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Background: Simple renal cysts are very common in the general population (about 10.5 %) and especially in older people. They are usually small and kidneys with these lesions can be used for transplantation in selected cases. However, the presence of a “giant” cyst occuping a considerable part of the organ is a challenging situation for the transplant surgeon. Material and methods: We report the case of a DBD donor kidney with a huge cyst and review of the literature. Results: On the 8th of Novemeber 2013 we were offered a DBD kidney with a giant cyst (diameter 8.5 cm) on the inferior pole. The cyst was deroofed and frozen section performed with a diagnosis of simple cyst. There was no evidence of neoplasia and/or connection with the calyces. The cyst edges were cauterized with diathermy. The kidney was allocated to a 52 year old female patient with a BMI of 24. The post-operative course was uneventful, the graft rapidly recovered its function with no need for dialysis. The recipient was discharged home on POD X with a creatinine of 1.5 mg/dl. Renal function has been good and stable for the following 9 years (last creatinine 0.8 mg/dl) and currently the patient is in very good conditions. Conclusions: Kidneys with giant cysts can be used for transplant in selected cases, increasing the transplantable kidney pool and limiting the organ shortage. Donor and recipient’s BMI must be considered in the allocation.

Introduction: Chylous ascites is a rare complication after laparoscopic donor nephrectomy (LDN). The management of these patients is controversial and has been changing in the last years. Material and Methods: We report the first case of chylous ascites at our institution and review the literature for the possible treatments (conservative vs surgical). Results: A 51 year old female living kidney donor, with a negative past medical history underwent a left hand-assisted laparoscopic nephrectomy with an uneventful post-operative course. She was discharged home on postoperative day (POD) IV on perfect conditions. On POD IX she was readmitted with fever and abdominal pain. Abdominal CT showed a big fluid collection in the nephrectomy site. A percutaneous drain was inserted and due to high output she underwent a re-exploration the next day. Treatment consisted of clipping of the open limphatic ducts, fibrin sealant application and abdominal drain positioning. Postoperatively, the patient was treated with a nil by mouth regimen, octreotide and progressive low-fat diet. She was discharged on POD 14 in satisfactory conditions. The incidence of chylous ascites in our centre is curently 1/98 (1.02%). Conclusion: Chylous ascites is an uncommon complication after LDN. There are no guidelines available for its management. Conservative treatment can be the first line option, but surgical approach must be considered in case of high volume and/or refractary ascites in order to avoid malnutrition, immunodeficiency and donor psychological discomfort.

Background: Laparoscopic donor nephrectomy (LDN) is currently the gold standard technique for living donor nephrectomy. It is usually a straightforward operation, however, in some instances it can unexpectedly turn into a technically difficult procedure. There are no objective criteria for predicting the potential difficulty of LDN. Our aim was to validate the efficacy of a newly developed scoring system (LAPDOCTORLAParoscopic DOnor nephreCTomy scORe) for preoperative assessment of the potential technical difficulty of LDN. Materials and methods: We developed a score based on 11 parameters that in a previous pilot analysis on 78 living donors showed a significant correlation with the difficulty of the operation as perceived by the operating surgeon (BMI, male sex, abdominal girth at the umbilicus, on the 9th rib and on the anterior iliac spine, thickness of anterior and posterior perirenal fat, density of anterior perirenal fat and at the superior and inferior pole, periumbilical fat density). Each operation was graded according to the score as standard, moderately difficult, very difficult. In the present analysis we attempted the preliminary internal validation of LAPDOCTOR in 20 prospective LDNs. The scores obtained with LAPDOCTOR were blindly compared with the difficulty grades assigned by the operating surgeon. Results: LAPDOCTOR showed a correspondence of 66.6% with the surgeon’s grading and a Pearson correlation coefficient of 0.65 (standard 55.5% vs 44.4%, moderately difficult 33.3 % vs 44.4%, very difficult 11.1% vs 11.1%) with a standard deviation of 0.5 for standard and moderately difficult interventions and 0 for the very difficult cases. Conclusions: LAPDOCTOR is a very promising tool which could predict LDN difficulty and might help the surgeon in making a better evaluation of the operative risk of a living donor. These results are currently undergoing further validation in a prospective national multicentric study.

Introduction. Combination of Everolimus (EVR) with Tacrolimus (Tac) permits reduced calcineurin inhibitors exposure and, recently, has been demonstrated safe and effective. Two different once-daily Tacrolimus formulations, with different pharmacokinetic profiles are now available: ER-Tac and LCPT. Aim of this study was to compare in kidney transplant recipients (KTx), the short-term efficacy and safety of ER-Tac versus LCPT, both in combination with EVR, administered concomitantly once a day. Methods. Fifty-seven KTx were open randomized to once-daily maintenance immunosuppressive regimen based on ER-Tac + EVR + Steroids (ER-Tac+EVR, n=30) or LCPT + EVR + Steroids (LCPT+EVR, n=27). All patients received induction therapy with Thymoglobuline (total dose 200 mg). Results vMedian follow-up was 10 months (range 3-18). Here we present the intention-to-treat analysis at 6 months. There were no differences in patients as well as in graft survival. Moreover, we found no differences in renal function, acute rejection rate, CMV infection. According to the Concentration/Dose ratio of Tacrolimus, there was a significantly higher number of slow metabolizers 1-month after transplant in the LCPT+EVR group. Our data show that the two extended release Tac formulations, when administered with EVR once-daily, have comparable 6-month safety and efficacy. We can speculate that the higher number of slow metabolizers in the LCPT group may be an advantage to reach target exposure early after transplantation.

Background. Selection of the right or left living donor kidney for transplantation is influenced by many variables. In the present multi centric study including 21 Italian transplant centres, we evaluated whether centre volume or surgical technique may influence the selection process. Methods. Intra- and perioperative donor data, donor kidney function, and recipient and graft survival were collected among 693 mini-invasive living donor nephrectomies performed from 2002 to 2014. Centre volume (LOW, 1-50 cases; HIGH,>50 cases) and surgical technique (FULL-LAP, full laparoscopic and robotic; HA-LAP, hand-assisted laparoscopy; MINI-OPEN, mini-lumbotomy) were correlated with selection of right or left donor kidney and with donor and recipient outcome. Results. HIGH-volume centres retrieved a higher rate of donor right kidneys (29.3% versus 17.6%, P<0.01) with single artery (83.1% versus 76.4%, P<0.05) compared with LOW-volume centres. Surgical technique correlated significantly with rate of donor right kidney and presence of multiple arteries: MINIOPEN (53% and 13%) versus HA-LAP (29% and 22%) versus FULL-LAP (11% and 23%), P<0.001 and P<0.05, respectively. All donors had an uneventful outcome; donor bleeding was more frequent in LOW-volume centres (4% versus 0.9%, P<0.05). Conclusions. Centre volume and surgical technique influenced donor kidney side selection. Donor nephrectomy in LOWvolume centres was associated with higher risk of donor bleeding.

AIM: Aim of this study was to evaluate the association between attachment style, compliance, quality of life and renal function in adult patients after kidney transplantation. METHODS: A total of 43 adult patients who received a kidney transplant more than 3 months before were enrolled and were asked to complete two Self-Report questionnaires: Attachment Style Questionnaire (ASQ-40) and Short Form Health Survey (SF-36). Also compliance was measured using appropriate questions. RESULTS: Linear regression analysis showed associations between the confidence in relationships (ASQ-40) and compliance [beta = -0.37; B = -0.02; t(41) = -2.51; p = 0.02]; aspects of anxious attachment style (ASQ-40) and creatinine levels [beta = 0.3; B = 0.13; t(41) = 2.03; p = 0.04]; aspects of avoidant attachment style (ASQ-40) and compliance [beta = -0.37; B = -3.15; t(41) = -2.35; p = 0.02]. Patients who exhibited avoidant attachment had a significantly better perception of their own general health than patients with anxious [F(2,37) = 6.8; p < 0.05] or secure attachment; however, they had a worse perception regarding role limitations due to emotional problems, compared to patients with anxious attachment [F(2,37) = 6.4; p < 0.05]. DISCUSSION: The results of this study suggest that the evaluation of the attachment style in adult kidney transplant patients can contribute to plan a goal-directed psychological support program for these patients, in order to increase their compliance. The association between aspects of anxious attachment style and creatinine level needs more investigations.

The aim of this study was to evaluate psychological differences and quality of life between kidney recipients from living (mother) and multi-organ donor. Overall, 40 patients who had undergone both living (mother) and multi-organ kidney transplantation 3-6 months before were asked to complete four self-report instruments: Toronto Alexithymia Scale, Short Form Health Survey, Regulatory Emotional Self-efficacy, and Attachment Style Questionnaire. A greater difficulty in emotional, social, and mental health functioning was found in recipients receiving kidney from mother living donor. Moreover, in these patients, higher levels of avoidant attachment dimensions were associated with a worse quality of life.

We present a case report of visceral leishmaniasis in an elderly kidney transplant recipient (age, 73 years) with high intermittent fever in the 2 months before admission. Symptoms started 16 years after transplant. The patient received appropriate treatment with liposomal amphotericin and experienced transient increases in serum creatinine levels. Progression to dialysis was avoided with short duration of therapy (5 consecutive days, plus 1 more dose 1 week apart, a schedule alternative to 15-21 days [supported by the literature]) and a temporary reduction in tacrolimus exposure. After 4 months, recurrence of symptoms without other explanation required a second bone marrow aspirate; it revealed the persistence of amastigote forms. Visceral leishmaniasis is a potentially life-threatening infection; to the best of our knowledge, this is the oldest transplanted patient with a case of leishmaniasis described in the literature.

Extended-Release Tacrolimus Plus Everolimus or Micophenolate Mofetil in Deceased Donor Kidney Transplant Recipients: 6-Month Results of a Prospective Randomized Clinical Trial

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