Histology for nephrology, from pre-implantation to post-transplant kidney biopsy. Lesson learned from ReBIrth (Renal BIopsy for Kidney Transplantation Therapy).

A meeting entitled Renal BIopsy for Kidney Transplantation Therapy (ReBIrth) took place on May 31st, 2022 in Bologna, Italy. The meeting drew together nephrologists, surgeons, and pathologists and recognized as experts in the field of kidney transplantation in Italy. In this paper, we present our experience working with kidney transplants in the current era of immunosuppression therapy. The primary aim is to report the histopathological characteristics of failed kidney allografts after a consensus of experts reviewed the cases on a wholeslide imaging digital platform. Regardless of the cases discussed, digital pathology was reliable in identifying all the morphological and immunohistochemical features required to improve the correct use of immunosuppressive therapy to prevent graft failure and optimize patient management.

Image-Guided Thermal Ablation in De Novo Renal Tumor Arising in Kidney Allograft: 3-Year Follow-Up. A Case Report.

De novo tumors in renal allograft recipients are a severe complication during long-term follow-up after transplantation and may require transplantectomy. Herein we present a case of de novo renal tumor arising in the renal allograft, treated with the less invasive image-guided radiofrequency ablation (RFA) with long-term follow-up. A tumor was detected during the routine annual follow-up in a patient with good renal function who underwent renal transplantation in 1989. Computed tomography (CT) showed a mass in the allograft whose shape, vascularization, and density suggested the presence of a solid, malignant mass, located in the upper renal pole, that measured 17 mm. CT-guided RFA was performed successfully, and the outcome was verified by an immediate control CT after the intervention. No residual pathologic tissue, major bleeding, or damage to the adjacent parenchyma was evidenced. The patient was discharged with stable renal function. CT scan and ultrasound were performed 3, 6, 12, 18, 24, and 36 months after RFA. No signs of change in renal function, recurrence, neovascularization, or damage to the adjacent microcirculation were observed during the 3-year follow-up. In conclusion, percutaneous RFA of small renal tumors occurring in renal allografts can be considered a function-sparing, safe, and effective therapeutic option when difficult surgical removal may be anticipated. Our experience also supports the need for yearly renal allograft ultrasound follow-up for early identification of small neoplasm than can be treated less invasively.

Living Kidney Donation in a Type 1 Dent's Disease Patient from His Mother.

INTRODUCTION: Dent's disease is a rare X-linked recessive disorder that manifests in childhood or early adulthood and can lead to end-stage renal disease (ESRD). It occurs in males, who are hemizygous. In patients who develop ESRD, a deceased donor kidney transplant cures the disease. Females are obligate carriers of the mutated gene, and some show a mild Dent's disease phenotype. There may be reason for concern when considering a female obligate carrier (i.e., the mother) for kidney donation because of the risk of kidney function deterioration. CASE PRESENTATION: We describe the first successful kidney transplantation involving a patient with type 1 Dent's disease and ESRD given a kidney by an obligate carrier of the gene mutation, his mother. CONCLUSIONS: After careful assessment of the female obligate carriers, intrafamilial kidney donation in Dent's disease type 1 is feasible. No deteriorating renal function in the donor was observed.

Radiofrequency thermal ablation of renal graft neoplasms: A literature review.

Neoplasms occurring in renal grafts represent a relatively novel and rare condition, whose treatment has not been standardized yet. Radiofrequency thermal ablation (RFA) of renal graft neoplasms is a nephron-sparing treatment, reported to be safe and effective. However, even in the RFA field, there is no procedural standardization. In this review of the literature, mostly composed by case reports and case series, we aim to assess efficacy and complication rates of RFA in the treatment of kidney graft neoplasms, and summarize the various procedural protocols found in the literature, using an easy-to-read point format. We performed a literature search in PubMed/MEDLINE with an overall description of 66 renal graft lesion treated with RFA, with a mean follow-up of 16.3 months (range 3-54.3). Technical success was achieved in all cases, with only one recurrence reported (1/66; 1.5%), occurring at 6-months follow-up. Complications occurred in 11 (11/66; 16.7%) patients. Based on literature review, RFA of renal graft neoplasms seems to be a feasible, safe, and effective treatment.

Perioperative-, Recipient-, and Donor-Related Factors Affecting Delayed Graft Function in Kidney Transplantation.

OBJECTIVES: Delayed graft function is a frequent complication in deceased-donor kidney transplant, with an incidence ranging from 10% to 50% among different centers; it is also associated with lower graft survival. In this study, we aimed to identify risk factors for delayed graft function, particularly those associated with perioperative management (including cold ischemia time) and nonmodifiable recipient- and donor-related factors. The effects of delayed graft function on graft and patient outcomes were also evaluated. MATERIALS AND METHODS: Our retrospective analyses included 125 adult patients who underwent deceased-donor kidney transplant. Delayed graft function was diagnosed if at least 1 dialysis treatment was required during the first week posttransplant according to Perico's definition. RESULTS: Prevalence of delayed graft function was 30.4% (n = 38). Cold ischemia time was significantly prolonged in patients with delayed graft function compared with those without it. Multivariate regression showed that cold ischemia time was the only predictor of delayed graft function. A cutoff of 9 hours and 12 minutes was found as a limit beyond which delayed graft function occurred (sensitivity = 90%; specificity = 29%; area under the curve = 0.68). Greater donor and recipient age and longer pretransplant dialysis time in recipients were associated with occurrence of delayed graft function. In patients with delayed graft function, hospital stay duration was significantly greater and 1-year graft survival was significantly lower. CONCLUSIONS: Efforts should be focused on limiting cold ischemia time and associated injury to reduce occurrence of delayed graft function and consequently improve long-term graft survival in kidney transplant recipients. Optimization of posttransplant renal function with the help of new technologies, such as pulsatile perfusion, could be crucial for minimization of cold ischemia time.

Inferior Long-Term Outcomes for Kidney Transplant Recipients With an Immunologically Mediated Primary Renal Disease.

OBJECTIVES: Recurrent glomerulonephritis can negatively affect kidney allograft survival. However, how primary renal disease affects transplant outcomes in the new era of immunosuppression remains unclear. MATERIALS AND METHODS: We categorized 426 kidney transplant recipients (performed from 1996 to 2007) into 4 disease groups: (1) 99 recipients with biopsy-proven immunologically mediated kidney disease, (2) 40 recipients with urologic disease, (3) 67 recipients with polycystic kidney disease, and (4) 220 recipients with other causes of terminal renal failure/uncertain kidney disease. Long-term transplant outcomes were compared between groups at 1, 5, and 10 years of follow-up. RESULTS: Compared with the urologic, polycystic, and other diseases groups, the immunologic group showed significantly lower time of graft survival (9.5 ± 4 vs 8 ± 4 vs 8.5 ± 4 vs 7 ± 4 years, respectively) and estimated glomerular filtration rate (52.5 ± 32 vs 49 ± 22 vs 50 ± 32 vs 35.5 ± 30 mL/min; P < .05). Relative risk of 10-year graft loss for the immunologic group was 2.8 (95% confidence interval, 1.6-4.9). Recurrence rate was 12% in the immunologic group versus 1% and 0% in the other diseases and remaining groups (P < .05). The relative risk of 10-year graft loss for patients with recurrence was 2.7 (95% confidence interval, 1.2-6.3). Ten-year graft loss rates for patients with biopsy-proven acute rejection, chronic allograft nephropathy, and recurrent glomerulonephritis were 30%, 23%, and 42% (P < .05). For those with biopsy-proven recurrent glomerulonephritis, 10-year estimated glomerular filtration rate was significantly lower than for those with biopsy-proven acute rejection or chronic allograft nephropathy (14 ± 6 vs 18 ± 7 vs 30 ± 10 mL/min; P < .05). CONCLUSIONS: Kidney transplant recipients with immunologically mediated kidney diseases have inferior long-term allograft survival and function versus patients with other causes of renal failure. Recurrence represents the strongest risk factor for premature loss of function and transplant failure.

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.

Thymoglobuline plus basiliximab a mixed cocktail to start?

Recent results reported by Ciancio et al. have demonstrated the long term successful use of dual induction therapy in kidney transplant recipients. Our experience using an "induction cocktail", thymoglobuline plus basiliximab, started in 2007 and we have treated 235 patients through the past 10years. In our population, we used a combination of CNIs and MMF or mTORi as maintenance therapy. Our results in term of patient and graft survival, acute rejection rate, renal function and incidence of post-transplant lymphoproliferative disorder support the data reported by Ciancio. We believe that double induction therapy allows on one hand to delay the CNIs introduction, reducing delayed graft function, and on the other hand protects the patient while building the targeted drugs exposures, so reducing the incidence of acute rejection.

Attachment style predict compliance, quality of life and renal function in adult patients after kidney transplant: preliminary results.

AIM: Aim of this study was to evaluate the association between attachment style, compliance, quality of life and renal function in adult patients after kidney transplantation. METHODS: A total of 43 adult patients who received a kidney transplant more than 3 months before were enrolled and were asked to complete two Self-Report questionnaires: Attachment Style Questionnaire (ASQ-40) and Short Form Health Survey (SF-36). Also compliance was measured using appropriate questions. RESULTS: Linear regression analysis showed associations between the confidence in relationships (ASQ-40) and compliance [beta = -0.37; B = -0.02; t(41) = -2.51; p = 0.02]; aspects of anxious attachment style (ASQ-40) and creatinine levels [beta = 0.3; B = 0.13; t(41) = 2.03; p = 0.04]; aspects of avoidant attachment style (ASQ-40) and compliance [beta = -0.37; B = -3.15; t(41) = -2.35; p = 0.02]. Patients who exhibited avoidant attachment had a significantly better perception of their own general health than patients with anxious [F(2,37) = 6.8; p < 0.05] or secure attachment; however, they had a worse perception regarding role limitations due to emotional problems, compared to patients with anxious attachment [F(2,37) = 6.4; p < 0.05]. DISCUSSION: The results of this study suggest that the evaluation of the attachment style in adult kidney transplant patients can contribute to plan a goal-directed psychological support program for these patients, in order to increase their compliance. The association between aspects of anxious attachment style and creatinine level needs more investigations.

Emotional self-efficacy and alexithymia may affect compliance, renal function and quality of life in kidney transplant recipients: results from a preliminary cross-sectional study.

UNLABELLED: Recent studies show that alexithymia may influence compliance and quality of life in different clinical situations. The aim of this study was to evaluate the associations between alexithymia or emotional self-efficacy and compliance, quality of life (QoL) and renal function in renal transplant patients. METHODS: Forty-three patients were enrolled during a follow-up visit (>3 months post-transplant) and were asked to complete three self-report questionnaires (TAS-20, SF-36, RESE) to answer the following items: "In the past four weeks, how many times did you fail to take your prescribed dose?" and "How would you rate your adherence levels from 0 to 100?" (visual analogue scale). RESULTS: Alexithymia was positively correlated with non-compliance (r=.314; p=.04), and negatively with QoL dimensions. Analysis of variance confirmed that patients with high levels of alexithymia reported a negative perception of their QoL (mental health: F(1,41)=7,6; p=.008) and lower levels of compliance (F(1,41)=12,5; p=.001) compared with patients with low levels of alexithymia. The self-efficacy in the management of negative emotions was significantly correlated (r=-.314; p=.04) with creatinine levels and positively with the QoL (mental health: r=.421; p=.005). DISCUSSION: The inability to recognize and express emotions, as well as the ability to manage negative emotions, may influence compliance and QoL of renal transplant patients. Focused psychological support could be useful in these patients in order to increase their compliance and QoL.

One-shot versus multidose perioperative antibiotic prophylaxis after kidney transplantation: a randomized, controlled clinical trial.

BACKGROUND: There is no consensus on the optimal perioperative antibiotic prophylaxis regimen for renal transplant recipients. Some studies have reported that irrigation of the wound at the time of closure without systemic antibiotics may suffice to minimize the risk for surgical site infection (SSI), but many centers still use long-term, multidose regimens in which antibiotics are administered until removal of foreign bodies occur, such as the urethral catheter, drain and central line. METHODS: We designed a prospective, randomized, multicenter, controlled trial to compare a single dose versus a multidose regimen of systemic antibiotic prophylaxis in adult, nondiabetic, non-morbidly obese patients undergoing renal transplantation. The primary endpoint was the incidence of SSI; the assessment of other infection in the first postoperative month was the secondary endpoint. RESULTS: Two hundred five patients were enrolled and randomized to receive either a single (n = 103) or multidose antibiotic regimen (n = 102) for prophylaxis. The incidences of SSI and urinary tract infection were similar in both groups. CONCLUSION: As the dramatic increase in antibiotic resistance has mandated the implementation of global programs to optimize the use of antibiotic agents in humans, we believe that the single dose regimen is preferred, at least in nondiabetic, non-morbidly obese, adult renal transplant recipients.

Effectiveness of the Transoral Endoscopic Vertical Gastroplasty (TOGa®): a good balance between weight loss and complications, if compared with gastric bypass and biliopancreatic diversion.

BACKGROUND: The effectiveness of restrictive procedures has been inferior to that of malabsorbitive ones. Recent variants of restrictive procedures, i.e., gastric banding and sleeve gastrectomy, confirm the strive for more efficacious solutions with less complications. We investigated the balance between effectiveness and complications for a new restrictive procedure, a Transoral Endoscopic Vertical Gastroplasty (TOGa®) METHODS: Seventy-nine morbidly obese patients were submitted to one out of three surgical procedures: TOGa® (29 patients), laparoscopic gastric bypass (LRYGBP; 20 patients), and biliopancreatic diversion (BPD; 30 patients). Mean BMI were 41.7 (35.4-46.6), 44.8 (36.4-54), and 47.5 (41-60.3), respectively. All the patients reached a 2-year follow-up. RESULTS: In TOGa® group BMI, respectively at 12 and 24 months, was 34.5 and 35.5, with 44 and 48.3% of patients with BMI lower than 35. In LRYGBP group, BMI was 30.7 and 29.2 kg/m(2), with 80 and 85% of patients with BMI < 35. In BPD group, BMI was 30 and 29.6 kg/m(2), with 100 and 93.3% of patients with BMI < 35. In TOGa® group, 59% of patients with an initial BMI < 45 reached a BMI < 35, in comparison to 48% recorded in the whole group and to 14.3% in patients with initial BMI ≥ 45. CONCLUSIONS: In selected patients, TOGa®, was associated with good results after two years in terms of weight loss, even in comparison with LRYGBP and BPD. Minimal trauma, absence of complications, and short hospital stay justify this procedure for patients with low BMI.