INTRODUCTIONIliac lymphadenectomy is performed to provide anastomotic access during the vascular implantation procedure in renal transplantation. Iliac lymph nodes (LNs) are often enlarged, but there are no standardised guidelines for the management of incidentally enlarged LNs during transplantation. We aimed to evaluate histological findings of LNs sent for examination at our unit.METHODSPatients were evaluated in two distinct date cycles. In the first cycle, lymphadenectomy and histological assessment were performed at the discretion of the transplanting surgeon. In the second cycle, all incidentally enlarged LNs were sent for histological assessment, regardless of size.RESULTSIn the first cycle (n = 76), 11 patients (14.47%) had incidentally enlarged iliac LNs on lymphadenectomy and histology showed only reactive changes. In the second cycle (n = 165), eight patients (4.85%) had incidentally enlarged LNs on lymphadenectomy. One patient was found to have mature B cell chronic lymphocytic leukaemia. The patient was referred to haematology and a "watch and wait" approach was taken, with the patient still alive at last follow-up (511 days post-transplantation).DISCUSSIONThere are currently no published guidelines on the management of incidentally enlarged iliac LNs during transplantation. Current literature suggests that clinically significant lymphadenopathy needs to be investigated in all patients. Based on our centre's experience of a 5.26% (1 in 19) positive pathological LN sampling, we recommend that all incidental LNs with suspicious features and/or that are greater than 10mm in diameter should be considered for histological, microbiological and molecular assessment as appropriate.

Abstract Introduction During renal transplant, lymphadenectomy around the iliac vessels is performed to provide adequate access. Enlarged iliac lymph nodes have unclear clinical significance and standard guidance. We audited lymph node histopathology to evaluate their significance. Methods Two audit cycles (January to August 2020 and September 2020 to October 2021, respectively) were performed. Following the first cycle, recommendation was that all enlarged lymph nodes should be biopsied. We reviewed patient histopathology and subsequent follow-up of patients with enlarged lymph nodes. Results 241 patients underwent renal transplantation, with 19 Patients having enlarged lymph nodes (median 35mm, range 12–77mm, figure 1) sent for histopathology. Specimens from 16 patients showed benign/reactive changes (7 patients CMV positive, 14 EBV positive). Two specimens contained no lymph node. One patient (CMV and EBV positive) demonstrated evidence of chronic lymphocytic leukaemia, followed up with a bone trephine biopsy and staging CT. Staging revealed lymphadenopathy on both sides of the diaphragm and an incidental 19mm renal cell carcinoma in the native right kidney. A watch and wait strategy was employed. All 19 patients who underwent lymph node sampling were alive at last follow up. Conclusion A literature review revealed no study into the best practice for managing incidentally enlarged lymph nodes. They are of unclear significance but may represent significant pathology requiring further follow up and management. We recommend that all lymph nodes with suspicious features and/or measuring >30mm are sampled for histopathology. Take-home message Enlarged lymph nodes (>30mm) should be biopsied, as they may be associated with significant pathology requiring follow up and/or intervention.

Abstract Aim Biopsy of localised renal masses is generally accurate at detecting benign or malignant histology but can cause complications. The aim of this study was to determine the detection rate and complication rate of renal mass biopsies. Method Patients undergoing a renal mass biopsy at a single tertiary centre between January 2015 and December 2019 were identified electronically using a prospective database. Details about their biopsies were recorded including tumour size, radiological guidance, number of cores, longest margin of biopsy, accuracy of biopsy, histology type, and complications. Results This study included 334 biopsies (Median age 68 years (IQR 60-72); 61.4% (n = 204) male). Median size of tumour was 30mm (IQR 25-50) and 79.9% (n = 267) were solid masses. The biopsies were done under ultrasound (78.4%) or computed tomography (21.6%) guidance. 91.9% had core biopsies (n = 307) with median biopsy margin of 14mm (IQR 9-21). Benign histology was observed in 18.9% (n = 63), malignant in 72.1% (n = 241) while biopsy was non-diagnostic in 9.0% (n = 30). 62.6% (n = 209) of the cases were renal cell carcinoma with clear cell subtype more commonly seen (72.2%, n = 151). Complications following biopsy included haematoma (n = 7, 2.1%), haemorrhage (n = 3, 0.9%), pneumothorax (n = 1, 0.3%) and vasovagal episode (n = 1, 0.3%), resulting in an overall complication rate of 3.6%. Conclusions Biopsy of localised renal masses in this study showed a detection rate of 91% and complication rate of 3.6%. This study suggests renal mass biopsies have high diagnostic yield and low complication rate.

BACKGROUND Kidney transplantation is the definite surgical treatment for end-stage renal disease. Shortage of organs and the increasing number of patients with end-stage renal disease has led to an expansion of the selection criteria promoting the use of organs from marginal donors. Use of kidneys with renal artery aneurysm (RAA) is one such example. Description of the case: We report a case of living-related kidney transplantation from a 46-year-old female donor with unilateral RAA to her 68-year-old father. The pre-operative donor's assessment with a computed tomography angiogram revealed a saccular aneurysm of the left renal artery. The transplant team proceeded to the left nephrectomy, surgical ex vivo repair of the aneurysm and transplantation of this kidney to the recipient, with the total ischemic time of 130 minutes. At revascularization, there was no anastomotic leak with good perfusion of the organ and normal postoperative kidney function. CONCLUSION RAA is a rare renal anatomical abnormality with unproven clinical significance. Advanced microvascular surgical techniques can be used to repair the aneurysm with subsequent successful use for transplantation. Hippokratia 2016, 20(1): 90-92.

BACKGROUND:The risk of the development of renal cell cancer (RCC) in renal transplant recipients is several times higher than the general population. There can often be a delay between initial radiological imaging and patients undergoing renal transplantation. We present and evaluate the prevalence and clinical characteristics of RCC in renal transplant recipients at a single UK transplant center, with particular focus on tumors diagnosed in the immediate post-operative period, that is, likely present before transplantation.METHODS:This is a retrospective cohort study examining all renal transplant recipients with the diagnosis of RCC of native and/or graft kidneys followed up in a single UK transplant center.RESULTS:Between January 2002 and April 2014, 1386 patients underwent renal transplantation. 19 of 1386 patients had development of RCC (1.4%): 17 native and 2 graft tumors. The mean interval between pre-operative native renal imaging and transplantation was 3.5 years in 13 of 19 patients (range, 1-10 years). Six patients had no documented renal imaging before their renal transplant. The median time from transplantation to diagnosis of RCC was 5 years (range, 1 month to 30 years). In 5 patients (26.3%), RSS developed within 6 months of undergoing renal transplantation.CONCLUSIONS:In our study, we identified several patients with RCC diagnosed shortly after surgery, which raised the possibility that this was present before transplantation. With transplant recipients at increased risk of development of RCC and early detection key in the management of RCC, there appears to be a role for native renal radiological screening for patients undergoing renal transplantation.

Introduction: Evasion from immune system is one of the many steps required for tumour development and progression. In allografts tumour can either be transplanted inadvertently or develop de novo. Transplanted tumour being “nonself” to host is expected to be rejected by the immune system in the absence of any immunosuppression. Thus acute rejection could be employed as a therapeutic strategy should a tumour recur by stopping the immunosuppression. This study looks at the influence of matching and role of rejection on transplanted tumours. Methods: Luciferase labelled kidney tumour cells of Wistar origin were injected subcutaneously into either Wistar or Lewis strains mimicking a well and a poorly matched combination respectively. Animals were divided into controls with no immunosuppression and experimental group receiving one of the 3 agents (Cyclosporine, Sirolimus, leflunomide) for 2 weeks followed by treatment withdrawal to mimic acute rejection. Weekly IVIS spectrum imaging was performed to monitor the tumour behaviour.Figure: [Control animals]Results: With no immunosuppression, the transplanted tumour cells were rejected in two weeks in well matched and within one week in poorly matched animals (p < 0.001). In Cyclosporine group, only 4/8 Wistar animals rejected the tumour, while all the Lewis animals rejected the tumour within 2 weeks of treatment withdrawal (p < 0.001). In Sirolimus group, both the Wistars and Lewis rats rejected the tumour within one week of treatment withdrawal as opposed to the treatment continue group which took a total of 4 weeks of treatment to destroy the tumour (p < 0.05). In Leflunomide group, 5/7 animals rejected tumour after treatment withdrawal (Only Wistar rats were studied in this group). Control animals Conclusions: In both the controls and treatment withdrawal groups the tumour rejection was significantly stronger among poorly matched animals. Clinically, patients receiving high risk organs (eg; kidneys from patients with small RCC after ex vivo resection) could benefit from a less well HLA matching, to enable rejection “therapy” should a tumour recur in allograft.

Background: We reviewed the empirical use of antibiotics in patients with secondary haemorrhage following transurethral resection of bladder tumour. Patients and methods: A retrospective review of 2830 patients undergoing TURBT between January 2006 and April 2009 was performed from two large independent urology centres in the UK. Patients with secondary haemorrhage were identified and their urine culture results and risk factors for bleeding were studied. Result: Secondary haemorrhage causing hospital admission was seen in 2% (51 cases). However, only 14% of these cases had significant bacteriuria on urine culture. In patients with secondary haemorrhage we show potential risk factors for bacteriuria: resection weight greater than 2g (71% versus 28%), muscle invasive bladder cancer (43% versus 20%) and macroscopic residual disease (43% versus 12%); although they did not reach statistical significance. Interestingly there was no significant difference in the clinical parameters supportive of infection between patients with bacteriuria and sterile urine — in particular only 1/51 had a temperature of greater than 37.5°C. Nevertheless, 73% (37/51) of patients were treated with antibiotics. Conclusion: Typically, patients with secondary haemorrhage following TURBT do not have evidence of demonstrable infection and only a few had evidence of bacteriuria. Routine prescription of antibiotics in secondary haemorrhage following TURBT is therefore not justified.

Introduction: Transplantation has immense benefits for the recipients, but there can be some serious risks associated both in short and long terms. One such risk factor is either the development of a de-novo tumour or transmission of a tumour from the donor inadvertently. The use of immunosuppression in transplant recipients can remove the natural checks against cancerous cells by the immune system and thus the behaviour of tumours can be unpredictable. We describe a tumour transplant model to assess the behaviour of transplanted tumour in hosts in the presence of different immunosuppressive agents. Methods: Rat kidney tumour cells (BP36B) were transfected with a lentivirus based construct designed to produce stable transfects that would express both green fluorescence protein (GFP) and Luciferase. The presence of Luciferase can be detected by supplying a substrate, luciferin, which produces a bioluminescent product. The substrate can be injected into live animals and the cells expressing the luciferase be detected in real time. Fixed number of tumour cells of Wistar origin (1.8* 107) were injected subcutaneously into two different strains of rats - Wistar and Lewis; to mimic well-matched (Wistar) and poorly-matched (Lewis) groups. Animals were further divided into treatment group receiving cyclosporine and a control group with no immunosuppression. Tumour behaviour was monitored in real time with IVIS spectrum in vivo imaging system. 10-15 minutes before imaging, the animals were injected with Luciferin (substrate for Luciferase) and the anaesthetised animals were placed in a heated dark chamber and photons emitted from the labelled tumour cells were detected on an ultra sensitive CCD camera. Animals were scanned once weekly for 4-6 weeks and tumour behaviour was monitored in different experimental conditions. Cyclosporine treatment in half of the animals from both strains was stopped midway to further determine the role of rejection on transplanted tumour cells. Tumour depth was determined in some animals with 3D reconstruction and was reconfirmed after post mortem examination in palpable tumours. Results: All the animals displayed good bioluminescent signals. Due to the high sensitivity of the imaging system, we were able to monitor the tumour cells even in the absence of palpable tumour lumps. Significantly varied tumour behaviour under different experimental conditions was observed using this model. Conclusions: This model provides a highly sensitive approach of monitoring tumour behaviour under different experimental conditions even in the absence of palpable tumours. Accurate measurements for local and distant spread can be made in live animals. Furthermore post mortem analysis of the tumour cells can be done with florescent microscopy for tissue invasion and flow cytometry for hematopoietic metastasis.Figure: [Rat image]

Introduction: Recently, kidneys from patients with small renal cell carcinoma (RCC) have been used for transplantation after ex vivo resection of tumour with excellent results. Such an approach can have great potential to increase the donor pool. Concerns regarding the behaviour of the tumour (inadvertently transplanted/recurrence) under the influence of standard immunosuppression prevents this potential source from being popularised. Aim of our study was to compare the tumour behaviour with standard immunosuppression (Cyclosporine) and immunosuppressives with anti proliferative properties (Sirolimus and Leflunomide). Methods: This was a rodent tumour transplant model. Wistar rat kidney tumour cells were labelled with Green Florescent Protein (GFP) and Luciferase to enable real time in vivo monitoring of tumour cells injected into the subcutaneous tissue of Wistar/Lewis rats to mimic well matched and poorly matched groups respectively. Both strains of rats were divided into groups of 12, receiving Cyclosporine (25mg/kg), Sirolimus (2mg/kg) and Sirolimus (0.5mg/kg). Leflunomide (20mg/kg) group comprised of 14 wistar rats. After two weeks of continuous immunosuppression, these groups were further segregated by stopping immunosuppression in half of the animals to monitor the role of rejection. Tumour progression was monitored with IVIS spectrum imaging system once a week. After 4 weeks of study period the animals were humanely euthanased and isolation of splenocytes followed by Flwo cytometric analysis of CD4, CD8, NK and T regulatory cells supplemented gross post mortem findings. Results: With Cyclosporine immunosuppression, tumour continued to grow to palpable sizes among both strains, more in Wistar than in Lewis (p 0.033) for the study period. With high dose Sirolimus, the tumour was eradicated within 2 weeks in all Wistars and 3 weeks in all Lewis rats (p < 0.001 between Cyclosporine and SIrolimus groups). Both Wistar and Lewis rats receiving low dose Sirolimus also eradicated the tumour within four weeks of continuous treatment (p < 0.01 between Cyclosporine and Low dose Sirolimus). In Leflunomide group, 5/7 animals rejected the tumour within the 4 weeks of study period (p < 0.001 between Cyclosporine and Leflunomide).Figure: [Cyclosporine v Sirolimus]Conclusions: 1) Transplanted tumour continues to grow under Cyclosporine immunosuppression 2) Sirolimus (low and high dose) immunosuppression was significantly superior to Cyclosporine and Leflunomide for tumour destruction. 3) Leflunomide immunosuppression was significantly better than cyclosporine. 4) Clinically, recipients of such kidneys should perhaps be immunosuppressed with agents with anti proliferative properties eg Sirolimus to prevent/counter tumour recurrence.

INTRODUCTION: End stage renal failure is a common condition requiring renal replacement therapy in the form of haemodialysis or peritoneal dialysis as a short-term measure with renal transplantation as a more definitive treatment option. The aim of this study was to evaluate the set up of arenal transplant unit in a developed country and compare its results with other centers of the world. METHODS: A retrospective observational study was conducted to see the results of two years activities of a well known renal transplant unit in the United Kingdom. A description of the setup of a renal transplant unit has been made and its results have been discussed. RESULTS: Of the total patients, who had transplants in the renal transplant unit in year 2006 and 2007, 209 were renal, 14 were simultaneous kidneypancreas and two were pancreas after kidney transplants. Our one year graft survival rate was 93%, delayed graft function was 15%, early rejection rate was 11% and mortality rate was 3% in one year follow up. CONCLUSIONS: To attain good results in renal transplantation surgery, a multi-disciplinary team approach is crucial. Our set up is an example where the results are comparable to published and unpublished data from other established units world-wide. Keywords: complications, immunosuppression, renal transplant.