Robotic-Assisted Versus Open Techniques for Living Donor Kidney Transplant Recipients: A Comparison Using Propensity Score Analysis

Background: Following the rapid advancements in minimally invasive urology, living donor robotic-assisted kidney transplantation (RAKT) has developed into a feasible alternative to open kidney transplantation (OKT). The procedure has been performed in multiple international programs, but a relative dearth of experience exists in the US. In this investigation, we compare RAKT to OKT using a propensity score analysis, to elucidate the safety and feasibility of RAKT as a suitable alternative to OKT. Methods: A retrospective review of 101 living kidney transplants (36 RAKT, 65 OKT), which occurred between January 2016 and June 2018, was conducted. Selection for RAKT was based on Robot availability. Recipient and donor demographic variable were collected, in addition to perioperative parameters. A propensity score analysis was conducted, matching for recipient age, gender, body mass index, race, pre-operative dialysis, preoperative serum creatinine, panel reactive antibody, and donor age. Primary outcomes assessed included perioperative factors such as estimated blood loss (EBL), cold ischemic time (CIT), warm ischemic time (WIT), operative time, as well as several patient outcomes including, length of stay, narcotics consumed on postoperative days one and two, and change in serum creatinine (SCr) at five time points (day 3, day 7, day 14, 6 months, and 1 year). Final analysis included 35 patients in each group. Results: Recipients’ (N=101) mean age was 49 years (range 19-74), with RAKT recipients slightly younger than OKT recipients (46 vs 51 years). 61 recipients were male and 62 white (29 Black, 10 other). Average recipient BMI was 29 (range 20-40), with equivalent BMIs in RAKT and OKT subsets. Following propensity score analysis, RAKT recipients demonstrated significantly greater WIT (49 vs 38 minutes, p\u3c0.001) and less EBL (62.5 vs 150 mL, p\u3c0.001). However, total operative time and overall length of stay were not significantly different in the groups. Postoperative narcotics consumed on postoperative days one and two were similar between the groups (31.8 vs 32.3 morphine equivalents). Additionally, SCr was evaluated at days 3, 7, and 14 as well as 6 months and 1 year, without significant differences between the groups. Conclusion: RAKT offers an important minimally invasive alternative to OKT, with a short learning curve, and similar graft and patient outcomes. Notably, this study compares RAKT to OKT with a heterogeneous study population, using propensity scoring. The largest limitation of this study is a small sample size. Interestingly, despite the significantly longer WIT in RAKT, we found an equivalence of SCr between groups in the early and intermediate postoperative period. Although the small sample size limits our ability to detect differences in graft and patient outcomes, trends demonstrate shorter lengths of stay, shorter operative times, and smaller amounts of blood loss for RAKT recipients. Additionally, trends demonstrate fewer narcotics administered by the second postoperative day. Similar to the advent of laparoscopic technology in living donor nephrectomy, early findings in RAKT demonstrate a safe and reasonable alternative for living donor kidney transplantation in various populations.https://scholarlycommons.henryford.com/merf2019clinres/1052/thumbnail.jp

Persistence of SARS-CoV-2 Virus in a Kidney Transplant Recipient

Background: We are now discovering the sequelae of the novel coronavirus disease (COVID-19) as they relate to the transplant population. Questions regarding duration of viral shedding, infectivity, and reinfection remain. We present the case of a kidney transplant recipient who had COVID-19 prior to transplantation. The patient had presumably cleared the infection, but subsequently tested positive after transplantation. Case: A 30-year-old female with chronic kidney disease secondary to IgA nephropathy was found to be suitable for a living related kidney transplant. Shortly after her evaluation, before her surgery, she developed symptoms of SARS-CoV-2 virus, and was found to be positive via PCR. She presumably cleared her infection as evidenced by negative PCR testing, two weeks after cessation of symptoms. She underwent robotic-assisted living-related kidney transplantation with basiliximab induction. She developed a postoperative hematoma that required operative evacuation. Thus, she was tested for the virus prior to reoperation, and found to be positive-83 days following symptom onset. She remained asymptomatic by this point. She also tested positive for SARS-CoV-2 IgG antibodies. Conclusion: This case illustrates the persistence of SARS-CoV-2 virus and highlights the potential for viral replication after initiation of immunosuppression. It also highlights the possibility of prolonged viral shedding, beyond the maximum reported timeframe. Depletion of T cells from immunosuppression may explain the persistent viral replication and shedding. The clinical significance of prolonged viral shedding in transplant patients remains undefined. The timing of clearance for transplantation, role of retesting after transplantation, and management of immunosuppression are questions that need to be investigated

Robot-assisted Transplant Ureteral Repair to treat transplant ureteral strictures in patients after Robot-assisted Kidney Transplant: a case series

OBJECTIVE: To describe the use of robotic-assisted transplant ureteral repair (RATUR) for treating transplant ureteral stricture (TUS) in 3 patients who had undergone robot assisted kidney transplant (RAKT). METHOD: We reviewed the medical records of 3 patients who experienced TUS after RAKT and who underwent RATUR between 2017 and 2020. The patients\u27 RAKT, post-transplant clinical course, endourological interventions, reoperation, and recovery were assessed. RESULTS: All patients diagnosed with TUS presented with deterioration of kidney function after RAKT. Method of diagnosis included ultrasound, antegrade ureterogram, and CT scan. All 3 patients had a short (\u3c1 \u3ecm) area of TUS and underwent RATUR. For 2 patients, distal strictures were bypassed with modified Lich-Gregoir ureteroneocystostomy reimplantation. One patient was treated with pyelo-ureterostomy to the contralateral native ureter. No intraoperative complications, conversions to open surgery, or significant operative blood loss requiring blood transfusion for any patient were observed. Also, no patients had urine leaks in the immediate or late postoperative period. After RATUR, 2 patients developed Clavien grade II complications with rectus hematoma or urinary tract infection. CONCLUSION: RATUR is a technically feasible operation for kidney transplant patients with TUS after RAKT. This procedure may provide the same benefits of open operation without promoting certain comorbidities that may occur from open surgical procedures

A comparison of robotic and open living donor kidney transplantation -The minimally invasive option and its outcomes

Background: Robotic assisted kidney transplantation (RAKT) has become a feasible option in field of transplantation. We have been routinely performing this technique in living donor kidney transplant with excellent outcomes. Here, we compare our results with our open living donor kidney transplants (OKT). Methods: From 2013 to 2016, a total of 96 OKTs and 25 RAKTs have been performed at a tertiary care center. Pre-operative characteristics, operative parameters and post-operative patient outcomes were analyzed. Results: The technique of RAKT included proper positioning, placement of a Gellpoint-port and 3 other ports followed by intraperitoneal kidney implantation. Two patients had to be converted to open because of technical complications, while one was aborted due to poor insufflation. The comparison between RAKT and OKT is outlined in Table 1. RAKT offered lower blood loss and cold ischemia time, while warm ischemia time was higher. There was no increased incidence of delayed graft function, while post-operative pain and return to ambulation was similar to OKT. There was lower incidence of wound related complications in RAKT. Patient and graft survival at 1 year was 100% for both. Conclusion: Robotic kidney transplantation offers minimally-invasive option with equivalent outcomes to open kidney transplants. In obese patients, it is technically easier to perform. We believe that beyond the learning curve, robotic kidney transplant can provide a minimally invasive option which will eventually reduce overall complications while maintaining great renal outcomes

Allograft loss from acute Page kidney secondary to trauma after kidney transplantation

We report a rare case of allograft loss from acute Page kidney secondary to trauma that occurred 12 years after kidney transplantation. A 67-year-old Caucasian male with a past surgical history of kidney transplant presented to the emergency department at a local hospital with left lower abdominal tenderness. He recalled that his cat, which weighs 15 lbs, jumped on his abdomen 7 d prior. On physical examination, a small tender mass was noticed at the incisional site of the kidney transplant. He was producing a normal amount of urine without hematuria. His serum creatinine level was slightly elevated from his baseline. Computer tomography revealed a large subscapular hematoma around the transplant kidney. The patient was observed to have renal trauma grade II at the hospital over a period of three days, and he was finally transferred to a transplant center after his urine output significantly decreased. Doppler ultrasound demonstrated an extensive peri-allograft hypoechoic area and abnormal waveforms with absent arterial diastolic flow and a patent renal vein. Despite surgical decompression, the allograft failed to respond appropriately due to the delay in surgical intervention. This is the third reported case of allograft loss from acute Page kidney following kidney transplantation. This case reinforces that kidney care differs if the kidney is solitary or a transplant. Early recognition and aggressive treatments are mandatory, especially in a case with Doppler signs that are suggestive of compression

Robotic assisted live donor kidney transplantation - Technique and outcomes

Background: Robotic assisted kidney transplantation (RAKT) is now a feasible minimally invasive option in place of open living donor kidney transplant (OKT). Here, we briefly describe and compare the technical aspects and outcomes. Methods: From Jan 2013 to Aug 2017, we compared a total of 94 OKTs and 27 RAKTs and analyzed their outcomes. Results: The technique of RAKT included Trendelenburg in a modified lithotomy position at 10 degrees, placement of a midline Gellpoint port, 2 other robotic and 1 assistant ports. This was followed by intraperitoneal kidney implantation. Of the 27 recipients, 2 patients were converted to open because of technical complications. RAKT offered lower blood loss and lower cold ischemia time, while warm ischemia time was higher. There was no increased incidence of delayed graft function, with similar post-operative pain and length of stay. There was lower incidence of wound related complications in RAKT. Patient and graft survival was 100% for both. We divided our first 13 and our next 14 RAKTs for comparison. With experience, our mean blood loss and cold ischemia times have decreased moderately, while warm ischemia times decreased significantly (p=0.029). The mean pain scores and days to ambulation were also much lower in the latter period. Conclusions: RAKT offers minimally invasive option with equivalent outcomes to open kidney transplants. In obese patients, it is technically easier to perform. It has a short learning curve with a trend towards lower pain and warm ischemia times. RAKT can provide a minimally invasive option with equal or better short term patient outcomes while maintaining excellent renal outcomes

Robotic Assisted Live Donor Kidney Transplantation - Technique and Outcomes

Background: Robotic assisted kidney transplantation (RAKT) is now a feasible minimally invasive option in place of open living donor kidney transplant (OKT). Here, we briefly describe and compare the technical aspects and outcomes. Methods: From Jan 2013 to Aug 2017, we compared a total of 94 OKTs and 27 RAKTs and analyzed their outcomes. Results: The technique of RAKT included Trendelenburg in a modified lithotomy position at 10 degrees, placement of a midline Gellpoint port, 2 other robotic and 1 assistant ports. This was followed by intraperitoneal kidney implantation. Of the 27 recipients, 2 patients were converted to open because of technical complications. RAKT offered lower blood loss and lower cold ischemia time, while warm ischemia time was higher. There was no increased incidence of delayed graft function, with similar post-operative pain and length of stay. There was lower incidence of wound related complications in RAKT. Patient and graft survival was 100% for both. We divided our first 13 and our next 14 RAKTs for comparison. With experience, our mean blood loss and cold ischemia times have decreased moderately, while warm ischemia times decreased significantly (p=0.029). The mean pain scores and days to ambulation were also much lower in the latter period. Conclusions: RAKT offers minimally invasive option with equivalent outcomes to open kidney transplants. In obese patients, it is technically easier to perform. It has a short learning curve with a trend towards lower pain and warm ischemia times. RAKT can provide a minimally invasive option with equal or better short term patient outcomes while maintaining excellent renal outcomes

Mycophenolate Mofetil and Pulmonary Fibrosis After Kidney Transplantation: A Case Report

BACKGROUND Mycophenolate mofetil (MMF) induced lung disease has been described in only a few isolated reports. We report a case of fatal respiratory failure associated with MMF after kidney transplantation. CASE REPORT A 50-year-old Hispanic male with a history of end-stage renal disease secondary to hypertension underwent deceased donor kidney transplantation. His preoperative evaluations were normal except for a chest x-ray which showed bilateral interstitial opacities. Tacrolimus and MMF were started on the day of surgery. His postoperative course was uneventful and he was discharged on postoperative day 5. One month later, he presented with shortness of breath and a cough with blood-tinged sputum. His respiratory condition deteriorated rapidly, requiring intubation. Chest computer tomography (CT) demonstrated patchy ground-glass opacities with interlobular septal thickening. Comprehensive pulmonary, cardiac, infectious, and immunological evaluations were all negative. Open lung biopsy revealed extensive pulmonary fibrosis with no evidence of infection. He temporarily improved after discontinuation of tacrolimus and MMF, however, on resuming MMF his respiratory status deteriorated again and he subsequently died from hypoxic respiratory failure. CONCLUSIONS An awareness of pulmonary lung disease due to MMF is important to prevent adverse outcomes after organ transplantation. MMF must be used with utmost care in recipients with underlying lung disease as their pulmonary condition might make them more susceptible to any harmful effects of MMF

Perioperative Ketorolac Use: A Potential Risk Factor for Renal Dysfunction After Live-Donor Nephrectomy

BACKGROUND Ketorolac is a nonsteroidal anti-inflammatory drug indicated for pain control after surgeries in many fields. The aim of this study was to evaluate the impact of ketorolac use after live-donor nephrectomy (LDN). MATERIAL AND METHODS We reviewed data on 251 patients who underwent laparoscopic LDN from April 2008 to March 2016. Ketorolac was given to 167 patients intraoperatively or postoperatively within 24 h after LDN. Glomerular filtration rate (GFR) percentage was defined as postoperative GFR/preoperative GFR. GFR and GFR percentage at 2 weeks, 6 months, and 1 year after LDN were compared between patients with and without ketorolac administration. Multivariate analysis was performed to identify risk factors for low GFR percentage 1 year after LDN. RESULTS GFR at 1 year was significantly lower in patients who received ketorolac than in those who did not (62 ml/min/1.73 m² vs. 73 ml/min/1.73 m², P\u3c0.01). The differences in GFR and GFR percentage between 2 weeks and 1 year after LDN was significantly lower in the ketorolac group (GFR; 3.0 ml/min/1.73 m² vs. 14.0 ml/min/1.73 m², P\u3c0.01; GFR percentage; 2.0% vs. 12.0%, P\u3c0.01). Urinary albumin/creatinine ratio 1 year after LDN was significantly higher in the ketorolac group compared to the non-ketorolac group (8.6 mg/g vs. 12.6 mg/g, P=0.02). Multivariate analysis revealed that ketorolac use was an independent risk factor for low GFR percentage 1 year after LDN (odds ratio 1.38). CONCLUSIONS Ketorolac appears to be a risk factor for renal dysfunction in the long term after LDN. Prospective clinical trials are needed to reassess its safety