Are there any relations among transplant centre volume, surgical technique and anatomy for donor graft selection? Ten-year multicentric Italian experience on mini-invasive living donor nephrectomy.

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: MINI-OPEN (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 LOW-volume centres was associated with higher risk of donor bleeding.

Ultrasonographic findings in dual kidney transplantation.

INTRODUCTION: Organ shortage has led to using grafts from expanded criteria donors (ECD). Double kidney transplantation is an accepted strategy to increase the donor pool, using organs from an ECD which are not acceptable for single kidney transplantation (SKT). Aim of this retrospective study was to analyse the role of colour Doppler ultrasound (CDUS) in the diagnosis of major surgical complications in DKT, performed with unilateral or bilateral placement. MATERIALS AND METHODS: From 2000 to 2011 we performed 54 DKT. Unilateral placement of both kidneys was done in 26 patients and bilateral DKT in 28, through two separate Gibson incisions (18) or one midline incision (10). Each patient underwent at least 3 CDUS before hospital discharge. The main surgical complications, discovered initially thanks to ultrasound (US), were hydronephrosis from ureteral obstruction, lymphocele and deep venous thrombosis (DVT). RESULTS: Mean follow-up was 42.7 months. Good postoperative renalfunction was demonstrated in 25 patients (46.3%), while delayed graft function occurred in 29 (53.7%). US showed ureteral obstruction requiring surgery in 5 unilateral DKT while no patient subjected to bilateral DKT developed severe hydronephrosis. Lymphoocele, surgically drained, was demonstrated in 6 bilateral DKT with a midline incision, 2 bilateral DKT with two separate incisions and 3 unilateral DKT. CDUS also enabled diagnosis of 2 cases of DVT in ipsilateral DKTs. CONCLUSIONS: CDUS provides useful information in patients with DKT, allowing the detection of clinically unsuspected unilateral diseases. US study of our patients demonstrated that unilateral DKTs are more susceptible to the development of DVT and ureteral stricture, while the incidence of voluminous lymphocele is more frequent in bilateral DKT through a single midline incision. In this scenario, all patients undergoing DKT should be carefully monitored by US after surgery.

Value of the resistive index in patient and graft survival after kidney transplant.

INTRODUCTION: The resistive index (RI) obtained by performing doppler sonography is a hemodynamic index commonly used to measure flow resistance within an organ to assess if there is a vascular disease associated with that organ. It is a well-known predictor of kidney transplant outcome. The purpose of this study was to analyze the impact of RI values on patient and graft survival, as well as kidney graft function during 5-year follow-up. MATERIALS AND METHODS: We retrospectively investigated 761 kidney transplant recipients from cadaveric donors performed between 1998 to 2011. RI was measured at hospital discharge after the kidney transplant. All the patients were divided into tertiles, according to the baseline RI value (group 1: RI < 0.70, group 2: RI between 0.70 and 0.79 and group 3: RI > 0.80). RESULTS: Patients with a low RI (<0.70) showed the lowest incidence of delayed graft function (DGF) compared to the other two groups (20.2% vs. 32.2% vs. 33%). Recipients with low RI values displayed significantly better creatinine clearance (70 vs. 55 vs 35 ml/min, respectively) than those with medium or high RI values at 5-year follow-up. Kaplan-Meier estimates of cumulative graft survival were significantly worse in patients who had a RI of 0.70 or more than in patients with a RI of less than 0.70 (p = 0.02). Cumulative patient survival showed the same behavior (0.01) CONCLUSIONS: Low RI values measured in segmental arteries in the very early post-transplant period predict better kidney graft function and reduce the risk of all-cause graft loss, including patient death in a 5-year follow-up period.

Ureteral strictures after kidney transplantation: risk factors.

INTRODUCTION: Ureteral obstruction is one of the most commonly reported urological complications after kidney transplantation often occurring within the first 3 months after surgery. Ischemia is the most frequent cause of ureteral stenosis and is the result of excessive hilar dissection and a poor anastomotic technique. Aim of this study was to identify the main risk factors for ureteral stenosis after kidney transplantation from cadaveric donors and to assess their impact on both graft survival and patient. MATERIALS AND METHODS: We retrospectively investigated 761 kidney transplants from cadaveric donors performed between 1998 to 2011. In all the patients, the ureteroneocystostomy was stented with a double J stent 4.7Ch x 12 cm held in place for an average time of 4-6 weeks post-operatively. Each patient underwent at least 3 ultrasound scans during hospital stay and subsequently during follow-up. All patients with severe hydronephrosis were followed by sequential renal scintigraphy with MAG3 and diuretic stimulus. RESULTS: After a mean follow-up of 60.1 (+/- 38.5) months, severe ureteral stenosis was discovered in 21 patients (2.76%), with exclusive involvement of the vesicoureteral junction. No statistically significant correlation was found with donor age and the incidence of delayed graft function, whereas a significant correlation between ureteral obstruction and unilateral placement of both grafts in dual kidney transplantation (DKT) (p < 0.001) was found. These patients had a longer mean hospital stay than the control group, but there was no influence on survival of the organ or patient. CONCLUSIONS: ureteral obstruction after renal transplantation often features subtle and late symptoms. Early ultrasound monitoring is therefore essential and in the presence of severe hydronephrosis, scintigraphic confirmation of the obstruction. In fact. early resolution of the stenosis appears to provide optimal graft and patient survival.

The European Union Interreg Program: Italian-Albanian experience with kidney transplants.

INTRODUCTION: A collaboration between the Regional Health Agency of Puglia (ARES), the Italian Ministry of Health and the Albanian Ministry of Health, was realized in 2008. One of the areas of interest was to promote the performance of kidney transplants in Albania by Albanian medical staff, funded with nearly 2 million euros. The program included two major goals: to transmit the required know-how to health care staff and to upgrade the Albanian facilities and equipment to the standards necessary for successful transplantation. MATERIALS AND METHODS: During the year 2008, two couples of Albanian patients were transplanted at the Department of Emergency and Organ Transplantation-Urology Unit in Bari, Italy. The surgical procedures were performed by mixed surgical teams, with the active participation of Albanian medical staff under the guidance of the Italian colleagues. The first kidney transplant was performed at the end of January 2008 and the second in June 2008. Both surgical procedures and post-transplant periods were clinically uneventful. RESULTS: After returning to Albania the trained team started to carry out team-work, preparing the patients for the first kidney transplantation. The first donor-patient couple was prepared for kidney transplantation at the end of 2008. On the 26th March 2009 the first kidney transplant was performed by the Albanian medical team, with the active participation of 2 Italian urologists from the University of Bari. CONCLUSIONS: Appropriate training, equipment, and infrastructure are necessary to build a rational, functional national system for organ transplantation. Continuous exchange of ideas and data on kidney transplantation between Albania and Italy will probably contribute to extend such forms of cooperation to the western Balkans in the near future.

Surgical complications of renal transplantation: ultrasound diagnosis.

OBJECTIVE: Ultrasound is the principal imaging technique for the evaluation of a renal allograft; it is a safe imaging technique to assess the structure of the graft and its perfusion without the need for intravenous contrast or ionizing radiation. The evaluation of kidney transplant complications is easy due to its presence in the iliac fossa lying anterior to the external iliac vessels. Complications may be classified as medical and surgical; the latter are classified in urologic, vascular and general surgical complications. MATERIALS AND METHODS: Our experience on surgical complications in kidney recipients from donors, on the role of ultrasound in the diagnosis of these complications and their impact on the graft and patient survival rates is reported. RESULTS: Ultrasonography represents a safe imaging technique to assess the structure of the graft and its perfusion without the use of ionizing radiation and iodinated contrast medium, and a quick, accurate method for the evaluation of complications. CONCLUSIONS: Although it possesses limitations and is ultimately operator dependent, ultrasound is considered an excellent tool for the assessment of the kidney transplant and in our experience it represents the main imaging technique used in the evaluation of graft complications.