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Robotic-assisted kidney transplantation (RAKT) represents the most recent innovation in the evolution of kidney transplantation surgery. Vascular techniques enabling kidney transplantation have existed since the early 20th century and contributed to the first successful open kidney transplant procedure in 1954. Technical advances have since facilitated minimally invasive laparoscopic and robotic techniques in live-donor surgery, and subsequently for the recipient procedure. This review follows the development of surgical techniques for kidney transplantation, with a special focus on the advent of robotic-assisted transplantation because of its potential to facilitate transplantation of those deemed previously too obese to transplant by standard means. The different techniques, indications, advantages, disadvantages, and future directions of this approach will be explored in detail. Robot-assisted kidney transplantation may become the preferred means of transplanting morbidly obese recipients, although its availability to such recipients remains extremely limited and strategies targeting weight loss pretransplantation should never be abandoned in favor of a “RAKT-first” approach.This review describes the advent of robotic-assisted kidney transplantation, including indications, the different available techniques, advantages, disadvantages, and future directions, with particular emphasis on its potential to facilitate transplantation of those deemed previously too obese to transplant using standard surgical techniques. Supplemental digital content is available in the text.

Using the ANZDATA Living Kidney Donor Registry, the authors compare between predonation profile and national guidelines for acceptance: 26% of donors have at least 1 relative contraindication to donation and 9% have at least 1 absolute contraindication. Follow-up and reporting outcomes of these outliers is therefore mandatory.

This Australian survey shows that the community prefers a new organ donation policy that would have a simple registration process, less frequent reconfirmation of intent to donate, direct payment or reimbursement for funeral expenses, and formal recognition of donation.

Howard and colleagues analyze community perception and choices for organ allocation. In contrast to some current allocation algorithms, community respondents favored need (current life expectancy) over utility (future life expectancy). Supplemental digital content is available in the text.

Simultaneous pancreas and kidney (SPK) transplantation is performed to restore normoglycemia and renal function in patients with type 1 diabetes mellitus and end-stage renal failure. The National Pancreas Transplant Unit (NPTU) in Sydney provides a service to a population spread across 7.4 million km2. We aimed to see if SPK transplantation outcomes differed between recipients from metropolitan (M) centers and those from nonmetropolitan (NM) regions.

Despite broad community support for organ donation, there is a chronic shortage of donor organs for transplantation. This study elicited community attitudes on deceased organ donation and the current Australian organ donation system.

Management of lymphoceles after kidney transplantation is highly variable. The aim of this study was to evaluate and compare the different approaches of lymphocele management among kidney transplant recipients.

Given the disparity between static supply and increasing demand for organs, the greatest challenge is broadening access to the benefits of kidney transplantation. Organs from small deceased pediatric donors are a potentially underused resource. These may be transplanted as en bloc kidney transplants (EBKTs) to one recipient or as single kidney transplants (SKTs) to two recipients, albeit with an increased risk of graft failure.

Organs for transplantation are a scarce community resource but community preferences and how they are incorporated into allocation policies are unclear. This systematic review aimed to ascertain community preferences for organ allocation and the principles underpinning these preferences.

Immunological unresponsiveness of T cells to alloantigen can be induced by intrathymic injection of donor-specific antigen in small-animal models. Intrathymic tolerance to vascularized grafts in large animals has not previously been reported.

In a well-characterized rat model of liver transplantation, Piebald Virol Glaxo strain livers are accepted long term in fully mismatched Dark Agouti recipients (tolerance; TOL), but rejected in Lewis recipients (rejection; REJ). Spontaneous tolerance induction is associated with increased interferon- expression, and we examined the role of the interferon--inducible immunomodulatory enzyme indoleamine dioxygenase (IDO) in this model. On day 3 after transplantation, IDO expression in the spleen of TOL recipients was significantly greater than in REJ. The B-cell population accounted for this early IDO increase. Intragraft expression of IDO increased to the same extent in both TOL and REJ. IDO inhibition for 7 days after transplantation reduced survival, but did not cause acute rejection of the liver in the TOL model. In conclusion, the differential IDO expression by B lymphocytes in the spleen of TOL recipients is not critical for preventing acute rejection.

Subclinical rejection (SCR) causes chronic allograft damage, which may be prevented by antirejection therapy.

Glomerulosclerosis (GS) is characteristic of chronic allograft nephropathy and graft failure; however, its natural history and pathophysiology are poorly defined.

Chronic interstitial fibrosis (CIF) is an adverse prognostic feature of chronic allograft nephropathy.

The role and burden of cyclosporine (CsA) nephrotoxicity in long-term progressive kidney graft dysfunction is poorly documented.

Subclinical rejection (SCR) is defined as histologically proven acute rejection in the absence of immediate functional deterioration.

Chronic renal allograft failure remains a major challenge to overcome. Factors such as donor quality, delayed graft function (DGF), acute rejection, and immunosuppression are known to affect long-term outcome, but their relationship to histological damage to graft outcome is unclear.

Cataract is a major cause of visual disturbance after transplantation.Although corticosteroid therapy has been linked with posterior subcapsular cataract, its natural history in the cyclosporine era is not well understood.

Cardiovascular and cerebrovascular disease are major causes of morbidity and mortality after kidney transplantation.The aim of this longitudinal study was to examine the natural history of carotid plaque and to determine risk factors for the progression of vascular disease in uremic, type 1 diabetic patients who received a combined kidney and pancreas transplant.

The quality of a damaged kidney, the complexity of the surgery, and the events in the first weeks after transplantation, such as delayed graft function (DGF) and acute rejection, may influence its histological appearance and long-term survival. The aim of this study was to evaluate the importance of these factors in predicting renal allograft histology at 3 months.

Systemic viral disease after renal transplantation, especially after treatment with OKT3 or antithymocyte globulin, has usually been attributed to cytomegalovirus (CMV) infection. Identification of human herpesvirus 6 (HHV6) has raised the possibility that infection or reactivation of this virus may also occur in the same setting.

The effect of total-lymphoid irradiation on survival of canine pancreas and kidney allografts was studied. TLI had a marked immunosuppressive effect as measured by in vitro immune responses and reduced circulating leukocytes. Despite the changes, median graft survival times for animals treated with 800 cGy (9 days) or 1800 cGy (9.5 days) were not significantly different from untreated control animals (7 days). The addition of low-dose antithymocyte globulin (10 mg/kg/day) on post-transplant days 0, 2, 4, 6, 8, and 10 had no measurable synergistic effect. Similarly, median segmental pancreas allograft survival times after 1700–2200 cGy of TLI treatment (16.5 days) were only marginally longer than those of untreated controls (9 days). The only animal to maintain a graft for greater than 200 days was matched to the donor in mixed lymphocyte culture (MLC). This animal was able to reject a third-party skin graft after 8 days while a graft from the original donor was still surviving after 21 days when the pancreas graft failed from a chronic-type rejection. These results indicate that TLI alone or in combination with ATG will not be predictably effective as a method of prolonging allograft survival. The role of matching major histocompatibility complex antigens in TLI treatment requires clarification.

In view of the known problems that diabetic recipients have with drug absorption and of the potential advantages of the microemulsion formulation of cyclosporine (Neoral), 17 previously diabetic recipients of simultaneous pancreas and kidney allografts were studied before and after conversion from Sandimmune (SIM) to Neoral (NEO) formulations of cyclosporine a mean of 4.75±2.0 years after transplantation.

Serum creatinine is an important clinical measure of impairment of glomerular filtration rate (GFR) after kidney transplantation. The use of formulas that predict GFR (such as the Cockcroft-Gault) derived from patients with chronic renal failure and standardized against measured creatinine clearance may not be accurate when applied to kidney transplant recipients. The purpose of this study, was to investigate the level of inaccuracy and its causes and then to derive predictive GFR formulas that are appropriate to renal transplantation. Determinants of isotopic GFR, serum creatinine, and muscle mass were evaluated in consecutive kidney recipients (n146) using 99mTc DTPA GFR (n751) as a reference method. Factors that predicted GFR apart from serum creatinine included sex, height, body weight, serum urea, years on dialysis, numbers of rejections and infective episodes, and prednisolone dose. The relationship between serum creatinine and GFR was highly variable and dependent on factors that alter muscle mass and muscle catabolic rate. The relationship was further altered by ATN and chronic rejection when tubular secretion of creatinine was reduced. Three alternative GFR formulas (which can be applied to renal transplant patients according to the availability of clinical parameters) were derived and tested against six published methods of GFR estimation. Our derived formulas had the highest correlation, no overall bias, least scatter of sum of squares, and least error at low levels of GFR. They represent a better estimation of GFR in kidney transplantation than published formulas, and would allow a standardized approach to the study of longterm renal dysfunction.

Acute rejection is a frequent cause of early graft dysfunction in renal transplantation, and serum creatinine is the most important measure of clinical response. However, there is little information on serum creatinine during rejection episodes. In this study, the determinants that might influence the clinical response of serum creatinine during acute rejection were evaluated in 96 renal transplant recipients with 100 episodes of biopsy-proven rejection, by univariate and multivariate analysis. The factors assessed for their influence on serum creatinine in acute rejection included presence and severity of vascular or cellular rejection on biopsy, time taken to institute therapy, HLA mismatch, and the use of OKT3. The presence of vascular rejection on biopsy (n28) was a major determinant of impaired reciprocal area under the curve (AUC) of serum creatinine (P<0.01), and was correlated with HLA-A and -B mismatch (r0.21, P<0.05). Acute rejection associated with HLA-DR mismatch resulted in a more rapid increase of serum creatinine, a higher maximal creatinine, and a greater AUC creatinine (all P<0.05). Treatment of acute rejection with OKT3 had a beneficial effect on AUC creatinine (P<0.05) when compared with intravenous corticosteroids, by multivariate analysis. However, vascular rejection and HLA-DR mismatch had no effect on serum creatinine 1 year after transplantation. The biopsy cellular rejection score had no effect on AUC creatinine, although there was a modest effect on gradient of creatinine prior to biopsy. A minor adverse effect of delay in therapy of acute rejection could be demonstrated in the methlyprednisolone-treated subgroup. In summary, HLA-DR mismatch and the presence of vascular rejection were the most important predictors of the severity of rejection assessed by the response of serum creatinine to treatment. Appropriate antirejection therapy should be instituted promptly to optimize clinical response during acute rejection.