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Background De novo donor-specific antibodies (dn DSA) after renal transplant are associated with acute rejection ( AR) and graft loss, yet most recipients with dn DSA have stable function and no AR. We assessed whether the persistence of dn DSA increased the risk of a detrimental outcome. Methods A single-center review of renal transplant recipients monitored for dn DSA at multiple time points post-transplant. An Isolated dn DSA was defined as one positive dn DSA and no additional positive tests, whereas ≥2 positive dn DSA was defined as persistent dn DSA. Results Of 708 recipients, 22% developed dn DSA, of whom 64% had persistent dn DSA. At median follow-up of 35 (range 12-74) months, there were fewer episodes of AR in the isolated dn DSA vs the persistent dn DSA group (2% vs 22%; P<.001,) and fewer graft losses with isolated dn DSA vs persistent dn DSA (0% vs 10%; P=.03). Within the persistent dn DSA group, recipients with dn DSA ≥60% of time points, had more AR (32% vs 16%, P=.10) and more graft losses (21% vs 2%; P=.003) than those with dn DSA<60%. Conclusions Persistence of dn DSA resulted in more AR and graft failure than a single positive value. Recipients with longer duration of dn DSA persistence had an additional increased risk of AR and graft failure. [ABSTRACT FROM AUTHOR]

Background. Acceptance of dual kidney transplantation (DKT) has proven difficult, due to surgical complexity and concerns regarding long-term outcomes. We herein present a standard technique for ipsilateral DKT and compare outcomes to single-kidney transplant (SKT) recipients. Methods. A retrospective single-center comparison of DKT and SKT performed between February 2007 and July 2013. Results. Of 516 deceased donor kidney transplants, 29 were DKT and 487 were SKT. Mean follow-up was 43 ± 67 months. DKT recipients were older and more likely than SKT recipients to receive an extended criteria graft (p<0.001). For DKT versus SKT, the rates of delayed graft function (10.3 versus 9.2%) and acute rejection (20.7 versus 22.4%) were equivalent (p = ns). A higher than expected urologic complication rate in the DKT cohort (14 versus 2%, p<0.01) was reduced through modification of the ureteral anastomosis. Graft survival was equivalent between DKT and SKT groups (p = ns) with actuarial 3-year DKT patient and graft survivals of 100% and 93%. At 3 years, the groups had similar renal function (p = ns). Conclusions. By utilizing extended criteria donor organs as DKT, the donor pool was enlarged while providing excellent patient and graft survival. The DKT urologic complication rate was reduced by modification of the ureteral anastomosis. [ABSTRACT FROM AUTHOR]

What's known on the subject? and What does the study add? Most transplant centres harvest living donor kidneys via a conventional laparoscopic surgical approach. Laparoendoscopic single-site donor nephrectomy ( LESS-DN) is a relatively novel minimally invasive approach that allows the surgery to be performed via a single incision. This technique may be advantageous in decreasing surgical morbidity and improving cosmetic outcomes, thus plausibly reducing the barriers to kidney donation., The study demonstrates the safety and feasibility of LESS-DN in a large consecutive series of kidney donors. Comparative analysis between LDN and LESS-DN showed that there was a significant decrease in intra-operative blood loss and allograft warm ischaemia time in the LESS-DN group, but also a significant increase in operating time. Other peri-operative outcomes were similar between the two approaches. Evaluation of the LESS-DN cases alone revealed that, the operating times did not significantly change through the course of the series. Using this outcome as a surrogate for technical difficulty suggests a relatively shallow learning curve for LESS-DN., Objective To present a comparative analysis of peri-operative outcomes for >200 cases of conventional laparoscopic donor nephrectomy ( LDN) and laparoendoscopic single site donor nephrectomy ( LESS-DN)., Patients and Methods From 2006 to 2011, 213 donor nephrectomies were performed by two surgeons ( R.E.L and W.A.M.) at a tertiary transplant centre. The approach changed from conventional LDN to LESS-DN over the course of the series., The two approaches were compared retrospectively and evaluated for differences in peri-operative outcomes., Statistical significance was assessed using Student's t-test and chi-squared analysis., Results A total of 111 patients underwent LDN and 102 patients underwent LESS-DN., Total operating time was significantly longer in the LESS-DN group (206.1 vs 181.9 min, P < 0.001), but LESS-DN resulted in less intra-operative blood loss (61.5 mL vs 85.9 mL, P < 0.001) and shorter warm ischaemia times (4.4 vs 5.0 min, P = 0.01)., There were no significant differences in analgesic requirements, subjective pain scores, length of hospital stay, postoperative graft function, or donor's postoperative glomerular filtration rate between the two approaches., Complication rates were low regardless of the approach, and there were no major complications (>grade II) in the LESS-DN group., Conclusions In experienced hands, LESS-DN results in peri-operative outcomes similar to those of conventional LDN without compromising donor safety, while providing a desirable cosmetic result., For surgeons familiar with LDN, transitioning to the LESS approach using this technique appears to have a relatively short learning curve. [ABSTRACT FROM AUTHOR]

Patel SJ, Knight RJ, Suki WN, Abdellatif A, Duhart BT, Krauss AG, Mannan S, Nezakatgoo N, Gaber AO. Rabbit antithymocyte induction and dosing in deceased donor renal transplant recipients over 60 yr of age. Clin Transplant 2011: 25: E250-E256. © 2011 John Wiley & Sons A/S. Antithymocyte globulin (rATG) is a commonly used induction agent in renal transplantation; however, data in older kidney recipients are limited. We reviewed charts of 301 deceased donor renal transplants who received a protocol consisting of 3-7 doses of rATG and triple maintenance therapy. Outcomes of patients >60 yr of age (n = 45) were compared to those aged 18-59 yr (n = 256). Older recipients had more diabetics, were more likely to receive expanded criteria donor kidneys (p < 0.01), and over 30% were sensitized. Recipients >60 received less cumulative rATG (4.6 vs. 5.1 mg/kg; p < 0.01). Three-yr acute rejection was lower in the >60 group (2% vs. 16%, p < 0.01) although glomerular filtration rates were similar between groups. Actuarial graft survival was similar; however, patient survival in the >60 group at three yr was lower (80% vs. 95%; p = 0.02). Specifically, patients >60 with delayed graft function and rATG cumulative dosing >6 mg/kg had a survival of <50% by two yr. Recipients over 60 yr receiving rATG induction have acceptable renal function and a low risk of rejection; however, reduced survival was noted among those receiving >6 mg/kg. These data suggest that when used, lower cumulative dosages of rATG are preferable in the older recipient. [ABSTRACT FROM AUTHOR]

Aim: To compare the outcomes of single paediatric vs. adult kidneys transplanted into adult recipients, Methods: A retrospective single-centre review of 38 single cadaver kidney transplants from donors less than five yr of age to wait-listed patients of low body mass index (BMI). Survival of grafts and quality of renal function were compared with 121 similarly low BMI recipients of grafts from donors 18–45 yr of age that were transplanted during the same period. Immunosuppression consisted of sirolimus, minimal-dose cyclosporine and prednisone. The mean age of the paediatric vs. adult donors was 2.8 ± 1.0 and 31.1 ± 9.2 yr, respectively (p<0.01) and of the recipients, 42.0 ± 12.4 and 45.7 ± 14.8 yr, respectively (p = NS). The mean BMI of paediatric vs. adult donor kidney recipients was 21.8 ± 2.9 and 22.4 ± 2.0 kg/m2 (p = NS). Sixty-six per cent of paediatric donor recipients were women compared with 44% of adult donor recipients (p = 0.03). Results: Death censored actuarial graft survivals at one and five yr for recipients of paediatric vs. adult donor grafts were 93 and 84% compared with 93 and 85% (p = NS). There were no graft losses because of technical complications in the paediatric kidney donor group. At one and five yr post-transplantation, the mean estimated creatinine clearances of the paediatric donor graft recipients were 52.9 ± 19.6 and 54.0 ± 17.8 mL/min, respectively, compared with 56.4 ± 19.8 and 49.1 ± 21.7 mL/min for recipients of adult donor grafts at the same times (p = NS). Conclusion: Transplantation of single paediatric donor kidneys into low BMI adult recipients provided equivalent outcomes to those of grafts from adult donors between the ages of 18 and 45 yr. [ABSTRACT FROM AUTHOR]

Increasing evidence suggests a detrimental effect of donor-specific antibodies directed against the human leukocyte antigen (HLA)-A, -B, and -DR loci on renal allograft outcomes. Limited data exist on the impact of de novo HLA-DQ antibodies. Over a 3-year period, we prospectively monitored 347 renal transplant recipients without pre-transplant donor-specific antibodies for their development de novo. After 26 months of follow-up, 62 patients developed donor-specific antibodies, of which 48 had a HLA-DQ antibody either alone (33 patients) or in combination with an HLA-A, -B, or -DR antibody (15 patients). Only 14 patients developed a donor-specific HLA-A, -B, or -DR antibody without a HLA-DQ antibody present. Acute rejection occurred in 21% of the HLA-DQ-only patients, insignificant when compared with 11% of patients without donor-specific antibodies. At the last follow-up, the mean serum creatinine and the fraction of patients with proteinuria were significantly higher in those that developed only HLA-DQ than those without antibodies. The 3-year graft survival was significantly worse when HLA-DQ antibodies were combined with non-DQ antibodies (52%) compared with HLA-DQ alone, non-DQ antibodies alone, or no antibodies (92-94%). Thus, our prospective monitoring study found that donor-specific HLA-DQ antibodies were the most common type detected and these antibodies may contribute to inferior graft outcomes. Ongoing surveillance is necessary to determine the long-term outcome of patients developing HLA-DQ donor-specific antibodies. [ABSTRACT FROM AUTHOR]