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International audience; Kidney transplant survival is shortened by chronic rejection and side effects of standard immunosuppressive drugs. Cell-based immunotherapy with tolerogenic dendritic cells has long been recognized as a promising approach to reduce general immunosuppression. Published trials report the safety and the absence of therapy-related adverse reactions in patients treated with tolerogenic dendritic cells suffering from several inflammatory diseases. Here, we present the first phase I clinical trial results using human autologous tolerogenic dendritic cells (ATDC) in kidney transplantation. Eight patients received ATDC the day before transplantation in conjunction with standard steroids, mycophenolate mofetil and tacrolimus immunosuppression with an option to taper mycophenolate mofetil. ATDC preparations were manufactured in a Good Manufacturing Practice-compliant facility and fulfilled cell count, viability, purity and identity criteria for release. A control group of nine patients received the same standard immunosuppression, except basiliximab induction replaced ATDC therapy and mycophenolate tapering was not allowed. During the three-year follow-up, no deaths occurred and there was 100% graft survival. No significant increase of adverse events was associated with ATDC infusion. Episodes of rejection were observed in two patients from the ATDC group and one patient from the control group. However, all rejections were successfully treated by glucocorticoids. Mycophenolate was successfully reduced/stopped in five patients from the ATDC group, allowing tacrolimus monotherapy for two of them. Regarding immune monitoring, reduced CD8 T cell activation markers and increased Foxp3 expression were observed in the ATDC group. Thus, our results demonstrate ATDC administration safety in kidney-transplant recipients.

Objective: To evaluate the educational impact of a pilot MOOC (Massive Open Online Course), validated by the French College of Urology Teachers (FCUT), on the surgical technique of kidney transplantation.Materials and methods: We developed a MOOC on the surgical technique of kidney transplantation, based on a video of a surgical procedure, performed by an expert surgeon. The MOOC has been validated by the FCUT. We have created 2 student groups: 1) MOOC-pre-QCM group: visualization of the MOOC then answer to the MCQs and satisfaction questions; 2) MOOC-post-QCM group: answer to the MCQs then visualization of the MOOC then answers to the satisfaction questions. In total, 20 MCQs on the kidney transplantation technique were completed by the 2 groups. The answers were anonymous.Results: A total of 142 people answered the MCQs (MOOC-pre-QCM group (n=66) and MOOC-post-QCM group (n=76)). Twenty-nine percent (41/142) of the participants were fellows and 71 % (101/142) were residents. The proportion of fellows and residents was identical between the 2 groups. The rate of correct answers to the 20 MCQs was statistically higher in the MOOC-pre-QCM group, compared to the MOOC-post-QCM group (88.6 % versus 73.3 %, P, ObjectifÉvaluer l’impact pédagogique d’un MOOC (Massive Open Online Course) pilote, validé par le Collège français des enseignants en urologie (CFEU), sur la technique chirurgicale de transplantation rénale.Matériel et méthodesNous avons réalisé un MOOC sur la technique chirurgicale de transplantation rénale, à partir d’une vidéo d’une intervention chirurgicale, réalisée par un chirurgien expert. Le MOOC a été validé par le CFEU. Nous avons créé 2 groupes d’étudiants : 1) groupe MOOC-pré-QCM : visualisation du MOOC, puis réponse aux QCM et aux questions de satisfaction ; 2) groupe MOOC-post-QCM : réponse aux QCM, puis visualisation du MOOC, puis réponse aux questions de satisfaction. Au total, 20 QCM sur la technique transplantation rénale ont été remplis par les 2 groupes. Les réponses étaient anonymes.RésultatsAu total, 142 personnes ont répondu aux QCM (groupe MOOC-pré-QCM (n = 66) et groupe MOOC-post-QCM (n = 76)). 29 % (41/142) des participants étaient des CCA ou assistants et 71 % (101/142) étaient des internes. La proportion de CCA/assistants et d’internes était identique entre les 2 groupes. Le taux de réponses correctes aux 20 QCM était statistiquement supérieur dans le groupe MOOC-pré-QCM, en comparaison au groupe MOOC post-QCM (88,6 % contre 73,3 %, p < 0,0001). Au total, 91 % des étudiants ont trouvé le MOOC « Très Utile » ou « Utile ». La médiane de la note du MOOC, donnée par les étudiants, était de 8/10.ConclusionCette étude a montré un impact positif du MOOC sur les connaissances théoriques de la technique chirurgicale de transplantation rénale. Ce MOOC pourrait servir de projet pilote pour le développement d’autres MOOC sur la chirurgie urologique.Niveau3.

Background : The true incidence and natural history of renal artery aneurysm (RAA) remain unclear and still exists controversy over indication for treatment. Several techniques of conventional surgical reconstructions are described in literature, and more recently endovascular therapies have been reported with satisfying results and lower complication rate. This paper aims to investigate the outcomes of both endovascular and open repair of RAA achieved in a single institution involving 3 medical teams (urology, vascular surgery and neuroradiology). Material and Methods : We conducted a single-centre retrospective observational study about all patients surgically or endovascularly treated for RAA over a 15-year period. Pre-operative, procedural and post-operative data at the early, mid- and long-term follow-up were collected and analysed, focusing on operative technique used for repair and related outcomes. Results : A total of 27 patients (n = 17 (63%) women, mean age 58 ± 13.2, n = 26 saccular RAA) were included. Mean aneurysm was size was 18.8 ± 6.3 mm. Most diagnosis were accidental. Symptomatic RAA showed with macroscopic haematuria (n = 3, 25.9%), unstable hypertension (n = 2; 7%), chronic lumbar pain (n = 1, 3.7%) and renal infarct (n = 1, 3.7%). Conventional surgery (ex-vivo repair, aneurysmorraphy, aneurysm resection and end-to-end anastomosis) was performed in 14 (51.8%) cases and endovascular coiling embolization in 13 (48.2%). Mean hospital length of stay was 5.4 ± 3.6 days. Intensive Care Unit stay was needed only in the surgically treated patients (mean 1.1 ± 1.2 days). During the early follow-up, morbidity rate was 7/14 in surgically treated patients vs. 1/13 in endovascular group; it included bleeding, retroperitoneal hematoma, arterial thrombosis and bowel obstruction. The discharge imaging showed complete aneurysm exclusion and renal artery patency in all cases. At a mean follow-up of 39 ± 42 months, 3 patients (11%) were lost to follow up and 2 (7.4 %) died from unrelated cause. None of these patients required dialysis but a statistically significant (P = 0.09) decrease in GFR was noted between the preoperative period and last follow-up control. RAA repair neither showed blood pressure control improvement nor reduced the need for anti-hypertensive drug use. Conclusion : Open or endovascular techniques are both safe and efficient to treat RAA. Even though, surgical management is burdened with higher morbidity rate, the operative technique should be selected according to anatomical features, diameters and location of RRA; and the number of renal branches involved. Further larger studies are needed to define the feasibility and safety for a wider application of the endovascular approach.

Summary Introduction The objective was to evaluate, by self-questionnaire, the feeling of participants in surgical training sessions on a live porcine model. Methods A computerized questionnaire (GoogleForm ©) was sent to the members of the French Association of Urologists-in-Training (AFUF) (fellows and residents). Only questionnaires from Urologists-in-training who had participated in surgical training sessions were included. The sessions consisted of performing surgeries such as laparoscopic nephrectomies or laparoscopic cystectomies. Results Overall, 198 met the inclusion criteria. A total of 36.4% (72/198) of the participants were fellows and 63.6% (126/198) were residents. According to the participants, the main interest of sessions was to be able to train for emergency situations. A total of 79.8% (158/198) of the participants wanted surgical simulation to become compulsory. To their opinion, the main advantage of surgical simulation on a live porcine model was: technical progress in 87.4% (173/198) of cases. A total of 13.1% (26/198) of the participants found it was unethical to perform the first technical procedures on live animal models. A total of 65.7% (130/198) of the participants considered that there is currently no system of substitution. Conclusion For the participants, surgical training on a live porcine model allows technical progress while training for serious emergency situations. Surgeons and patients could benefit from this risk-free mock surgical scenario. Level of evidence 3.

Resumen El objetivo de este articulo es ofrecer una vision actualizada sobre el lugar del autotrasplante renal en el tratamiento de las afecciones renales complejas como los aneurismas de la arteria renal, las estenosis extensas del ureter y algunos tumores renales bilaterales o que se desarrollan en un rinon unico anatomico o funcional. Estas intervenciones se realizaban inicialmente por una doble via de acceso, lumbar e iliaca, o por una incision medial xifopubica. Las tecnicas quirurgicas han evolucionado mucho con la utilizacion de la laparoscopia y mas recientemente con la asistencia robotica. Han permitido que se recobre el interes por este procedimiento al disminuir la morbilidad y la mortalidad a la vez que se mantiene el mismo nivel de seguridad que con la cirugia abierta. Sin embargo, esta cirugia debe quedar limitada a centros expertos que cuenten con cirujanos experimentados tanto en el trasplante renal como en la laparoscopia robotica.

Controlled donation after circulatory death (cDCD) is used for "extended criteria" donors with poorer kidney transplant outcomes. The French cDCD program started in 2015 and is characterized by normothermic regional perfusion, hypothermic machine perfusion, and short cold ischemia time. We compared the outcomes of kidney transplantation from cDCD and brain-dead (DBD) donors, matching cDCD and DBD kidney transplants by propensity scoring for donor and recipient characteristics. The matching process retained 442 of 499 cDCD and 809 of 6185 DBD transplantations. The DGF rate was 20% in cDCD recipients compared with 28% in DBD recipients (adjusted relative risk [aRR], 1.43; 95% confidence interval [CI] 1.12-1.82). When DBD transplants were ranked by cold ischemia time and machine perfusion use and compared with cDCD transplants, the aRR of DGF was higher for DBD transplants without machine perfusion, regardless of the cold ischemia time (aRR with cold ischemia time18 h, 1.57; 95% CI 1.20-2.03, vs aRR with cold ischemia time ≥18 h, 1.79; 95% CI 1.31-2.44). The 1-year graft survival rate was similar in both groups. Early outcome was better for kidney transplants from cDCD than from matched DBD transplants with this French protocol.

Resume Introduction La penurie de transplants renaux incite au quotidien a repousser les limites d’eligibilite au don. De nombreux donneurs en etat de mort encephalique presentent une insuffisance renale aigue lors de leur deces. Est-ce une reelle contre-indication au prelevement et a une transplantation renale ? Cette etude a pour objectif d’evaluer la survie des transplants issus de donneurs en mort encephalique ayant une mauvaise fonction renale lors du prelevement. Materiels et methodes L’ensemble des 2385 transplantations realisees sur deux centres hospitaliers universitaires entre 2010 et 2017, ont ete analyses de facon retrospective. L’ensemble des patients ayant eu une mono transplantation renale issue d’un donneur en etat de mort encephalique presentant une insuffisance renale aigue (IRA) ont ete inclus dans l’analyse. L’IRA a ete definie ici par une modification de plus de 50 % du debit de filtration glomerulaire (DFG) entre l’entree en reanimation et le prelevement, jusqu’a un seuil inferieur a 45 mL/min/1,73m2 au moment du prelevement. La survie des transplants a 12 mois, la reprise retardee de la fonction (RRF) des transplants et le DFG a 12 mois ont ete analyses. Une analyse de la survie en fonction des resultats de la biopsie preimplantatoire a egalement ete realisee lorsque celle-ci etait disponible. Resultats Un total de164 patients ont ete inclus ainsi durant cette periode. A l’arrivee en reanimation le DFG moyen etait 67,7 ± 19 mL/min/1,73m2. Lors du prelevement l’âge moyen des donneurs etait de 56,4 ± 17,7 ans, le DFG etait de 33,7 ± 8,0 mL/min, 16 %(n = 26) des donneurs etaient anuriques. L’ischemie froide (IF) etait de 16,8 ± 5,0 heures. L’âge moyen des receveurs etait de 55,6 ± 14,1 ans. Il s’agissait d’une premiere transplantation dans 81 % des cas. La reprise de la fonction renale a eu lieu dans les 7,8 ± 9,4 jours apres transplantation. Il y a eu deux non fonctions primaires « primary non function » (PNF). 152 patients (93 %) avaient un transplant fonctionnel a 12 mois. Le DFG moyen a 12 mois etait de 46,8 ± 20,1 mL/min/1,73 m2 et 122 patients (73 %) avaient un DFG superieur a 30 mL/min1,73 m2. Soixante et onze pour cent des biopsies preimplantatoires objectivaient de la necrose tubulaire aigue (NTA), la survie de ces transplants etait de 85 %, comparable a la population totale (p = 0,21). Aucune necrose corticale n’a ete observee. Conclusion L’insuffisance renale aigue du donneur en etat de mort encephalique ne doit pas a elle seule etre une contre-indication au prelevement renal.

The transplantation field requires the identification of specific risk factors associated with the level of immunosuppression. Here, our aim was to analyze the association between the number of circulating lymphocytes, monitored routinely by complete blood cell counts during outpatient visits, and patient and graft survival. In total, 2,999 kidney or combined kidney-pancreas recipients transplanted between 2000 and 2016, from two University hospitals, were enrolled. We investigated the etiological relationship between time-dependent lymphocyte count beyond one year after transplantation and patient and graft survival, viral infection and cancer risk using time-dependent multivariate Cox models. Model 1 considered kidney function at one year and model 2 as time-dependent variable. At the time of inclusion (one year after transplantation), 584 patients (19.4%) had deep lymphopenia (under 750 /mm3) and 1,072 (35.7%) had a normal count (over 1,500 /mm3). A patient with deep lymphopenia at a given follow-up time had significantly higher risks of graft failure, death and viral infection than comparable patients with a normal lymphocyte count at the same time point. Thus, after the first year of transplantation, the occurrence of deep lymphopenia within a patient's follow-up is a risk factor for long-term graft failure, death and viral infection.