion patient survival rate was 90.9% in the early conversion group and 100% in the late conversion group (P = 0.11). CONCLUSIONS:Early post-transplant conversion to belatacept can improve the eGFR more meaningful when compared to late conversion. Patients who receive belatacept and MPA rather than tacrolimus may have increased rates of T-cell-mediated rejection.

OBJECTIVES:Chylous ascites is a rare complication that may occur after living donor nephrectomy. The continuous loss of lymphatics, which carries a high risk of morbidity, may ensue in possible immunodeficiency and protein-calorie malnutrition. Here, we presented patients who developed chylous ascites after robotassisted living donor nephrectomy and reviewed the current literature of therapeutic strategies for chylous ascites.MATERIALS AND METHODS:We reviewed the medical records of 424 laparoscopic living donor nephrectomies performed at a single transplant center; among these, we studied the records of 3 patients who developed chylous ascites following robot-assisted living donor nephrectomy.RESULTS:Among 438 living donor nephrectomies, 359 (81.9%) were laparoscopic and 77 (18.1%) were by robotic assistance. In the 3 cases highlighted in our study, patient 1 did not respond to conservative therapy, which consisted of diet optimization, total parenteral nutrition, and octreotide (somatostatin). Patient 1 subsequently underwent robotic-assisted laparoscopy with suture ligation and clipping of leaking lymphatic vessels, allowing the chylous ascites to subside. Patient 2 similarly did not respond to conservative treatment and developed ascites. Despite initial improvement after wound interrogation and drainage, patient 2 had continued symptoms, resulting in diagnostic laparoscopy and repair of leaky channels leading to the cisterna chyli. Patient 3 developed chylous ascites 4 weeks postoperatively and received ultrasonographic-guided paracentesis by interventional radiology, with results showing an aspirate consistent with chyle. The patient's diet was optimized, allowing for initial improvement and eventual return to normal diet.CONCLUSIONS:Our case series and literature review demonstrate the importance of early surgical intervention after failed conservative management for resolution of chylous ascites in patients after robotassisted donor laparoscopic nephrectomy.