Successful transplantation of LUCAS device assisted uncontrolled DCD kidneys with prolonged relative warm ischemia time: An underutilized option in North America.

Approximately 25% of deceased donors in the United States are procured in a donation after circulatory death (DCD) setting. Successful transplant outcomes from uncontrolled DCD (uDCD) practices have been reported in multiple European programs. They utilize established protocols for uDCD procurement with normo-thermic or hypothermic regional perfusion to reduce ischemic damage. Further, manual or mechanical chest compressions using extrinsic devices, such as the LUCAS device, are implemented to maintain circulation before organ retrieval. Currently, uDCDs are not a major part of DCD organ utilization in the United States. We report our experience with utilization of kidneys from uDCD with the use of the LUCAS device without normothermic or hypothermic regional perfusion. We transplanted four kidneys from three uDCD donors without utilization of in situ regional perfusion and with prolonged relative warm ischemia time (rWIT) (>100 min). All recipients had functional renal allografts and improved renal function after the transplant. To our knowledge, this is the 1st successful series reported in the United States of the utilization of kidneys from uDCDs without the utilization of in situ perfusion to maintain organ preservation with prolonged rWIT.

Wound related complications and the anterior rectus sheath versus Gibson approach to kidney transplantation: A single center randomized controlled trial.

INTRODUCTION: Wound related complications (WRC) are a significant source of morbidity in kidney transplant recipients, and may be mitigated by surgical approach. We hypothesize that the anterior rectus sheath approach (ARS) may decrease WRC and inpatient opiate use compared to the Gibson Approach (GA). METHODS: This double-blinded randomized controlled trial allocated kidney transplant recipients aged 18 or older, exclusive of other procedures, 1:1 to ARS or GA at a single hospital. The ARS involves a muscle-splitting paramedian approach to the iliopsoas fossa, compared to the muscle-cutting GA. Patients and data analysts were blinded to randomization. RESULTS: Seventy five patients were randomized to each group between August 27, 2019 and September 18, 2020 with a minimum 12 month follow-up. There was no difference in WRC between groups (p = .23). Nine (12%) and three patients (4%) experienced any WRC in the ARS and GA groups, respectively. Three and one Clavien IIIb complications occurred in the ARS and GA groups, respectively. In a multiple linear regression model, ARS was associated with decreased inpatient opioid use (ß = -58, 95% CI: -105 to -12, p = .016). CONCLUSIONS: The ARS did not provide a WRC benefit in kidney transplant recipients, but may be associated with decreased inpatient opioid use.

Altering the Approach: Open Minimally Invasive Renal Transplant in Obese Patients Through the Anterior Rectus Sheath.

OBJECTIVE: To retrospectively analyze the wound issues for obese renal transplant patients, as well as post-transplant outcomes including graft and patient survival, hypothesizing improvement over the standard approach. As the obese population has expanded, minimally invasive renal transplant techniques have attempted to improve the issues of complications related to wounds and hernias. The anterior rectus sheath approach, which facilitates a minimal incision, has been adopted at our center for all renal transplants, including obese patients. METHODS: Between January 1, 2011 and December 31, 2014, 166 renal transplants were performed at the Charleston Area Medical Center with the new approach adopted in November 2012. Of the extraperitoneal transplants, 71 adult patients were classified as morbid/severe (≥35) or obese (30-34.9) by body mass index. Demographics, perioperative results, and outcomes were retrospectively collected for the conventional (CON) and anterior rectus sheath (ARS) approaches until August 21, 2015. RESULTS: The ARS and CON groups comprised 40 of 71 (56%) and 31 of 71 (44%) patients, respectively. The majority of demographics and perioperative data indicated no significant statistical differences between procedures (P < .05). Wound complications, incision length, operative time, and glomerular filtration rate at 6 and 12 months were significantly different. Multivariate calculations indicated procedure as the only variable expected to affect wound healing in obese patients. CONCLUSION: For obese patients, the ARS approach was shown to be an effective option that reduced wound complications and operative times. This easily adopted approach provides the obese and morbidly obese with comparable overall graft outcomes and significant improvement on wound complications.

First experience: Open small incision rectus sheath approach renal transplant: A case series.

BACKGROUND: Prevention of wound complications is an important goal in surgery, and reduction of modifiable risks factors are an important step towards protecting patients from further complications. Renal transplantation has sought to be more inclusive giving access to transplantation to complex patient populations, many of which have an increased risk of complications specifically obese recipients. Surgical techniques continue to advance and may contribute to reducing complications. We hypothesized that the Anterior Rectus Sheath (ARS) Approach would provide an open transplant with minimal damage and less wound complications, including fluid collections such as lymphoceles, when compared to the conventional technique (CON) with equivalent graft function and survival. MATERIALS AND METHODS: The ARS approach was adopted at our center in November of 2012. Medical records for 44 patients that underwent kidney transplantation at our Center between May 1, 2012 and March 31, 2013 were reviewed with data collected up to August 2015. Two were excluded (2 intraperitoneal transplants), leaving 22 in the ARS group and 20 in the CON group. RESULTS: Demographics, data, and perioperative factors were found to be similar, but operative and post-operative findings indicated significant differences between the groups. Significant reductions of wound complications, including fluid collections, were observed and operative time, incision length, and drain usage were improved with the ARS technique. Secondary outcome assessing overall patient outcomes showed no significant difference. CONCLUSION: This retrospective review case series quantified that this easily adopted modification of the conventional transplant technique is a safe, effective, and swift approach to renal transplantation with favorable graft results and improved surgical outcomes with less post-operative wound complications.

Paired kidney donor exchanges and antibody reduction therapy: novel methods to ameliorate disparate access to living donor kidney transplantation in ethnic minorities.

BACKGROUND: Currently ethnic minority patients comprise 60% of patients listed for kidney transplantation in the US; however, they receive only 55% of deceased donor renal transplants and 25% of living donor renal transplants. Ethnic disparities in access to kidney transplantation result in increased morbidity and mortality for minority patients with end-stage renal disease. Because these patients remain dialysis dependent for longer durations, they are more prone to the development of HLA antibodies that further delay the possibility of receiving a successful kidney transplant. STUDY DESIGN: Two to 4 pretransplant and post-transplant plasma exchanges and i.v. immunoglobulin were used to lower donor-specific antibody levels to less than 1:16 dilution; cell lytic therapy was used additionally in some cases. Match pairing by virtual cross-matching was performed to identify the maximal exchange benefit. Sixty candidates for renal transplantation were placed into 4 paired kidney exchanges and/or underwent antibody reduction therapy. RESULTS: Sixty living donor renal transplants were performed by paired exchange pools and/or antibody reduction therapy in recipients whose original intended donors had ABO or HLA incompatibilities or both (24 desensitization and 36 paired kidney exchanges). Successful transplants were performed in 38 ethnic minorities, of which 33 were African American. Twenty-two recipients were white. Graft and patient survival was 100% at 6 months; graft function (mean serum creatinine 1.4 g/dL) and acute rejection rates (20%) have been comparable to traditional live donor kidney transplantation. CONCLUSIONS: Paired kidney donor exchange pools with antibody reduction therapy can allow successful transplant in difficult to match recipients. This approach can address kidney transplant disparities.