BackgroundImmunosuppressive agents are still inefficient in preventing biopsy-proven acute rejection (BPAR) after expanded criteria donor (ECD) kidney transplantation. The aim of this study was to investigate the relationships between early immunosuppressive exposure and the development of BPAR.

MethodsWe performed a retrospective study of 58 recipients of ECD kidney transplantation treated with enteric-coated-mycophenolate sodium, tacrolimus (Tac), and prednisone. The levels of mycophenolic acid-area under the curve (MPA-AUC) and Tac Cwere measured at the 1 week and the 1 month posttransplant, respectively. The correlation was assessed by multivariate logistic regression.

ResultsThe occurrence rates of BPAR and antibody-mediated rejection were 24.1% and 10.3%, respectively. A low level of MPA-AUC at the 1 week posttransplant was found in BPAR recipients (38.42 ± 8.37 vs. 50.64 ± 13.22, P < 0.01). In addition, the incidence of BPAR was significantly high (P < 0.05) when the MPA-AUClevel was <30 mg·h·L at the 1 week (15.0% vs. 44.4%) or the Tac Cwas <4 ng/ml at the 1 month posttransplant (33.3% vs. 21.6%). Multivariable logistic regression analysis showed that the MPA-AUC at the 1 week (OR: 0.842, 95% CI: 0.784-0.903) and the Tac Cat the 1 month (OR: 0.904, 95% CI: 0.822-0.986) had significant inverse correlation with BPAR (P < 0.05).

ConclusionsLow-level exposure of MPA and Tac Cin the early weeks posttransplant reflects an increased acute rejection risk, which suggested that MPA-AUC <30 mg·h·L and Tac C <4 ng/ml should be avoided in the first few weeks after transplantation.

Adult ; Female ; Graft Rejection ; immunology ; prevention & control ; Humans ; Immunosuppressive Agents ; chemistry ; therapeutic use ; Kidney Transplantation ; adverse effects ; methods ; Male ; Middle Aged ; Mycophenolic Acid ; chemistry ; therapeutic use ; Retrospective Studies ; Tacrolimus ; chemistry ; therapeutic use ; Time Factors

Background: Hypothermic machine perfusion (HMP) is being used more often in cardiac death kidney transplantation; however, the significance of assessing organ quality and predicting delayed graft function (DGF) by HMP parameters is still controversial. Therefore, we used a readily available HMP variable to design a scoring model that can identify the highest risk of DGF and provide the guidance and advice for organ allocation and DCD kidney assessment. Methods: From September 1, 2012 to August 31, 2016, 366 qualified kidneys were randomly assigned to the development and validation cohorts in a 2:1 distribution. The HMP variables of the development cohort served as candidate univariate predictors for DGF. The independent predictors of DGF were identified by multivariate logistic regression analysis with a P < 0.05. According to the odds ratios (ORs) value, each HMP variable was assigned a weighted integer, and the sum of the integers indicated the total risk score for each kidney. The validation cohort was used to verify the accuracy and reliability of the scoring model. Results: HMP duration (OR = 1.165, 95% confidence interval [CI]: 1.008-1.360, P = 0.043), resistance (OR = 2.190, 95% CI: 1.032-10.20, P < 0.001), and flow rate (OR = 0.931, 95% CI: 0.894-0.967, P = 0.011) were the independent predictors of identified DGF. The HMP predictive score ranged from 0 to 14, and there was a clear increase in the incidence of DGF, from the low predictive score group to the very high predictive score group. We formed four increasingly serious risk categories (scores 0-3, 4-7, 8-11, and 12-14) according to the frequency associated with the different risk scores of DGF. The HMP predictive score indicates good discriminative power with a c-statistic of 0.706 in the validation cohort, and it had significantly better prediction value for DGF compared to both terminal flow (P = 0.012) and resistance (P = 0.006). Conclusion The HMP predictive score is a good noninvasive tool for assessing the quality of DCD kidneys, and it is potentially useful for physicians in making optimal decisions about the organs donated.
Adult ; Delayed Graft Function ; Female ; Humans ; Immunosuppressive Agents ; therapeutic use ; Kidney Transplantation ; adverse effects ; methods ; Logistic Models ; Male ; Multivariate Analysis ; Odds Ratio ; Organ Preservation

BACKGROUNDRecently, the most common incision for kidney transplantation (KT) is an inverted J-shaped incision known as the "hockey-stick." However, demands for minimally invasive surgery in KT are increasing as in other various fields of surgery. Hence, we evaluated whether there is difference between minimal skin incision technique in kidney transplantation (MIKT) and conventional KT (CKT) .

METHODSBetween June 2006 and March 2013, a total of 452 living kidney transplant patients were enrolled. The MIKT group included 17 young unmarried women whose body mass index was <25 kg/m2 and had no anatomic variation. The CKT group included 435 patients. The MIKT operation technique restricted to the 10 cm-sized skin incision in the lower right abdomen from laterally below the anterior superior iliac spine to the midline just above the pubis was performed. We compared the baseline clinical characteristics and postoperative results between two groups. For proper comparison, propensity score matching was implemented.

RESULTSThere was no difference in graft function, survival, and postoperative complication rate between MIKT and CKT groups (all P > 0.05). The 5-year graft survival was 92.3% and 85.7% in MIKT and CKT groups, respectively (P = 0.786).

CONCLUSIONSOur results indicated that MIKT showed more favorable cosmetic results, and there were no statistical differences in various postoperative factors including graft function, survival, and complications compared with CKT. Hence, we suggested that MIKT is an appropriate method for selected patients in living KT.

Adult ; Female ; Humans ; Kidney Transplantation ; adverse effects ; methods ; mortality ; Living Donors ; Male ; Middle Aged ; Propensity Score ; Retrospective Studies

The optimal immunosuppressive strategy for renal transplant recipients at high immunologic risk remains a topic of investigation. This prospective single arm pilot study was undertaken to evaluate the safety and efficacy of a combined tacrolimus and sirolimus regimen in recipients at immunological high risk and to compare outcomes with a contemporaneous control group received tacrolimus and mycophenolate mofetil. Patients that received a renal allograft between 2010 and 2011 at high risk (defined as panel reactive antibodies > 50%, 4 or more human leukocyte antigen mismatches, or retransplantation) were enrolled. All patients received basiliximab induction and corticosteroids. A total of 28 recipients treated with tacrolimus and sirolimus were enrolled in this study and 69 recipients were retrospectively reviewed as a control group. The sirolimus group showed a higher, but not statistically significant, incidence of biopsy proven acute rejection and a lower glomerular filtration rate than the control group. Furthermore, sirolimus group was associated with significant increases in BKV infection (P = 0.031), dyslipidemia (P = 0.004), and lymphocele (P = 0.020). The study was terminated prematurely due to a high incidence of adverse events. A de novo tacrolimus/sirolimus combination regimen may not be an ideal choice for recipients at high immunological risk.
Adult ; Drug Therapy, Combination/methods ; Female ; Graft Rejection/diagnosis/*etiology/*prevention & control ; Humans ; Immunocompromised Host ; Immunosuppressive Agents/administration & dosage/adverse effects ; Kidney Transplantation/*adverse effects ; Longitudinal Studies ; Male ; Middle Aged ; Sirolimus/*administration & dosage/adverse effects ; Survival Rate ; Tacrolimus/*administration & dosage/adverse effects ; Treatment Outcome

This study was designed to evaluate whether sirolimus (SRL) conversion effectively improves renal function and histopathology in calcineurin inhibitor (CNI)-treated renal recipients with mild to moderate renal insufficiency. SRL conversion from CNI was performed in patients who underwent kidney transplantation from 6 months to 5 yr prior to screening. Forty-five patients were enrolled. The effect of SRL conversion on graft function was evaluated, and protocol biopsies were performed preconversion and 1 yr after conversion. Overall graft function after SRL conversion gradually improved, and the improvement in renal function was closely associated with the shorter duration of CNI exposure. When we divided the patients by the duration of CNI exposure, the patients with less than 1 yr of CNI exposure demonstrated significant improvement, but patients with a greater than 1 yr CNI exposure did not exhibit significant improvement. In contrast, protocol biopsies demonstrated no significant improvements in the modified "ah" score or other Banff scores after SRL conversion. Furthermore, the duration of CNI treatment prior to SRL conversion was not associated with histological findings 1 yr after SRL conversion. SRL conversion improved graft function in renal recipients with mild to moderate renal insufficiency, but this effect is not accompanied by histological improvement.
Adult ; Calcineurin Inhibitors/*administration & dosage ; Drug Synergism ; Female ; Graft Rejection/*etiology/*prevention & control ; Graft Survival/drug effects ; Humans ; Immunosuppressive Agents ; Kidney Transplantation/adverse effects/*methods ; Male ; Renal Insufficiency/diagnosis/*therapy ; Republic of Korea ; Severity of Illness Index ; Sirolimus/*administration & dosage ; Transplantation Tolerance/drug effects ; Treatment Outcome

Since the introduction of pancreas transplantation more than 40 years ago, surgical techniques and immunosuppressive regiments have improved and both have contributed to increase the number and success rate of this procedure. However, graft survival corresponds to early diagnosis of organ-related complications. Thus, knowledge of the transplantation procedure and postoperative image anatomy are basic requirements for radiologists. In this article, we demonstrate the imaging spectrum of pancreas transplantation with enteric exocrine drainage.
Adult ; Anastomosis, Surgical/methods ; Diagnostic Imaging/methods ; Drainage/methods ; Female ; Graft Rejection/pathology ; Graft Survival ; Humans ; Iliac Artery/radiography/surgery ; Immunosuppressive Agents ; Kidney Transplantation ; Male ; *Medical Illustration ; Mesenteric Artery, Superior/radiography/surgery ; Middle Aged ; Pancreas/*blood supply/radiography ; Pancreas Transplantation/adverse effects/*methods ; Pancreatitis, Graft/etiology ; Portal Vein/radiography/surgery ; Postoperative Complications/radiography ; Postoperative Hemorrhage/etiology ; Survival Rate

PURPOSE: Although there is no clinical evidence of nephrotoxicity with the volatile anesthetics currently used in general anesthesia, a better agent should be needed in terms of preserving postoperative renal function in living kidney donors who have only single remaining kidney. The purpose of the current retrospective, single-center study was to evaluate and compare renal function of living kidney donors after nephrectomy under either sevoflurane or desflurane anesthesia. MATERIALS AND METHODS: From January 2006 through December 2011, a total of 228 donors undergoing video assisted minilaparotomy surgery nephrectomy for kidney donation were retrospectively enrolled in the current study. The donors were categorized into a sevoflurane group or desflurane group based on the type of volatile anesthetic used. We collected laboratory data from the patients preoperatively, immediately after the operation, on the first postoperative day and on the third postoperative day. We also compared renal function of the kidney donors after donor nephrectomy by comparing creatinine level and estimated glomerular filtration rate (eGFR). RESULTS: The decrease in renal function after surgery in both groups was the most prominent on the first postoperative day. There were no significant differences between the two groups in postoperative changes of creatinine or eGFR. CONCLUSION: Sevoflurane and desflurane can be used safely as volatile anesthetics in donors undergoing nephrectomy.
Adult ; Anesthesia, General/methods ; Anesthetics, Inhalation/adverse effects/*therapeutic use ; Female ; Humans ; Isoflurane/adverse effects/*analogs & derivatives/therapeutic use ; Kidney/*physiology ; Kidney Function Tests ; *Kidney Transplantation ; *Living Donors ; Male ; Methyl Ethers/adverse effects/*therapeutic use ; *Nephrectomy ; Postoperative Complications ; Retrospective Studies

To establish a fluorescent quantitative PCR method (FQ-PCR) with TaqMan probe for simultaneous detection of polyomavirus (BKV) and cytomegalovirus (CMV) and to evaluate its clinical application in the renal transplantation recipients. The conservative sequences of BKV and CMV were targeted and amplified by nested PCR technique. The PCR products were cloned into the plasmids pcDNA3. 1(+). The recombinant plasmid containing target sequences of BKV and CMV were constructed as external standards. The TaqMan-based assay was optimized. For evaluating the assay, the sensitivity was determinated by diluted standard (5 X 103-10icopies/mL), and the specificity was verified by negative control and positive control, and the precision was assessed by intra-assay coefficient of variation (ICV) through detecting standard repeatedly (20 times). A total of 480 blood samples of renal transplantation recipients were used to detect BKV and CMV DNA simultaneously with FQ-PCR, and the concentrations of FK506 were measured by ELISA. The association of DNA copy and concentrations of FK506 was analyzed. The cloned target BKV and CMV DNA was confirmed by sequencing and analysis. The sensitivity of the FQ-PCR assay reached 5 X 103 copies/ml in detecting BKV or CMV DNA. Control DNA verified the assay specifically detecting target DNA. The precision of the assay to quantif target DNA copies was acceptable (Intra-assay CV was 3.44% for BKV and 2.23% for CMV; Inter-assay CV was 4. 98% for BKV and 3.76% for CMV;). Of 480 samples, 130 samples (27. 08%) were CMV DNA positive, significantly higher than the BKV DNA positive (13.33%, 64/480, P<0.05). The positive BKV or CMV DNA was found to be associated with high concentrations of FK506 (P<0. 05). In conclusion, the developed real-time PCR assay for detecting both CMV and BKV DNA simultaneously was s high sensitive, precise and time-effectiveand could be applied in the monitoring of the CMV and BKV infection in the renal transplantation recipients.
Adolescent ; Adult ; Aged ; Conserved Sequence ; Cytomegalovirus ; genetics ; isolation & purification ; Cytomegalovirus Infections ; diagnosis ; virology ; DNA, Viral ; blood ; Female ; Humans ; Immunosuppressive Agents ; blood ; Kidney Transplantation ; adverse effects ; Male ; Middle Aged ; Polyomavirus ; genetics ; isolation & purification ; Polyomavirus Infections ; diagnosis ; virology ; Real-Time Polymerase Chain Reaction ; methods ; Reproducibility of Results ; Sensitivity and Specificity ; Species Specificity ; Tacrolimus ; blood ; Time Factors ; Tumor Virus Infections ; diagnosis ; virology ; Viral Load ; Young Adult

INTRODUCTIONThe incidence of lymphoceles - lymphatic collections around a transplanted kidney - can be as high as 20%. We aimed to review the presentation, treatment and outcome of patients with lymphoceles.

METHODSWe reviewed a prospective database of 154 patients who underwent renal transplantation at our hospital from January 2005 to November 2008.

RESULTSThe mean age of the patients in our cohort was 46 (range 34-58) years. The incidence of lymphoceles in our series was 5.8% (n = 9). The median onset was 19 (range 6-28) days post-transplantation, while the median size of the lymphoceles was 5 (range 1.5-8) cm. Lymphoceles were most commonly found at the lower pole of the transplanted kidney. Eight patients with lymphoceles had received cadaveric transplants. While a majority of these patients did not have hydronephrosis on presentation, four had markedly elevated creatinine. Of the nine patients with lymphoceles, six were on macrolides (tacrolimus, sirolimus or everolimus), two were successfully managed conservatively, three were managed percutaneously and four required surgical drainage via either laparoscopic marsupialisation (n = 1) or open drainage (n = 3). There was no graft loss.

CONCLUSIONIt remains unknown whether the choice of immunosuppressants increases the risk of lymphocele formation. Intervention is necessary in the case of impaired drainage of the pelvicalyceal system in these patients. Minimally invasive intervention, while effective in treating lymphoceles, does not provide definitive treatment. Surgical intervention should be considered early for the treatment of post-transplantation patients with lymphoceles, so as to shorten hospital stay and prevent further complications.

Adult ; Databases, Factual ; Drainage ; adverse effects ; Female ; Humans ; Immunosuppressive Agents ; therapeutic use ; Incidence ; Kidney Transplantation ; methods ; Laparoscopy ; Lymphocele ; complications ; diagnosis ; Male ; Middle Aged ; Postoperative Complications ; Prospective Studies ; Renal Insufficiency ; complications ; therapy ; Treatment Outcome

BACKGROUNDCytomegalovirus (CMV) remains a significant clinical problem among immunosuppressed renal transplant patients. Quantitative PCR assays have become the most common methods in the determination of CMV infections in transplant patients. This study was to determine the relationship between CMV infection and the acute rejection of the transplanted kidney.

METHODSPlasma samples from 77 renal transplant patients that were pre-transplant negative for CMV infection were tested using real-time quantitative PCR and CMV gene-specific primers. The detected viral loads were retrospectively compared with the acute rejection rate and the chronic or mild rejection rates of the renal transplant.

RESULTSCMV-DNA was detected in 29 of 77 recipients, yielding a positive rate of detection of 37.7% for this procedure. Twelve of the 21 recipients (57.1%) who suffered acute rejection had positive CMV-DNA. Among the 56 recipients suffered from chronic or mild rejection, 17 (30.4%) had positive CMV-DNA plasma. Moreover, of the 29 recipients who had detectable CMV-DNA after transplant, 12 (41.4%) suffered from acute rejection; of the 48 recipients with undetectable CMV-DNA, only nine (18.8%) developed acute rejection. Post-transplant patients with acute rejection had a higher rate (57.1% vs. 30.4%, P = 0.03) of post-transplant CMV infection than those with chronic or mild rejection.

CONCLUSIONCMV infection is a risk factor of acute renal transplant rejection and CMV infection should be prevented and treated in renal transplant recipients.

Adult ; Cytomegalovirus Infections ; diagnosis ; genetics ; DNA, Viral ; genetics ; Female ; Humans ; Kidney Transplantation ; adverse effects ; Male ; Middle Aged ; Real-Time Polymerase Chain Reaction ; methods ; Viral Load ; Young Adult