The Kidney Transplant Lottery: A Highly Sensitized Patient, Without Mismatches and Vein Thrombosis of the Graft; A Case Report.

A kidney transplant is the best option for patients with end-stage renal disease. The waiting list period can be long, especially for highly sensitized patients. We describe a 60-year-old woman who received a second transplant and was highly sensitized to vascular access exhaustion, anuric, and performing peritoneal dialysis. At 27 days post-transplant, the patient developed thrombosis of the allograft vein, oliguria, and elevated serum creatinine. Fibrinolysis was attempted, but the patient remained oliguric and with acute graft dysfunction. She had a suction thrombectomy using the Penumbra System, allowing the removal of all thrombi and repermeabilization of the vein graft, resolving the acute graft dysfunction.

Dual Kidney Transplantation: Single-Center Experience.

BACKGROUND: Dual and en bloc kidney transplantation are strategies used to mitigate the disparity between a reduced organ pool and an ever-increasing need for organ procurement. En bloc refers to the implantation of 2 kidneys from a pediatric donor, compensating for small renal mass, whereas dual expanded criteria donor (DECD) transplantation refers to older donors with grafts otherwise rejected for single transplant, including expanded. This study describes one center's experience with dual and en bloc transplantation. METHODS: A retrospective cohort study of dual kidney transplants (en bloc and DECD) from 1990 through 2021. The analysis included demographic, clinical, and survival analysis. RESULTS: Of 46 patients who underwent dual kidney transplantation, 17 (37 %) received en-bloc transplantation. The overall mean recipient age was 49.4 ± 13.9 years old, younger in the en-bloc subgroup (39.2 vs 59.8 years old, P < .01). The mean time on dialysis was 37 ± 25 months. Delayed graft function was present in 17.4 % and primary nonfunction in 6.4 %, all from the DECD group. The estimated glomerular filtration rates at 1 and 5 years were 76.7 ± 28.7 and 80.4 ± 24.8 mL/min/1.73 m2, lower in the DECD group (65.9 vs 88.7 mL/min/1.73 m2, P = 0.02). Eleven recipients lost their graft during the study period: 63.6% from death with a functioning graft, 27.3% due to chronic graft dysfunction (a mean of 76.3 months after transplantation), and 9.1% due to vascular complications. Subgroup comparison found no differences regarding cold ischemia time or length of hospitalization. Kaplan-Meier estimates, censored for death with a functioning graft, resulted in a mean graft survival of 21.3 ± 1.3 years, with survival rates of 93.5, 90.5, and 84.1% at 1, 5, and 10 years, respectively, without significant differences between subgroups. CONCLUSIONS: Both DECD and en bloc strategies provide safe and effective options to further expand the use of otherwise rejected kidneys. Neither of the 2 techniques was superior to the other.

Borderline Changes in Renal Transplantation: Are We Aware of the Real Impact in Graft Survival?

BACKGROUND: Borderline changes suspicious for acute T-cell-mediated rejection (BC) are frequently seen on biopsy specimens, but their clinical significance and clinical management are still controversial. Our goal was to compare clinical outcomes of kidney transplant recipients with biopsy-proven BC vs acute T-cell-mediated rejection (aTCMR) and the influence of treating BC on graft outcomes. METHODS: A retrospective cohort study was performed in all kidney transplant recipients with biopsy-proven BC and aTCMR between January 2012 and December 2018, according to Banff 2017 criteria; patients with concomitant antibody-mediated rejection were excluded. RESULTS: We included 85 patients, 30 with BC (35.3%) and 55 with aTCMR (64.7%). There was no difference between groups regarding demographics, HLA matching and sensitization, immunosuppression, or time of transplant. Treatment with steroids was started in 15 patients with BC (50%) and in all patients with aTCMR, with 4 of the latter additionally receiving thymoglobulin (7.2%). At 1 year post biopsy, overall graft survival was 71%, and despite presenting better estimated glomerular filtration rate (eGFR) at biopsy (33.3 ± 23.4 vs 19.9 ± 13.2 mL/min/1.73 m2, P = .008), patients in the BC group presented the same graft survival as the aTCMR group according to Kaplan-Meyer survival curves. When analyzing the BC group (n = 30) and comparing the patients who were treated (n = 15) vs a conservative approach (n = 15), graft survival at 1 year was 87% for treated patients and 73% for nontreated patients (P = .651), with no difference in eGFR for patients with functioning graft. However, at longer follow-up, survival curves showed a trend for better graft survival in treated patients (70.2 ± 9.2 vs 38.4 ± 8.4 months, P = .087). CONCLUSION: Our study showed that patients with BC did not present better graft survival or graft function at 1 year after biopsy or at follow-up compared with the aTCMR group, despite better eGFR at diagnosis. We found a trend for better graft survival in patients with BC treated with steroids compared with a conservative approach. These results reinforce the importance of borderline changes in graft outcomes and that the decision to treat can influence long-term outcomes.