Long-Term Follow-Up after Paediatric Kidney Transplantation and Influence Factors on Graft Survival: A Single-Centre Experience of 16 years

Introduction: To evaluate graft- and patient survival after paediatric kidney transplantation and detecting influence factors, which affect the post-transplant time. Materials and Methods: We analysed long-term survival rates and complications after paediatric kidney transplantation and searched for predictive parameters for graft function. Results: In 132 patients, 143 kidney transplantations were performed. Graft failure occurred in 25%. Chronic rejections were the leading cause of graft loss (42.9%). Graft survival rates were 92.2% after 1 year, 85.5% after 5 years, 71.1% after 10 years and 62.1% after 15 years. The following parameters strongly influenced graft survival: number of transplants (p = 0.014), year of transplant (p 50 min (p = 0.008), delayed graft function (p = 0.003) and deceased donation (p = 0.039). The percentage of patients who died was 5.6%. Overall patient survival rates were 99.3% after 1 year, 95.2% after 5 years, 94.2% after 10 years and 90.7% after 15 years. Various types of infections (42.9%) were the main causes of death. Conclusions: The main causes of death after kidney transplantations in paediatric recipients are malignancy and infections. To avoid vascular complications especially in young recipients (< 9 years), the cold ischemia time should be as short as possible

REDUCTION OF RENAL PRESERVATION-REPERFUSION INJURY AFTER EXPERIMENTAL KIDNEY TRANSPLANTATION

HabilitationsschriftWegen des gravierenden Mangels an Spendernieren werden zunehmend Organe von marginalen Spendern transplantiert. Nach Transplantation marginaler Spendernieren ist der unvermeidbare Konservierungs-Reperfusionsschaden (K-R Schaden) besonders schwer, was oft mit einer verzögerten Funktionsaufnahme dieser Nieren einhergeht. Dies wiederum kann das Langzeitüberleben von Transplantnieren nachhaltig verkürzen. Das Ziel der hier zusammengefassten experimentellen Arbeiten war die Reduktion des K-R Schadens nach Nierentransplantation. Der komplexen Pathophysiologie des renalen K-R Schadens Rechnung tragend, wählten wir verschiedene Therapieansätze (antiinflammatorisch, antioxidativ, zytoprotektiv) und konnten zeigen, dass jede dieser Therapien für sich einen Beitrag zur Reduktion des K-R Schadens im experimentellen Nierentransplantationsmodell leistet. Ein neuer und wichtiger Aspekt der hier vorgestellten Arbeiten ist die erfolgreiche Behandlung des Spenders vor Beginn der Organentnahme und hypothermen Konservierung. Der Einfluss antiproliferativer Immunsuppressiva mit vermeintlich fehlender Nephrotoxizität auf die verzögerte Transplantatfunktion ist noch nicht hinreichend erforscht. Wir konnten im Tiermodell zeigen, dass Sirolimus (Rapamycin) im Gegensatz zu Mycophenolat Mofetil den vorbestehenden K-R Schaden und die damit verbundene Funktionsstörung verstärkt und deshalb bei Nieren mit verzögerter Funktionsaufnahme nicht eingesetzt werden sollte. Die aus tierexperimentellen Untersuchungen gewonnenen Erkenntnisse zur Pathophysiologie des renalen K-R Schadens und dessen Behandlung sind vielversprechend. Ein einzelnes im klinischen Alltag einsetzbares Therapeutikum steht bisher jedoch noch nicht zur Verfügung. Daher erscheint zum jetzigen Zeitpunkt in der Klinik ein multimodales Vorgehen sinnvoll, d.h. die Kombination verschiedener Substanzen mit antiinflammatorischer, antioxidativer oder vasodilatativer Wirkung.Delayed graft function (DGF) often occurs after transplantation of marginal kidneys DGF increases short-term morbidity of renal transplant patients and, more importantly, reduces long-term graft survival. We used an experimental kidney transplant model with prolonged cold ischemia and showed that antiinflammatory, antioxidative and cytoprotective agents efficiently reduce renal preservation reperfusion injury. Donor pretreatment before the ischemic insult proved to be as efficient as recipient treatment. Furthermore we sought to investigate the effects of antiproliferative immunosuppressants i.e. rapamycin (sirolimus) and mycophenolate mofetil on renal graft recovery from severe preservation reperfusion injury. While rapamycin significantly enhanced renal tubular damage irrespective of the amount of preexisting ischemic injury, mycophenolate mofetil showed no such effect in rat kidney transplants with moderate ischemic injury. We conclude that mycophenolate mofetil can be safely used in kidney transplants with delayed graft function, while rapamycin should be avoided

Matched comparison of outcomes following open and minimally invasive radical prostatectomy for high-risk patients

Comparative data related to the use of open and minimally invasive surgical approaches for the treatment of high-risk prostate cancer (PCa) remain limited. We determined outcomes of open radical prostatectomy (RRP), laparoscopic RP (LRP), and robot-assisted RP (RARP) in matched cohorts of patients with high-risk prostate cancer. A total of 805 patients with high-risk PCa [prostate-specific antigen (PSA) >20 ng/mL, Gleason score ≥8, or clinical stage ≥cT2c] were identified. A total of 407 RRP cases were propensity score (PS) matched 1:1 to 398 LRP or RARP cases to yield 3 cohorts (RARP, LRP, and RRP) of 110 patients each for analysis. PS matching variables included the following: age, clinical stage, preoperative PSA, biopsy Gleason score, surgeon experience, and nerve-sparing technique. Overall survival (OS) and recurrence-free survival (RFS) were compared with log-rank test. RFS predictor analysis was calculated within Cox regression models. Pathological Gleason scores 7 were found in 3.3, 50.9, and 45.8 % of patients. There were no statistically significant differences for pathological stage and positive surgical margins between surgical techniques. Mean 3-year RFS was 41.4, 77.9, and 54.1 %, for RARP, LRP, and RRP, respectively (p < 0.0001 for RARP vs. LRP). There were no significant differences for mean estimated 3-year OS for patients treated with RARP, LRP, or RRP (95.4, 98.1, and 100 %). RARP demonstrated similar oncologic outcomes compared to RRP and LRP in a PS-matched cohort of patients with high-risk prostate cancer

Outcome of kidney function after ischaemic and zero-ischaemic laparoscopic and open nephron-sparing surgery for renal cell cancer

Abstract Background Nephron-sparing surgery (NSS) remains gold standard for the treatment of localised renal cell cancer (RCC), even in case of a normal contralateral kidney. Compared to radical nephrectomy, kidney failure and cardiovascular events are less frequent with NSS. However, the effects of different surgical approaches and of zero ischaemia on the postoperative reduction in renal function remain controversial. We aimed to investigate the relative short- and long-term changes in estimated glomerular filtration rate (eGFR) after ischaemic or zero-ischaemic open (ONSS) and laparoscopic NSS (LNSS) for RCC, and to analyse prognostic factors for postoperative acute kidney injury (AKI) and chronic kidney disease (CKD) stage ≥3. Methods Data of 444 patients (211 LNSS, 233 ONSS), including 57 zero-ischaemic cases, were retrospectively analysed. Multiple regression models were used to predict relative changes in renal function. Natural cubic splines were used to demonstrate the association between ischaemia time (IT) and relative changes in renal function. Results IT was identified as significant risk factor for short-term relative changes in eGFR (ß = − 0.27) and development of AKI (OR, 1.02), but no effect was found on long-term relative changes in eGFR. Natural cubic splines revealed that IT had a greater effect on patients with baseline eGFR categories ≥G3 concerning short-term decrease in renal function and development of AKI. Unlike LNSS, ONSS was significantly associated with short-term decrease in renal function (ß = − 13.48) and development of AKI (OR, 3.87). Tumour diameter was associated with long-term decrease in renal function (ß = − 1.76), whereas baseline eGFR was a prognostic factor for both short- (ß = − 0.20) and long-term (ß = − 0.29) relative changes in eGFR and the development of CKD stage ≥3 (OR, 0.89). Conclusions IT is a significant risk factor for AKI. The short-term effect of IT is not always linear, and the impact also depends on baseline eGFR. Unlike LNSS, ONSS is associated with the development of AKI. Our findings are helpful for surgical planning, and suggest either the application of a clampless NSS technique or at least the shortest possible IT to reduce the risk of short-time impairment of the renal function, which might prevent AKI, particularly regarding patients with baseline eGFR category ≥G3

Correction to: Outcome of kidney function after ischaemic and zero-ischaemic laparoscopic and open nephron-sparing surgery for renal cell cancer

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