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Introduction: The left kidney is often preferred for living donor kidney transplantation because of its anatomical advantages. However, the right kidney may be procured due to donor conditions. Few studies have assessed the safety and graft outcome of right retroperitoneal laparoscopic donor nephrectomy (RDN). This study aimed to compare the outcomes between right and left RDN with respect to donor outcome and the graft function of recipients. Methods: This retrospective study included 230 consecutive living donor kidney transplants performed at our institution between May 2019 and March 2023. We reviewed the outcomes of kidney transplant in the right and left kidneys after RDN. Results: A total of 230 living donor kidney transplants were performed, with 32 donors receiving right RDN (right RDN group) and 198 donors receiving left RDN (left RDN group). The renal veins and ureters were significantly shorter in the right RDN group than in the left RDN group (both p <.001). Donor operation and warm ischemia time were significantly longer in the right RDN group than in the left RDN group (p =.012 and p <.001, respectively). None of the groups exhibited any cases of delayed graft function owing to donor‐related reasons. Perioperative changes in the estimated glomerular filtration rate of recipients and death‐censored graft survival were not significantly different between the two groups. Conclusions: In RDN, the outcomes of right donor nephrectomy were comparable to those of left donor nephrectomy in terms of donor safety and recipient renal function. [ABSTRACT FROM AUTHOR]

Introduction: Donor–recipient (D/R) size mismatch has been evaluated for a number of organs but not for pancreas transplantation. Methods: We retrospectively evaluated 438 patients who had undergone pancreas transplantation. The D/R body surface area (BSA) ratio was calculated, and the relationship between the ratio and graft prognosis was evaluated. We divided the patients into two groups and evaluated graft survival. The incidence of pancreas graft thrombosis resulting in graft failure within 14 days and 1‐year graft survival were compared using Kaplan–Meier curves, and the prognostic factors associated with graft thrombosis were identified by univariate and multivariate analyses. Results: The mean/median donor and recipient BSAs were 1.63 m2/1.65 m2, and 1.57 m2/1.55 m2, respectively; the mean and median D/R BSAs were both 1.05. The receiver operating characteristic curve cutoff for the D/R BSA ratio was 1.09, and significant differences were identified between patients with ratios of ≥1.09 (high group) versus <1.09 (low group). The incidence of graft thrombosis resulting in pancreas graft failure within 14 days was significantly higher in the high group than in the low group (p <.01). One‐year overall and death‐censored pancreas graft survival were significantly higher in the low group than in the high group (p <.01). Multivariate analysis identified recipient height, donor BSA, and donor hemoglobin A1c as significant independent factors for graft thrombosis. Cubic spline curve analysis indicated an increased risk of graft thrombosis with increasing D/R BSA ratio. Conclusion: D/R size mismatch is associated with graft thrombosis after pancreas transplantation. [ABSTRACT FROM AUTHOR]

Few studies have focused on the outcome of dialysis for kidney graft failure. We investigated the outcomes of dialysis for graft failure. We retrospectively studied 52 patients undergoing dialysis for graft failure at our facility from January 2004 to December 2018. The mean age at initiation of dialysis was 51.8 ± 13.5 years. The patient survival rates after initiation of dialysis at 1, 3, and 5 years were 96.0%, 93.8%, and 82.4%, respectively. The rate of unplanned initiation was 44.2%. In multivariate logistic analysis, lack of follow‐up by nephrologists and pre‐emptive kidney transplantation (PEKT) tended to be risk factors for unplanned initiation (P = 0.065 and P = 0.014, respectively). Our study suggests that the prognosis of patients with dialysis for graft failure is acceptable. Dialysis for graft failure, especially in patients with PEKT, tends to be unplanned, and for safe initiation, early involvement of nephrologists may be necessary. [ABSTRACT FROM AUTHOR]

Aim: Data on the treatment of chronic active T cell‐mediated rejection (CA‐TCMR) are scarce, and therapeutical strategies for CA‐TCMR have not been established. We retrospectively evaluated the outcomes and effects of treatment on pathological and clinical findings in patients with CA‐TCMR. Methods: This study comprised 37 patients who underwent kidney transplantation at our institute who were diagnosed with CA‐TCMR between January 2018 and December 2020. Patients were followed until October 2021. Results: A total of 32 of the 37 patients were treated. During the observation period, two patients died (5%), and five patients developed allograft loss (13%). A univariate Cox proportional hazards model showed that indication biopsy, higher spot urine protein/creatinine ratio (UPCR) and Banff ci/ct scores were risk factors for allograft loss. Of the treated patients, 23 underwent follow‐up biopsies. The Wilcoxon signed‐rank test showed significant improvement in the Baff scores for "ti", "i‐IFTA", "t" and "t‐IFTA" after treatment. On pathology, 13 (57%) of the patients who underwent follow‐up biopsy improved to "no evidence of rejection" or "borderline change." Assuming that improvement in pathology to "borderline change" or "no evidence of rejection" on follow‐up biopsy indicates response to treatment, multivariate logistic analysis showed that lower UPCR was a predictive factor for response to treatment. No specific effect of treatment type was observed. Conclusions: Our results indicate that treatment could improve the pathological findings in CA‐TCMR. SUMMARY AT A GLANCE: A total of 32 of the 37 patients with CA‐TCMR were treated. 13 (57%) of the 23 patients who underwent follow‐up biopsy after treatment improved to no evidence of rejection or borderline change on pathology. Lower UPCR was a predictive factor for response to treatment. No specific effect of treatment type was observed. [ABSTRACT FROM AUTHOR]

Background: To determine predictive formulas for operation time and surgical difficulty in laparoscopic living-donor kidney transplantation. Methods: We retrospectively analyzed data for 222 living donors aged >20 years and recorded factors affecting operation time from patients' CT images and medical records. We used the factors significantly affecting operation time to create a formula to predict operation time and designed a model to predict surgical difficulty based on the standardized partial regression coefficient, β. We also analyzed the relationship between surgical difficulty (high vs low) and operation time. Results: This study involved 111 pure retroperitoneoscopic donor nephrectomies (PRDN) and 111 hand-assisted laparoscopic donor nephrectomies (HALDN). Patients' mean age was 55.7 years, and 59.5% were women; 5.0% underwent right nephrectomy, and 77.0% vs 23.0% had single- vs multiple renal arteries. The average estimated kidney graft weight was 160.0 g, and actual average graft weight was 155.3 g. The following factors were significantly correlated with operation time in the regression analysis: number of renal arteries, Mayo adhesive probability score, estimated kidney graft weight, right nephrectomy, and operation type (PRDN). These five factors were used to create the operation time prediction equation and difficulty scoring system. The multiple r2 value was 0.40 for the operation time prediction equation. Receiver operating characteristic curve analysis of the difficulty scoring system revealed the following: sensitivity: 78.0%, specificity: 64.9%, and c-statistic: 0.76 (95% confidence interval: 0.70 to 0.83). Conclusions: The equation to predict operation time and the surgical difficulty prediction model created in this study are easy to calculate and are accurate. Both may help in selecting an appropriately skilled surgeon and in improving safety in living-donor kidney transplantation. [ABSTRACT FROM AUTHOR]

Introduction: We previously reported that the outcomes of pure retroperitoneoscopic donor nephrectomy are superior to those of hand‐assisted retroperitoneoscopic donor nephrectomy. Consequently, we introduced pure retroperitoneoscopic donor nephrectomy in our hospital. Here, we compared perioperative outcomes between hand‐assisted intra‐abdominal laparoscopic donor nephrectomy and pure retroperitoneoscopic donor nephrectomy. Methods: We retrospectively reviewed data from 315 living‐donor kidney transplantation procedures performed between October 2015 and December 2020 (213 involving hand‐assisted intra‐abdominal laparoscopic donor nephrectomy, October 2015 to June 2019; 102 involving pure retroperitoneoscopic donor nephrectomy, May 2019 to December 2020). After propensity score matching, 90 transplantations were included in each group (n = 180 overall). Results: Donors in the pure retroperitoneoscopic donor nephrectomy group had longer warm ischemia times (P <.001), lower serum C‐reactive protein concentrations and white blood cell counts on postoperative day 1 (P <.001 and P <.001, respectively), and shorter postoperative stays (P <.001) than donors in the hand‐assisted intra‐abdominal laparoscopic donor nephrectomy group. Five (5.6%) modified Clavien‐classifiable complications occurred in the hand‐assisted intra‐abdominal laparoscopic donor nephrectomy group; no complications occurred in the pure retroperitoneoscopic donor nephrectomy group (P = 0.008). One recipient in the hand‐assisted intra‐abdominal laparoscopic donor nephrectomy group had donor‐related delayed graft function. There were no significant differences between groups in recipient estimated glomerular filtration on postoperative day 7. Conclusion: The introduction of pure retroperitoneoscopic donor nephrectomy was safe and effective. Moreover, it was less invasive and less harmful for donors, compared with hand‐assisted intra‐abdominal laparoscopic donor nephrectomy; recipient outcomes were equivalent. [ABSTRACT FROM AUTHOR]

Background Cardiovascular disease (CVD) is a major cause of death in kidney transplant (KT) recipients. To improve their long-term survival, it is clinically important to estimate the risk of CVD after living donor KT via adequate pre-transplant CVD screening. Methods A derivation cohort containing 331 KT recipients underwent living donor KT at Kyushu University Hospital from January 2006 to December 2012. A prediction model was retrospectively developed and risk scores were investigated via a Cox proportional hazards regression model. The discrimination and calibration capacities of the prediction model were estimated via the c-statistic and the Hosmer–Lemeshow goodness of fit test. External validation was estimated via the same statistical methods by applying the model to a validation cohort of 300 KT recipients who underwent living donor KT at Tokyo Women's Medical University Hospital. Results In the derivation cohort, 28 patients (8.5%) had CVD events during the observation period. Recipient age, CVD history, diabetic nephropathy, dialysis vintage, serum albumin and proteinuria at 12 months after KT were significant predictors of CVD. A prediction model consisting of integer risk scores demonstrated good discrimination (c-statistic 0.88) and goodness of fit (Hosmer–Lemeshow test P   =   0.18). In a validation cohort, the model demonstrated moderate discrimination (c-statistic 0.77) and goodness of fit (Hosmer–Lemeshow test P   =   0.15), suggesting external validity. Conclusions The above-described simple model for predicting CVD after living donor KT was accurate and useful in clinical situations. [ABSTRACT FROM AUTHOR]

Background: Hepatitis B virus (HBV) reactivation is associated with complications and adverse outcomes in patients with clinically resolved HBV infection who are seronegative for hepatitis B surface antigen (HBs Ag), and seropositive for hepatitis B core antibody (HBc Ab) and/or hepatitis B surface antibody (HBs Ab) before kidney transplantation (KT). Methods: We retrospectively analyzed 52 patients with resolved HBV infection who were HBV‐DNA negative. HBV‐DNA after KT was evaluated, and the occurrence of HBV reactivation and outcomes were monitored. We defined HBV reactivation as seropositivity for HBV‐DNA at or above the minimal detection level of 1.0 log IU/mL and treated preemptively (using entecavir) when the HBV‐DNA level was at or above 1.3 log IU/mL, in accordance with the Japanese Guidelines for HBV treatment. Results: Among the 52 patients, the mean age was 57.2 ± 10.8 years. The median HBc Ab titer was 12.8 (interquartile range, 4.6‐42.6) cutoff index, and five (9.6%) cases of HBV reactivation occurred. No patients developed graft loss and died due to HBV reactivation. Statistical analysis showed that age and HBc Ab titer were significant risk factors for HBV reactivation (P =.037 and P =.042, respectively). No significant differences were found between graft survival and the presence or absence of HBV reactivation. Conclusion: These results suggest that HBc Ab titer and age could be significant risk factors for HBV reactivation. Resolution of HBV infection did not appear to be associated with patient or graft survival, regardless of whether HBV reactivation occurred, when following our preemptive strategy. [ABSTRACT FROM AUTHOR]

Background: Renin–angiotensin system blockers (RASBs) reduce end-stage kidney disease and cardiovascular event (CVE) development in chronic kidney disease. However, whether RASBs improve long-term prognosis in kidney transplant (KT) recipients remain unknown. Method: We investigated 900 kidney transplant patients in a multicenter retrospective cohort study in Japan and compared death-censored graft survival and CVE (total, cardiac events, stroke) based on RASB use within 12 months after KT. The associations were examined using a Cox hazard model and propensity score-matching analysis. Results: The cohort comprised 375 patients treated with RASBs (RASB group) and 525 patients without RASBs (control group). The median observational period was 82 months, with 68 patients reaching graft loss: 79 total CVE, 36 cardiac events, 26 stroke. In a matching cohort comprising 582 patients, death-censored graft survival, total CVE, and cardiac events were not different between the two groups. Only stroke incidence rate was significantly lower in the RASB group compared with the control group (1.4 vs. 6.4 per 1000 patients/year, log-ranked P = 0.005). In a multivariable analysis, stroke events were also significantly lower in the RASB group compared with the control group (Hazard ratio and 95% confidence interval, 0.20 [0.04–0.62]). Conclusion: Thus, RASBs potentially reduce stroke events in KT recipients. [ABSTRACT FROM AUTHOR]

Kidney transplantation is the treatment of choice for patients with advanced chronic kidney disease (CKD) and end stage renal disease (ESRD). However, acute rejection (AR) is a common complication in kidney transplantation and is associated with reduced graft survival. Current diagnosis of AR relies mainly on clinical monitoring including serum creatinine, proteinuria, and confirmation by histopathologic assessment in the biopsy specimen of graft kidney. Although an early protocol biopsy is indispensable for depicting the severity of pathologic lesions in subclinical acute rejection (subAR), it is not acceptable in some cases and cannot be performed because of its invasive nature. Therefore, we examined the detection of noninvasive biomarkers that are closely related to the pathology of subAR in protocol biopsies three months after kidney transplantation. In this study, the urinary level of microtubule-associated protein 1 light chain 3 (LC3), monocyte chemotactic protein-1 (MCP-1), liver-type fatty acid-binding protein (L-FABP), neutrophil gelatinase-associated lipocalin (NGAL), and human epididymis secretory protein 4 (HE4) were measured three months after kidney transplantation. Urine samples of 80 patients undergoing kidney transplantation between August 2014 to September 2016, were prospectively collected after three months. SubAR was observed in 11 patients (13.8%) in protocol biopsy. The urinary levels of LC3, MCP-1, NGAL, and HE4 were significantly higher in patients with subAR than in those without, while those of L-FABP did not differ between the two groups. Multivariate regression models, receiver-operating characteristics (ROC), and areas under ROC curves (AUC) were used to identify predicted values of subAR. Urinary HE4 levels were able to better identify subAR (AUC = 0.808) than the other four urinary biomarkers. In conclusion, urinary HE4 is increased in kidney transplant recipients of subAR three months after kidney transplantation, suggesting that HE4 has the potential to be used as a novel clinical biomarker for predicting subAR. [ABSTRACT FROM AUTHOR]

Living-donor kidney transplantation (LDKT) is the most realistic option for patients with end-stage kidney disease because of a severe shortage of deceased donors. Hand-assisted laparoscopic donor nephrectomy (HALDN) and hand-assisted retroperitoneoscopic donor nephrectomy (HARDN) have been undertaken at our institute. We compared these 2 surgical procedures with respect to donor outcome and the graft function of recipients. We reviewed data from 840 consecutive live-donor kidney transplants from October 2003 to April 2019. Propensity scores were calculated for each patient using bivariate logistic regression. After propensity-score matching, the 2 groups each contained 205 patients. Donors in the HALDN group had a longer procedure time (217 minutes, P <.0001), less estimated blood loss (51 mL, P <.0001), lower serum levels of C-reactive protein at postoperative day (POD) 1 (7.9 mg/dL, P <.0001) than those in the HARDN group. There were 22 modified Clavien-classifiable complications among the study groups. A significantly higher conversion to open surgery was noted in the HARDN group (P =.0181) than in the HALDN group, but there was no significant difference in the prevalence of complications in either group. There was no significant difference in the estimated glomerular filtration rate of recipients at POD14 between the 2 groups. Safety and early graft function of HALDN in LDKT are comparable to or even better than that of HARDN. [ABSTRACT FROM AUTHOR]

Long-term kidney allograft survival remains a major clinical challenge. Recurrent glomerulonephritis disease, including recurrence of IgA nephropathy (IgAN), is a significant barrier to long-term kidney allograft survival. We performed a retrospective, observational study to evaluate the role of everolimus (EVR) in the risk of recurrent IgAN. The study included data from 135 patients aged ≥16 years with biopsy-proven IgAN on native kidneys who underwent a kidney transplant (KT) between December 2002 and December 2018. Patients who underwent de novo KT received mycophenolate mofetil (MMF) (n = 107) or EVR (n = 28). The mean recipient age in the MMF and EVR groups was 44.9 ± 13.7 and 41.1 ± 10.1, respectively. The median (interquartile range) follow-up period was 90.9 (64.9-115.3) and 21.2 (11.4-30.6) months, respectively (<.0001). All patients received continuous corticosteroid and tacrolimus therapy. The death-censored graft survival rate after KT and the recurrence-free survival rate did not differ significantly between the groups. Univariate and multivariate Cox regression analyses identified EVR for de novo KT as an independent predictive factor for recurrence-free survival (P =.024). Our findings suggest that EVR-based regimens with tacrolimus and corticosteroid therapy for de novo KT reduce the recurrence of IgAN compared with MMF-based regimens with tacrolimus and corticosteroid therapy. • Everolimus-based regimen in kidney transplantation reduced the recurrence of IgA nephropathy. • Everolimus-based regimen was not a risk factor for death-censored graft survival. • Recurrence of IgA nephropathy was not a significant risk factor for graft survival. [ABSTRACT FROM AUTHOR]

Prevention and early detection of BK polyomavirus (BKV) infection is important for long-term kidney graft survival; hence, pretransplant screening methods are essential to identify recipients at high risk for BKV infection. This study investigated the association of pretransplant donor and recipient BKV antibody status with the occurrence of post-transplant BKV infection. We prospectively enrolled 47 adult living donor kidney transplant pairs from December 2014 to January 2016. Recipient and donor pretransplant BKV antibody titer was measured by hemagglutination inhibition (HI) test. Donor and recipient median HI titer of 1:20 was used as a cutoff to define seropositivity. Recipients were divided into 2 groups (BKV antibody donor-seropositive/recipient-seronegative (D+/R-) and non-D+/R-). Urinary cytology was used to screen for BKV infection. Plasma polymerase chain reaction testing for BKV DNA was used when decoy cells in urine were persistently detected. Nine (19.2%) of 47 patients belonged to the D+/R- group. Decoy cells were observed in 32 recipients (68.1%) during follow-up. BK viremia occurred in 3 (6.4%) cases. The maximum decoy cell count was significantly higher in the D+/R- group than in the non-D+/R- group (P =.0002). Decoy-cell-free survival was significantly shorter in the D+/R- group (P =.0220). Multivariate analysis identified only BKV antibody serostatus as an independent risk factor for decoy cell appearance (P =.0491). Pretransplant donor and recipient BKV antibody status was associated with higher maximum decoy cell count and shorter decoy-cell-free survival after kidney transplantation. • BK polyomavirus (BKV) antibody serostatus (donor-seropositive/recipient-seronegative [D+/R-]) is associated with a high maximum decoy cell count. • BKV antibody serostatus D+/R- is associated with short decoy-cell-free survival. • A high maximum decoy cell count is associated with short decoy-cell-free survival. [ABSTRACT FROM AUTHOR]

Graft biopsy is the gold standard for diagnosis of BK polyomavirus–associated nephropathy (BKPyVAN), and polymerase chain reaction is the most specific screening technique. Development of a noninvasive, cost-effective marker for BKPyVAN is important. We reviewed 492 adult kidney transplant patients. We investigated peripheral blood lymphocyte (PBL) count and urinary cytology at graft biopsy in patients with BKVPyAN (n = 21), acute T-cell–mediated rejection (n = 79), and no evidence of acute rejection (n = 149). We performed univariate and multivariate logistic regression and receiver operating characteristics analyses to compare the test performance of PBL count, urinary cytology, and their combination for diagnosis of BKPyVAN. The PBL count at biopsy was significantly lower in the BKPyVAN group than the acute T-cell–mediated rejection and no acute rejection groups (959 ± 290/μL, 1433 ± 673/μL, and 1531 ± 549/μL, respectively; P <.01). The PBL count was 959 ± 290/μL at diagnosis of BKPyVAN and increased to 1123 ± 377/μL, 1238 ± 419/μL, and 1292 ± 491/μL at 1, 2, and 3 months after treatment, respectively (P <.05). On univariate analysis, the area under the curve was significantly higher for the combined model than for PBL and cytology alone (0.930, 0.797, and 0.875, respectively; P <.01). The improved test performance in the combined model remained significant after multivariate adjustment (0.972, 0.844, and 0.928, respectively; P <.01). Decreased PBL count was found in BKPyVAN, and the predictive performance of the combination of PBL count and urinary cytology was significantly enhanced for diagnosis of BKPyVAN. • The peripheral blood lymphocyte count was decreased in patients who had BK polyomavirus–associated nephropathy at diagnosis. • The peripheral blood lymphocyte count was gradually increased after modification of immunosuppression. • The predictive value of the peripheral blood lymphocyte count for the diagnosis of BK polyomavirus–associated nephropathy implied moderate accuracy. • The combination of peripheral blood lymphocyte count and urinary cytology improved predictive performance. [ABSTRACT FROM AUTHOR]