Living donor kidney transplantation across positive crossmatch: the University of Illinois at Chicago experience.

BACKGROUND: To increase living donation for kidney transplantation, we investigated desensitization of recipients with positive crossmatch against a potential living donor. METHODS: Between June 2001 and March 2007, 57 consecutive sensitized candidates for kidney transplantation, with crossmatch positive potential living donors, were treated with various desensitization protocols. All patients received plasmapheresis every other day with intravenous immune globulin 100 mg/kg starting 1 week before the scheduled transplant. Postoperatively, the recipients continued to receive every other day plasmapheresis with intravenous immune globulin for the initial week. Immunosuppression therapy consisted of induction with thymoglobulin and a combination of tacrolimus, mycophenolate, and corticosteroids. RESULTS: Six patients failed to convert with pretransplant immunomodulation and were not transplanted; 51 underwent live donor kidney transplant. Mean follow-up was 23 months and 36 patients have more than 1-year follow-up. One-year patient and graft survivals were 95% and 93%, respectively. There were 25 episodes of biopsy-proven or clinically presumed rejection in 22 patients in the first year. Of the 17 biopsy-proven episodes, 12 were antibody-mediated rejection and five were acute cellular rejection. Of the patients with antibody-mediated rejection (biopsy proven or empiric), two patients (12%) lost their graft by 1 year. The median modification of diet in renal disease at 6 and 12 months was 55 mL/min (range 9-104 mL/min) and 48 mL/min (range 8-99), respectively. CONCLUSIONS: Despite increased rejection rates, graft and patient survivals indicate that desensitization of positive crossmatch patients is a reasonable alternative for a sensitized patient who could potentially wait 10 or more years for a suitable cadaveric kidney.

Robotic distal pancreatectomy and nephrectomy for living donor pancreas-kidney transplantation.

Living organ donation is of increasing importance to satisfy the demand of good quality organs for patients remaining for extended periods on the waiting list. While the benefit for the recipient is undeniable, the organ procurement represents an important burden to live donors in terms of invasiveness and long-term consequences. The latter can be minimized with careful donor selection. With the avenue of minimally invasive surgery, and more recently the availability of robotic technology, the surgical trauma can be reduced, the safety increased, and the recovery accelerated. In this case report, we present the first reported combined robotic distal pancreatectomy and left nephrectomy from a live donor. The surgery was performed using the Da Vinci robotic system with four small trocar incisions, and a short infraumbilical midline incision for hand-assistance and extraction of the organ. The donor operation lasted 5 hr and blood loss was only 100 mL. Both donor and recipient had an uncomplicated postoperative course and present with normal endocrine and renal function 3 mo after surgery. In experienced hands, advanced surgical procedures such as combined distal pancreatectomy and left nephrectomy can be safely performed in living donors with minimally invasive robotic surgery, dramatically reduced surgical trauma, and impressive postoperative recovery. The availability of minimally invasive robotic surgery may further increase the willingness for live organ donation from suitable donors.