5th Joint Meeting of ESPU-SPU - Virtual

S20: RENAL TRANSPLANTATION

Moderators: Antonio Macedo (Brasil)

ESPU-SPU Meeting on Saturday 25, September 2021, 15:15 - 16:03


15:15 - 15:18
S20-1 (PP)

THE IMPACT OF DONOR AND RECIPIENT GENDER ON PEDIATRIC LIVING-DONOR KIDNEY TRANSPLANT OUTCOME

Maria Virginia AMESTY 1, Aitor ARRIEN 2, Pedro LOPEZ PEREIRA 1, Marta MELGOSA 3 and Maria Jose MARTINEZ URRUTIA 1
1) Hospital Universitario La Paz, Pediatric Urology, Madrid, SPAIN - 2) Hospital Universitario La Paz, Madrid, SPAIN - 3) Hospital Universitario La Paz, Pediatric Nephrology, Madrid, SPAIN

PURPOSE

Gender is a factor that may influence kidney transplant outcome, which has not been studied in children. Our aim is to analyze the impact of recipient and donor gender in pediatric living-donor kidney transplant (LDKT).

MATERIAL AND METHODS

A retrospective review of children who received a LDKT with ≥4 years of follow-up was performed. Patients were divided according to recipient-donor gender into 4 groups: male to male (M-M), male to female (M-F), female to male (F-M) and female to female (F-F). Variables analyzed were age, ESRD cause, graft size, cold ischemia time, rejection episodes, GFR and serum creatinine at end of follow-up, graft and patient survival.

RESULTS

From a total of 149 LDKT, 85 were included. The number of recipient-donor pairs of each group were: F-M 35(41%), F-F 27(32%), M-M 15(18%), M-F 8(9%). There were no significant differences between groups in recipients and donors ages, graft size, cold ischemia time, rejection and follow-up. At the end of follow-up, the best GFR, the least decrease of GFR and lowest serum creatinine levels were found in pairs M-F and F-F (p<0.05). The worst outcome corresponded to pairs M-M and F-M, in terms of GFR, GFR decrease and serum creatinine levels (p<0.05). The were not significant differences in graft and patient's survival between groups, but there was a tendency to worse long-term graft survival in M-M and F-M groups.

CONCLUSIONS

LKDT outcome was better when recipients were female, and worse outcome was found in male recipients. More studies are needed to confirm these findings.


15:18 - 15:21
S20-2 (PP)

NATIVE NEPHRECTOMY PRIOR TO KIDNEY TRANSPLANT: A 16-YEAR INSTITUTIONAL EXPERIENCE

Jin Kyu (Justin) KIM 1, Lucshman RAVEENDRAN 2, Michael CHUA 2, Armando LORENZO 2, Walid FARHAT 3, Jessica MING 4 and Martin KOYLE 2
1) University of Toronto, Division of Urology, Department of Surgery, Toronto, CANADA - 2) The Hospital for Sick Children, Division of Urology, Department of Surgery, Toronto, CANADA - 3) University of Wisconsin, Urology, Madison, USA - 4) University of New Mexico, Division of Urology, Department of Surgery, Albuquerque, USA

PURPOSE

The associated risks of pre-transplant native nephrectomies in pediatric renal transplant patients remain unclear. This investigation aims to assess the clinical outcomes for pediatric renal transplant patients who underwent pre-transplant native nephrectomy.

MATERIAL AND METHODS

A retrospective review of renal transplants performed at our institution between 2000-2015 was performed. Transplant recipients were divided into those who underwent native nephrectomy and those who did not. Clinical outcomes (eGFR, Clavien-Dindo classification ≥3 complications, graft loss, and number of readmissions) were compared. Subgroup analyses were performed for unilateral/concurrent bilateral/staged bilateral nephrectomies.

RESULTS

324 patients were identified. 57 patients underwent native nephrectomy (18 unilateral, 27 concurrent bilateral, 12 staged bilateral). The nephrectomy group was more likely to be  younger, receiving living donor kidneys, and to have ≥2 donor kidney arteries (Table 1),while also having more patients with nephrotic syndrome, nephritis, and focal sclerosing glomerulosclerosis (p=0.002). The majority of nephrectomy indications were hypertension (42.7%) and proteinuria (28.1%). In multivariate analyses (controlling for significant baseline characteristics and nephrectomy specific factors - laparoscopic, nephrectomy at time of transplant, nephrectomy prior to transplant, previous transplant nephrectomy), bilateral nephrectomy (OR 5.254, 95%CI 1.711-16.119, p=0.004) was associated with higher readmission rates. Patients with nephrectomies were more likely to be readmitted with bacterial infections (29.8% vs. 15.4%, p=0.013).

CONCLUSIONS

While limited by the differences in the nature of disease that may subject patients for decision to undergo native nephrectomy, undergoing native nephrectomies, particularly bilateral native nephrectomies, may subject patients to worse clinical outcomes. Native nephrectomy should be reserved for select patients who will significantly benefit from them such as those with refractory proteinuria or hypertension.


15:21 - 15:24
S20-3 (PP)

ASSESSING THE TRENDS AND UTILITY OF PRE-TRANSPLANT VOIDING CYSTOURETHROGRAMS IN PEDIATRIC RENAL TRANSPLANT POPULATION

Jin Kyu (Justin) KIM 1, Armando LORENZO 2, Walid FARHAT 3, Michael CHUA 2, Jessica MING 4, Lucshman RAVEENDRAN 2 and Martin KOYLE 2
1) University of Toronto, Division of Urology, Department of Surgery, Toronto, CANADA - 2) The Hospital for Sick Children, Division of Urology, Department of Surgery, Toronto, CANADA - 3) University of Wisconsin, Urology, Madison, USA - 4) University of New Mexico, Division of Urology, Department of Surgery, Albuquerque, USA

PURPOSE

The role of pre-renal transplant (RT) lower urinary investigation (voiding cystourethrogram/VCUG, urodynamics studies/UDS, uroflowmetry) is unclear in the pediatric population. This study aims to investigate the clinical utility of pre-RT urologic investigations this population in relation to etiology.

MATERIAL AND METHODS

A retrospective review of RTs  performed at our institution between 2000-2015 was performed. Transplant recipients were stratified by those with primary non-urologic end-stage renal disease (ESRD) etiology and primary urologic ESRD etiology. Baseline characteristics, pre-transplant investigations (VCUG, UDS, Uroflowmetry), pre-transplant urologic interventions, and 1-year post-transplant outcomes (Clavien-Dindo classification ≥3 complications, graft loss) were assessed by time period of transplant (2000-2005, 2006-2010, 2011-2015). For patients with posterior urethral valves, only investigations after initial diagnosis and treatment were considered.

RESULTS

227 patients with primary non-urologic ESRD etiology (group 1) and 97 patients with primary urologic ESRD etiology (group 2) were identified. Over three periods (2000-2005, 2006-2010, 2011-2015), less pre-transplant VCUG was being ordered in group 1: 19.4%, 37.7%, and 7.45%, respectively (p<0.001). For VCUG and UDS ordered ≤1 year prior to transplant, the majority of indications were for routine transplant assessment without specific concerns. These had low yields for clinical findings leading to intervention (Group 1 – VCUG 0%, UDS 0%; Group 2 – VCUG 0%, UDS 8%). Overall, urologic investigations had minimal predictive value for patients requiring post-transplant urologic interventions (group 1 - 0.0 to 1.1%, group 2 0.0 to 7.7%). For both groups, multivariate analysis adjusting for differences in baseline characteristics did not show any difference with regards to graft loss or Clavien-Dindo ≥3 complications.

CONCLUSIONS

For pediatric RT recipients, ordering a routine pre-transplant lower urinary tract investigation without specific urologic concerns, especially in setting of previously available urologic investigations, has minimal clinical value.


15:24 - 15:33
Discussion
 

15:33 - 15:36
S20-4 (PP)

KIDNEY TRANSPLANT (KT) IN ANORECTAL MALFORMATION (ARM) PATIENTS: RISK FACTORS AND OUTCOME

Miriam DUCI 1, Francesco FASCETTI-LEON 1, Davide MENEGHESSO 2, Elisa BENETTI 2, Piergiorgio GAMBA 1, Federica DE CORTI 1 and Marco CASTAGNETTI 3
1) University Hospital of Padova, Pediatric Surgery, Padova, ITALY - 2) University Hospital of Padova, Pediatric Nephrology, Padova, ITALY - 3) University Hospital of Padova, Section for Paediatric Urology, Padova, ITALY

PURPOSE

End stage renal disease requiring KT remains an important cause of morbidity in ARM patients. 

This study aimed to identify risk factors for KT in ARM patients and compare the outcome of KT in ARM patients vs. patients with urological anomalies but no ARM.

MATERIAL AND METHODS

Data of ARM patients treated at our center between 2000-2016 were retrospectively reviewed. Variables in ARM patients undergoing KT (ARM-KT) were compared to those in ARM patients who did not required KT to identify risk factors for KT, and to those in patients with urological anomalies, but no ARM undergoing KT (Uro-KT) to compare outcomes.

RESULTS

Out of 117 (62 high, 55 low) ARM patients treated during the study period, 8 (7%) underwent KT. In all, the malformation was high, including 3 cloaca, 2 bladder fistula, 2 bulbar urethra fistula, and 1 no fistula. Associated urological anomalies were significantly more common in ARM-KT compared to other ARM patients, 100% vs. 52%, p=0.001. The urological malformation was clearly severe from the outset (bilateral dyspalsia, uropathy in single kidney, or lower urinary tract malformation). 

The Uro-KT group included 23 patients with urological conditions (mainly primary vesico-ureteral reflux and posterior urethral valves), but no ARM who underwent KT during the same period. Comparing ARM-KT with Uro-KT, there was no difference in the age at KT and type of donor (P=1 and 0.6, respectively). ARM-KT patients required more often hemodialysis before KT (50%vs.8.7%, p=0.05), required more often an aorto-caval anastomosis at KT (75%vs.30%, p=0.04), and, despite a significantly shorter follow-up (median 3vs.6.3 years, p=0.02), required more frequently a second KT (50%vs.8.6%, p=0.02).

CONCLUSIONS

In our experience, patients with high ARM and associated urological anomalies were at increased risk of KT compared to other ARM patients. The KT was generally more complex and the outcome poorer compared to patients with urological anomalies but no ARM.


15:36 - 15:39
S20-5 (PP)

EN BLOC KIDNEY TRANSPLATATION "PEDIATRIC TO PEDIATRIC": A SYSTEMATIC REVIEW

Fabrizio VATTA 1, Thomas BLANC 2, Olivia BOYER 3, Christophe CHARDOT 2, Sabine SARNACKI 2 and Yves HÉLOURY 2
1) Hopital Necker - Enfants Malades, Service de Chirurgie Viscérale et Urologie Pédiatriques, Paris, FRANCE - 2) Hôpital Necker - Enfants Malades, Service de Chirurgie Viscérale et Urologie Pédiatriques, Paris, FRANCE - 3) Hôpital Necker - Enfants Malades, Service de néphrologie pédiatrique, Paris, FRANCE

PURPOSE

To evaluate the results of en-bloc kidney transplantation (EBKT) from small children to pediatric recipients.

MATERIAL AND METHODS

Systematic review from 2005 to 2020 on PubMed. Exclusion criteria were case-reports or adult recipients.

RESULTS

Ten papers were selected (390 patients). Mean donor weight was 11.3Kg range(3.7-13.7), age 1.2years(0.1-2.3). Mean recipient weight was 35.7Kg(25-41), age 12.6years(8.5-13.2). Mean follow-up was 7.8years. Mean 1-year graft survival (GS) was 82.9% (70%-100%), 5-year GS 67.7% (63.5-100), 10-year GS 51.7% (51.6-52.4), and 25-year GS 25.4%. Eight papers found 29 (15.7%) immediate post-operative complications causing graft loss: 16 thrombosis, 4 non-primary function, 3 acute rejection, 2 hemorrhages, and 4 others. Two paper compared EBKT with standard-criteria donor transplantation (SCT): GS resulted inferior in the short and intermediate post-operative time, but the difference was not statistically different. One paper compared GS in the long period, confirming the higher immediate complication rate. EBKT performed in the latest decade did not have an increased risk of 1-year graft loss. Intermediate and long-term GS and renal function were found higher in EBKT. Furthermore, one paper stratified success of GS compared to SCT for volume of EBKT performed, finding a lower risk of graft loss in higher-volume center.

CONCLUSIONS

EBKT represents a viable option to expand the number of donors for pediatric recipients. Intermediate and long-term function is comparable, or even higher, to SCT. Nevertheless, due to a higher rate of immediate post-operative complications, EBKT should be reserved for specific patients and performed in high-volume centers.


15:39 - 15:42
S20-6 (PP)

ARTERIAL INFLOW AFTER RENAL TRANSPLANTATION: DOES ARTERIOTOMY TECHNIQUE IMPACT EARLY ALLOGRAFT PERFUSION AND FUNCTION?

Daniel T. KEEFE 1, Mandy RICKARD 1, Karthikeyan MANICKAVACHAGAM 1, Jessica HANNICK 2, Nicolas FERNANDEZ 3, Keara DE COTIIS 1, Chia Wei TEOH 4, Martin A. KOYLE 1 and Armando J. LORENZO 1
1) The Hospital for Sick Children, Urology, Toronto, CANADA - 2) Rainbow Babies and Children's Hospital, Pediatric Urology, Cleveland, USA - 3) Seattle Children's Hospital, Pediatric Urology, Seattle, USA - 4) The Hospital for Sick Children, Nephrology, Toronto, CANADA

PURPOSE

There are two main techniques for arterial reconstruction in renal transplantation(RT): Traditional arteriotomy (TA) using a stab longitudinal incision which creates an elliptical opening, and arterial punch (AP) which fashions a circular defect. We hypothesized that AP creates a natural anastomosis lumen, similar to the donor renal artery, which optimizes RT perfusion.

MATERIAL AND METHODS

A retrospective review of a single institution database was performed between 2000-2018. Twenty patients who underwent AP arteriotomy were compared to 40 TA matched controls. Data were collected on creatinine (preoperative, nadir and time to nadir), and Doppler ultrasound (DUS) resistive indices (RI) and peak systolic velocities (PSV) at 1 week, 3 months and 6-12 months post-RT.

RESULTS

Time to nadir creatinine (ttNC) was shorter in the AP group (5+/-4 vs. 12+/-13 days; p=0.03). PSV at 1 week were lower in the AP group (186+/-65 cm/s vs. 232+/-89 cm/s; p=0.04). There was no difference in nadir creatinine value(p=0.26), preoperative creatinine(p=0.66), and initial postoperative creatinine(p=0.80). RI at week 1 were not different between groups(p=0.37). Follow-up DUS showed the difference in PSV between groups became non-significant (one month p=0.50, and 6-12 months (p=0.53)(Table1).

 

Arterial Punch(n=20)

Traditional(n=40)

pvalue

Sex

-       Males (%)

 

10 (50)

 

19 (48)

 

0.86

Age (years)

8+5

8+5

0.91

Weight (kg)

28+16

27+16

0.89

Warm ischemia time (mins)

50+31*

36+11

0.02

Site

- Aorta (%)

- Common Iliac (%)

- External Iliac (%)

 

10 (50)

9 (45)

1 (5)

 

20 (50)

19 (48)

1 (2)

 

 

0.88

PSV 1 week (cm/s)

186+65

232+89

0.04

TTnc

5+/4

12+/-13

0.03



CONCLUSIONS

AP arteriotomy in RT improves early perfusion and function parameters (ttNC and initial PSV) as compared to TA. AP arteriotomy optimizes early allograft reperfusion, which may have important long-term implications and deserves further evaluation.


15:42 - 15:45
S20-7 (PP)

COMBINED LIVER-KIDNEY TRANSPLANTATION IN CHILDREN. LONG-TERM OUTCOMES.

Carlos DELGADO-MIGUEL 1, Antonio MUÑOZ-SERRANO 2, Virginia AMESTY 3, Susana RIVAS 3, Roberto LOBATO 3, Pedro LÓPEZ-PEREIRA 3, Francisco HERNÁNDEZ 2, Laura ESPINOSA 4, Manuel LÓPEZ-SANTAMARÍA 2 and María José MARTÍNEZ URRUTIA 3
1) La Paz Children's Hospital, Pediatric Surgery, Pediatric Urology, Madrid, SPAIN - 2) La Paz Children's Hospital, Pediatric Surgery, Madrid, SPAIN - 3) La Paz Children's Hospital, Pediatric Urology, Madrid, SPAIN - 4) La Paz Children's Hospital, Pediatric Nephrology, Madrid, SPAIN

PURPOSE

Combined liver-kidney transplantation (CLKT) is the treatment of choice in end-stage chronic kidney disease with associated liver disease. However, the experience with CLKT in children is limited due to the low incidence of these pathologies. Our aim is to describe our experience in CLKT and its long-term outcomes.

MATERIAL AND METHODS

An analytical retrospective study was carried out in patients who underwent CLKT between 1997-2019. We analyzed demographic, clinical and laboratory variables collected pre-transplantation, intraoperatively and postoperatively.

RESULTS

Fifteen patients (8 males, 7 females) were included, with median age at transplantation of 11.2 years (3-17). Underlying diseases were: primary hyperoxaluria (6 patients), polycystic kidney disease (4 patients), Alagille syndrome (2 patients), nephronoptisis (2 patients) and atypical hemolytic-uremic syndrome (1 patient). Nine patients required pre-transplantation hemodialysis (median of 13 months until CLKT).
In all patients both grafts were obtained from the same cadaver donor (median donor age 13.8 years; 3-51). Liver ischemia mean time was 6.7±1.7hours, anhepatic phase 50.4±4.5minutes and cold renal ischemia 11.2±2.8 hours. Mean hospital stay was 38.9±17.6 days.
Fourteen patients (93.3%) presented normal renal and hepatic graft function, with a long-term follow-up of 116 months (7-276). One patient required a liver re-transplantation 48 hours after CLKT due to hepatic artery thrombosis. A single episode of acute renal rejection was observed, occurring 1 month after transplantation. One patient died 5years after CLKT due to failure to comply with immunosuppressive treatment.

CONCLUSIONS

Our series of CLKT presents encouraging outcomes, with adequate graft function and high long-term survival. The most frequent indication in our environment is primary hyperoxaluria followed by polycystic disease.


15:45 - 15:48
S20-8 (PP)

PEDIATRIC KIDNEY RETRANSPLANTATION: WERE ARE WE AND WHAT ARE THE RESULTS

Romy GANDER 1, Marino ASENSIO 2, Jose Andrés MOLINO 2, Gloria Fatou ROYO 2, Mercedes LÓPEZ-GONZALEZ 3, Marina MUÑOZ 2, Victor PEREZ-BELTRAN 3, Manuel LÓPEZ 2 and Gema ARICETA 3
1) University Hospital Vall d'Hebron, Paediatric Surgery, Barcelona, SPAIN - 2) University Hospital Vall d'Hebron, Barcelona, Pediatric Surgery, Barcelona, SPAIN - 3) University Hospital Vall d'Hebron, Barcelona, Pediatric Nephrology, Barcelona, SPAIN

PURPOSE

Despite survival rates after pediatric kidney transplantation (KT) are on the rise it is still likely that most pediatric recipients will require more than one retransplant in their lifetime.  The aim of this study was to analyze the outcomes of repeated pediatric kidney transplantation (RPKT) in our center.

MATERIAL AND METHODS

Retrospective study of RPKT (<18 years)undertaken between January 2000-2020. We analyzed primary etiology of renal disease, time to graft loss (GL) , etiology of initial graft failure, history of acute rejection, previous delayed graft function, HLA missmatches at the initial transplant, panel reactive antibodies (PRA) in the first and subsequent transplants, surgical and medical complications and outcomes.

RESULTS

Out of 229 KT, 59 patients underwent RPKT (26 females/33 males). Median age was 11.37 years (SD:5.7). The most frequent primary renal disease was congenital nephrotic syndrome in 11 (18.6%). 54 (91.5%) were on renal replacement therapy at the time of transplant.41 patients received their second KT (69.5%), 14 (23.7%) the third, 3 (5.1%) the fourth and 1 (1.7%) the fifth. 54 (91.5%) received a cadaveric graft and 5 (8.5%) a living-related graft. Acute rejection (15) and chronic graft nephropathy (10) were the main causes of GL. In 18 (30.5%) patients previous GL occurred during the first year post-KT,remarkably, main causes were 9 graft thrombosis and 4 acute humoral rejections due to anti-MICA and anti-angiotensin II antibodies in 2 patients.

Graft survival at 1,3 and 5 years was 91%, 84% and 73% respectively. The most frequent cause of GL was chronic graft nephropathy in 15 (25.4%). After a mean follow-up of 8.40 years (SD: 4.7) only 2 patients died (3.4%),both with functioning grafts.

CONCLUSIONS

Pediatric KRT is challenging but can yield good results and aceptable graft survival rates. In our series overall mortality was low and unrelated to KT.


15:48 - 16:03
Discussion