[Kidney transplantation from Covid-19 positive deceased donor: what are the consequences for recipients?]

INTRODUCTION: In recent months, with the spread of COVID 19, the number of kidney transplants from deceased donors has declined significantly in most countries. One of the reasons is the possibility of infection of the recipient with SARS-CoV-2. Determining the risk of transmission of COVID 19 with a donor organ is very important for developing a kidney transplantation policy during a pandemic. MATERIAL AND METHOD: We present cases of kidney transplantation from COVID 19 positive deceased donor to two dialysis patients in single center. Deceased donor: a 45 years old man with diabetes, who had a major hemorrhagic stroke resulting in brain death. He had normal urine output and serum creatinine level for last 24 hours before kidney harvesting. For a few hours after organ harvesting, the donor was diagnosed COVID 19 (retrospective nasopharyngeal swab rRT-PCR which was confirmed by morphological examination and RNA-PCR of specimens from the trachea and bronchus). Recipient 1: a 49 years old man with polycystic kidney disease had been on hemodialysis for 28 months. He was in urgent list because of problems with vascular access. So non identical ABO (0-donor, B-recipient) kidney transplantation from this deceased donor was done in May 2020. Recipient 2: a 45 years old man with polycystic kidney disease on continuous ambulatory peritoneal dialysis (CAPD). was registered on urgent waiting list because of low transport capacity of peritoneum. Kidney transplantation from the same deceased donor was done at the same time. In both cases we completely abandoned any antilymphocytic agents for induction, despite non ABO identical transplantation in one of the recipients and the delayed graft function. Both patients received only basic immunosuppression, including tacrolimus, methylprednisolone and a mycophenolic acid. RESULTS: In first case cold ischemia time was 22 hours. The recipient had delayed graft function with increasing of urine output on day 8 post-transplant. No other deviations from the usual course were seen during hospital stay. The patient was discharge from hospital with serum creatinine level 122 mkmol/L. The cold ischemia time was 21 hours in another patient. Graft function was immediate with a decrease serum creatinine to 92.5 mkmol/L at discharge. Both patients had no febrile and no other symptoms of acute respiratory disease during all hospital stay. No abnormalities on chest X-ray were seen. No serum anti-SARS-CoV-2 IgM and IgG were detected before and during 6 weeks after surgery. Repeated nasopharyngeal swabs rRT-PCR were negative during all the period. Both recipients were discharged for 5 weeks after surgery to prevent out-of-hospital contamination of COVID 19, which would be difficult to differentiate from transmission infection. After 9 months both patients are doing well with no clinical or laboratory signs of COVID-19. CONCLUSION: Today we have no evidence of the possibility of transmission of COVID-19 from a SARS-Cov-2 positive donor to a kidney recipient. We also have no reason to suspect kidney damage by COVID-19 in a deceased donor at normal serum creatinine level. Avoiding the use of anti-lymphocyte drugs for induction of immunosuppression may also reduce the risk of developing COVID19 after transplantation. A careful collection and analysis of such dates is necessary to develop modern practical recommendations for transplant centers.

[Laparoscopic radical cystectomy: novel technique with late dividing of the ureters].

INTRODUCTION: Despite considerable progress during last decade, laparoscopic radical cystectomy (LRC) still remains a complex and time-demanding procedure. The number of patients with baseline chronic kidney diseases has gradually increased. AIM: to compare the results of our novel technique of LRC with late dividing of the ureters with conventional procedure. MATERIALS AND METHODS: A total of 50 patients with bladder cancer, who underwent to LRC in a single clinic between April 2013 and January 2017, were included in the study. A conventional LRC was performed in 25 patients, while in other 25 cases, a novel technique of LRC was used. In all cases, LRC was done with fully intracorporeal urinary diversion. Statistical analysis was performed using the Shapiro-Wilk test for parametric testing. In order to compare two groups, Student t-test was used for independent samples. RESULTS: There were no significant differences between two groups in average length of procedure, blood loss volume and length of hospital stay. Major intraoperative complications (injury of the rectum) occurred in two patients, one in each group. Both cases were successfully managed intraoperatively. In addition, there were two postoperative complications in each group that required repeat intervention. The mean serum creatinine level on the 2nd day after surgery was significantly higher after conventional LRC (171.6 and 147.7 mol/L), while glomerular filtration rate was significantly lower (58 and 72 ml/min/1.73 m2), compared to group of novel technique of LRC with late dividing of the ureters. A total of four patients in group of conventional LRC and two patients in group of novel technique had cancer progression. Two patients (one in each group) died because of cancer progression after 15 and 34 months after surgery. The mean follow-up was 25.6 (12-39) months after LRC with late dividing of the ureters and 33.2 (18-48) months in group of standard LRC. CONCLUSION: LRC with late dividing of the ureters allow to prevent prolonged contact of hyperosmolar and, in some cases, non-sterile urine with peritoneum and decrease inflammation and risk of postoperative adhesions. Using of novel technique may decrease rate of perioperative nephropathy, which is especially important in patients with decreased renal function (single functioning kidney, hydronephrosis, diabetes, renal failure, adjuvant chemotherapy). However, more procedures and longer follow-up period are necessary in order to evaluate ontological results of the novel technique.

[Retroperitoneoscopic radical nephrectomy with inferior vena cava thrombectomy].

INTRODUCTION: Although laparoscopic radical nephrectomy has confidently established itself as the "gold standard" for treating renal cell carcinoma, reports on laparoscopic level II-III inferior vena cava (IVC) tumor thrombus thrombectomy are still lacking. MATERIALS AND METHODS: From September 2013 through April 2015, three patients with renal cell carcinoma and level II IVC tumor thrombi underwent laparoscopic radical nephrectomy with IVC thrombectomy using a retroperitoneal approach. Tumor sized 10, 8, and 9 cm in the greatest dimension, the length of the IVC thrombi in proximal direction were 2.8, 4.1 and 3.5 cm, respectively. RESULTS: In all patients, the endoscopic interventions were completed successfully without conversion to open surgery. Blood loss was less than 450 ml. No significant intraoperative or postoperative complications were observed. The patients were discharged from the hospital in satisfactory condition at days 19, 7 and 14, respectively. One patient with multiple lung and bone metastases died 11 months after the operation. The two other patients showed no signs of disease progression during the follow-up (16 and 35 months). CONCLUSION: The retroperitoneal approach has certain advantages over the transperitoneal one. The method is relatively safe and reproducible. However, additional experience and further research are needed before the place of such operations in routine clinical practice can be assessed.