30th ESPU Congress - Lyon, France - 2019

S10: RENAL TRANSPLANT

Moderators: Sajid Sultan (Pakistan), Seppo Taskinen (Finland)

ESPU Meeting on Thursday 25, April 2019, 16:46 - 17:30


16:46 - 16:49
S10-1 (PP)

THE FUTURE OF DATABASE ANALYSIS: PREDICTING ESTIMATED GLOMERULAR FILTRATION RATE (EGFR) AFTER KIDNEY TRANSPLANTATION EMPLOYING MACHINE LEARNING TECHNOLOGY

Armando LORENZO 1, Mandy RICKARD 2, Anne-Sophie BLAIS 2, Nicolas FERNANDEZ 2 and Martin KOYLE 2
1) The Hospital for Sick Children, Urology, Toronto, CANADA - 2) The Hospital for Sick Children, Division of Urology, Toronto, CANADA

PURPOSE

The application of artificial intelligence is becoming widespread in medical communities and being explored to enhance patient care. Herein we explore this technology, by using commercially available machine learning algorithms to assist with prediction of posttransplant glomerular filtration rate (eGFR) in pediatric renal transplantation (RT) patients.

MATERIAL AND METHODS

A de-identified RT database was uploaded into Microsoft® Azure Machine Learning Studio. Probabilistic principal component analysis was employed for data imputation. Relevant clinical variables were included in two class decision jungle and logistic regression for model training. The outcome of interest (eGFR) was dichotomized into a binary variable of >60 or <60. Models were scored and evaluated after a 70/30 split of the data.

RESULTS

325 patients were included and the optimized model (decision jungle) achieved an area under the curve of 0.9, accuracy of 0.80 and precision of 0.80, employing a threshold of 0.5 to predict eGFR<60. Average run time to train, score and evaluate the model was 34 seconds. The predictive model was deployed as a web service in 25 seconds, generating a unique API key for app and webpage development. Individualized prediction based on the included variables was deployed as a web-based and batch execution Excel® file in less than one minute. Updating the model with new data was achieved within these timeframes.

CONCLUSIONS

We have demonstrated that cloud-based machine learning technology allows easy building, deployment, and sharing of predictive analytics solutions. Large databases can be easily combined and analyzed in real time, which allows for creation and updating of predictive models based on large amounts of information.


16:49 - 16:52
S10-2 (PP)

THE PAIRED KIDNEY EXCHANGE PROGRAM: A WAY TO INCREASE THE NUMBER OF LIVING DONOR PAEDIATRIC KIDNEY TRANSPLANTS. RETROSPECTIVE ANALYSIS OF BENEFITS AND SPECIFIC DIFFICULTIES.

Aurore BOUTY 1, Esther MACKNAMARA 2, Mike O'BRIEN 1, Joshua KAUSMAN 2 and Yves HELOURY 1
1) Royal Children's Hospital, Urology, Parkville, AUSTRALIA - 2) Royal Children's Hospital, Nephrology, Parkville, AUSTRALIA

PURPOSE

Paired kidney exchange (AKX) allows patients to receive a living donor transplant when direct related donation is impossible due to immunological barriers (donor-specific antibodies (DSA) or blood group mismatch (ABOi)). It involves multi way donation between pairs of donors and recipients that are better matched than related pairs. The goal of the study is to report the benefits and difficulties of paediatric AKX in a vast country.

MATERIAL AND METHODS

Unicentric retrospective review of paediatric renal transplants between 2010 and 2018. Electronic medical records were scanned with special emphasis on reasons for AKX and outcomes.

RESULTS

Seventy paediatric renal transplants were performed; 44 from living donors, including 9 AKX. Reason for AKX was as follow: DSA in 7 (three previous transplants, four blood transfusions), poor matching in one and Hep BcAb positive donor in one. Median number of recipients per chain was 3 (2-9) with a median of 4 (3-8) hospitals involved on a same day. The median of the longest distance travelled by a kidney is 878 km (36-3934). Two chains were cancelled and significant preoperative logistic challenges were present in 5 cases. Although median cold ischemia time was 337 minutes (202-521), there was no delayed graft function. All grafts were functional at a median of 33 months (4-51).

CONCLUSIONS

AKX has specific organisational constraints related to the number of patients and departments involved in the chains. It requires significant adaptability but allows to increase the possibility of living donor kidney transplant even in large geographic areas.


16:52 - 16:55
S10-3 (PP)

GRAFT SURVIVAL IN PAEDIATRIC RENAL TRANSPLANT: COMPARATIVE STATISTICAL ANALYSIS BETWEEN UROLOGICAL AND NO-UROLOGICAL CAUSES OF ESRD

Tessi CATALINA, Javier RUIZ, Snatiago WELLER, Felicitas LOPEZ IMIZCOZ, Cristian SAGER, Carol BUREK and Juan Pablo CORBETTA
GARRAHAN HOSPITAL BUENOS AIRES ARGENTINA, UROLOGY, Ciudad Autonoma De Buenos Aires, ARGENTINA

PURPOSE

Kidney transplantation is the treatment of choice for children with end stage renal disease (ESRD). Immunologic and surgical advances have improved patient and graft survival. Urological causes of ESRD had been associated with higher complication rates and poorer graft survival.
The aim of this study is to compare outcomes between urological and no-urological etiologies of ESRD in terms of graft survival and urologic complications.

MATERIAL AND METHODS

We performed a retrospective study of paediatric patients who underwent renal transplantation at our department from January 2014 to December 2016. Demographic data, cause of ESRD, type of donor, and cold ischemia time were recorded.
Overall graft survival rates and urologic complications were statistically analysed.

RESULTS

97 paediatric kidney transplants were analysed. Mean age at transplantation was 11.8 years (+- 4.2). Urological cause of ESRD represented 43.2% of the patients, in this group UTIs were more frequent (p<0.008). There were no statistical differences in other urologic and vascular complications between urological and non-urological causes of ESRD. Graft survival rates were 86.2% in the urological group and 88.4% in the non-urological group (log Rank test p 0.735 HR 1.2 IC95% 0.4-4.1). Age, weight, previous surgeries, and cold ischemia time were not associated with graft survival in univariate analysis. The mean follow-up was 32 months (23-43).

CONCLUSIONS

Kidney transplantation in patients with urological cause of ESRD has similar graft survival rates when compared with non-urological ESRD. Despite the fact that ITU were more frequent in urologic patients, complications rates were similar in both groups.


16:55 - 16:58
S10-4 (PP)

COMPARING OUTCOMES OF CONVENTIONAL URETERONEOCYSTOSTOMY VERSUS URETEROURETEROSTOMY IN PEDIATRIC RENAL TRANSPLANTATION

Fadi ZUBI, Michael CHUA, Jessica MING, Justin KIM, Mitchell SHIFF, Martha POKAROWSKI, Armando J. LORENZO, Walid A. FARHAT and Martin A. KOYLE
The Hospital for Sick Children, Urology, Toronto, CANADA

PURPOSE

Ureteroureterostomy (UU) has been proposed as an alternative to the conventional ureteroneocystostomy (UNC) in pediatric renal transplantation. This technique may proffer the advantage of maintaining a natural ureteral orifice with natural antirefluxing anatomy, and for endoscopic access if needed in the future. Herein we compare the outcomes of UU and UNC in the pediatric transplant population.

MATERIAL AND METHODS

We retrospectively reviewed all pediatric transplants performed in a single institution from January 2000 to September 2018. Two groups were evaluated: UU group and UNC group. We compared age at time of surgery, total operative time and estimated blood loss using the student T-test. Other variables including: underlying diagnosis (intrinsic vs urologic), living vs deceased donor, intraoperative complications, ureteral anastomosis related complications and urinary leaks were compared using Fisher exact test.

RESULTS

A total of 374 transplants were performed (68 UU and 306 UNC) during the study period. There was no significant difference between UU vs UNC in regards to age in months at time of surgery (128.2±6.9 vs 132.7±3.6, p =0.58), total operative time (287.±+11.6 vs 289.±+6.7, p=0.89), and estimated blood loss (206.4±23.8 vs 288±31.6, p=0.23). There was no significant difference in underlying conditions with intrinsic diagnoses in 79.4% UU vs 69.3% of UNC (p=0.1). We found a significant difference in donor type with living being 22.1% of UU vs 50.3% UNC (p<0.0001). There was no significant difference in intraoperative complications, ureteral anastomotic related complications (urinary leak or stenosis) between the UU and UNC groups.

CONCLUSIONS

Ureteroureterostomy has comparable outcomes to ureteroneocystostomy in the pediatric transplant population. It should be considered in certain complex situations include challenging small bladder due to anuria, valve bladder and in a neurogenic augmented bladder.


16:58 - 17:01
S10-5 (PP)

UPSIDE-DOWN KIDNEY PLACEMENT: AN ALTERNATIVE IN PEDIATRIC RENAL TRANSPLANTATION

Alba BUENO 1, Leire LARREINA 1, Javier SERRADILLA 1, Solón CASTILLO 2, Borja NAVA 1, Roberto LOBATO 2, Susana RIVAS 2, Pedro LOPEZ-PEREIRA 2, Leire GARCÍA 3, Laura ESPINOSA 3 and Maria José MARTÍNEZ-URRUTIA 2
1) Children's Hospital La Paz, Pediatric Surgery, Madrid, SPAIN - 2) Children's Hospital La Paz, Pediatric urology, Madrid, SPAIN - 3) Children's Hospital La Paz, Pediatric nephrology, Madrid, SPAIN

PURPOSE

Kidney placed "upside-down" (inverted) has been reported as an acceptable alternative in cases of technical difficulty in kidney transplantation but there is no literature on this resource in pediatric population.

The aim of our study is to analyze whether the placement of the upside-down kidney could affect the graft outcome or produce more complications.

MATERIAL AND METHODS

A retrospective study of pediatric kidney transplant performed in our center in the last 12 years (2005-2017), with at least 6 months of follow-up, was conducted.

Epidemiological and anthropometric data, type of donor (deceased/alive), graft position (normal/upside-down), reason for the inverted placement of the kidney, early, medium and long-term complications and renal function were analyzed and compared with patients transplanted in the same period with non-inverted graft's placement.

RESULTS

From 181 transplants, 167 grafts were placed in normal position (mean age and weight of yrs and kg respectively) and 14 were inverted (10yrs, 37kg), all of them due to shortness of vessels after laparoscopic nephrectomy. Male predominance was observed in both groups.
57% grafts from control group and 64% from study group came from a living donor.
4 vascular and 2 ureteral reanastomoses were recorded in control group and 2 vascular and 1 ureteral in study group (p>0.05). In the lattest, there were no graft loss due to vascular or urological causes and no patients have been on dialysis ever since

CONCLUSIONS

The inverted position of the renal graft is a safe alternative in pediatric population when required.


17:01 - 17:04
S10-6 (PP)

THE IMPACT OF MULTIPLE DONOR RENAL ARTERIES ON PERIOPERATIVE COMPLICATIONS AND ALLOGRAFT SURVIVAL IN PAEDIATRIC RENAL TRANSPLANTATION

Fardod O ' KELLY, Fadi ZUBI, Keara DE COTIIS, Mandy RICKARD, Armando LORENZO, Walid FARHAT and Martin KOYLE
The Hospital for Sick Children (Sick Kids), Paediatric Urology, Toronto, CANADA

INTRODUCTION

The use an impact of grafts with multiple donor arteries in paediatric kidney transplantation has not been clearly established with evidence suggesting their use may lead to higher risks of complications and delayed graft function in adult studies. The aim of this study was to determine whether kidney grafts with multiple arteries pose any adverse effects upon perioperative surgical outcomes, and graft survival up to 12 months post-transplant

MATERIAL AND METHODS

We reviewed 379 transplants performed in our institution (2000-2018), of which 90 (23.7%) contained multiple donor arteries. The number of arteries of the graft, donor type, vascular reconstruction technique, the occurrence of urological and vascular complications, the incidence of delayed graft function, estimated GFR and graft survival 1, 6 and 12 months after transplantation, graft loss and patient deaths were analysed, with log-rank, univariate and comparative statistical analysis performed to identify risk factors for vascular complications

RESULTS

There were found no significant differences found in age (p=0.42), BMI (p=0.39), estimated intraoperative blood loss (p=0.14), overall (p=0.63) or warm ischaemic time (p=0.37). 51.3% patients with multiple donor arteries underwent an ex-vivo reconstruction. There were no differences in the site of arterial anastomosis (aorta, iliac, epigastric), or anastomotic type (end-side; side-side). Whilst there was a significantly higher post-op lymphocoele rate in the multiple vessel cohort (p=0.033), there was no increase in post-transplant urine leaks, rejection episodes, graft loss (1.1% multiple  vs 2.1% single), perioperative complications (p=0.68) or estimated GFR at 1week (p=0.52), 1 month (p=0.59) and at 1 year (mean 95.76mL/min/1.73 m2;p=0.3)

CONCLUSIONS

This relatively large series demonstrates that multiple renal artery allografts which have previously been considered to carry a high complication risk can be safely used for paediatric renal transplantation with equivalent perioperative complications and graft outcomes to single artery allografts


17:04 - 17:22
Discussion
 

17:22 - 17:27
S10-7 (VP)

★ SINGLE SETTING ROBOT-ASSISTED KIDNEY TRANSPLANTATION (RAKT) IN A CHILD CONSECUTIVE TO SINGLE-SITE LAPAROSCOPIC NEPHRECTOMY IN THE CHILD AND LIVING-DONOR RELATED ROBOTIC NEPHRECTOMY: INITIAL EXPERIENCE.

Anne-Françoise SPINOIT 1, Achilles PLOUMIDIS 1, Athanasios PAPPAS 1, Ruben DE GROOTE 1, Elise DE BLESER 1, Caren RANDON 2, Agniezka PRYTULA 3, Johan VANDE WALLE 3, Ann RAES 3, Erik VAN LAECKE 1, Piet HOEBEKE 1 and Karel DECAESTECKER 1
1) Ghent University Hospital, Urology, Ghent, BELGIUM - 2) Ghent University Hospital, Vascular Surgery, Ghent, BELGIUM - 3) Ghent University Hospital, Pediatric Nephrology, Ghent, BELGIUM

PURPOSE

Kidney transplantation is gold-standard treatment for end-stage renal disease (ESRD) in children. Robot-Assisted Kidney Transplantation (RAKT) in adults is becoming increasingly common in centers of reference with promising results and potentially improved morbidity compared to open transplantation.  Our objective was to evaluate the feasibility, perioperative and early postoperative outcomes of RAKT in children.  To our knowledge, this is the first report of RAKT in a child.  The technique is presented in our video.

MATERIAL AND METHODS

January 2018: a 7-years-old boy with ESRD due to congenital uropathy received a kidney transplant from his mother.  Simulteanously in two operation theatres, the boy underwent single port (GelPOINT®) right laparoscopic nephro-ureterectomy (LNU) and his mother underwent robot-assisted left donor nephrectomy (RADN). The GelPOINT® was used as single-site  for the LNU to minimize invasiveness.  Two full surgical teams were operating at the same time. Subsequently, the boy underwent RAKT, introducing the kidney through the GelPOINT®. 

RESULTS

Total operative time for RAKT, RADN and LNU was 195, 140, 180 min respectively, with warm, cold and rewarming ischemia times 1.5, 200 and 47 min respectively. Vascular and ureterovesical anastomosis times were 30 and 25 min respectively.  Blood loss was 50, 20, 300 cc respectively. No intraoperative or postoperative complications were noted. Convalescence of both the donor and the recipient was uneventful.  Estimated glomerular filtration rate of the graft at day 1, 3, 7, 30 and 90 was 75, 94, 62, 46 and 60 ml/min/1,73m2 respectively. At 4 weeks, he was diagnosed with acute humoral rejection grade IA (Bannf score g0i2t2) treated successfully with pulsed corticosteroids.

CONCLUSIONS

RAKT in children is technically feasible and safe, resulting in excellent graft function. Concomitant nephrectomy can be done laparoscopically through the single-site GelPOINT®. It should be attempted by an experienced RAKT team with the full support of pediatric nephrologists. 


17:27 - 17:30
Discussion