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Kidney Transplantation: Current Challenges and Future Perspectives

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A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Nephrology & Urology".

Deadline for manuscript submissions: 30 November 2024 | Viewed by 9607

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Dr. Alberto Piana

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Guest Editor

Department of Oncology, Division of Urology, San Luigi Gonzaga Hospital, University of Turin, 10043 Orbassano, Italy
Interests: kidney transplantation; urologic oncology; endourology; urolithiasis; laparoscopic urology; prostate; prostate cancer

Dr. Angelo Territo

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Unit of Uro-Oncology and Kidney Transplant, Department of Urology, Puigvert Foundation, Universitat Autònoma de Barcelona (UAB), 08025 Barcelona, Spain
Interests: kidney transplantation; robotic surgery; kidney cancer; prostate cancer; bladder cancer; BPH
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Special Issue Information

Dear Colleagues,

This Special Issue aims to investigate new scenarios and challenges in the field of kidney transplantation.

This Special Issue invites original research articles, review papers, and clinical studies that contribute to enrich our knowledge about kidney transplantation. We encourage submissions focusing on topics such as urologic cancers in transplanted patients, surgical challenges in kidney transplantation, and the use of technology for patient-tailored clinical management.

To ensure the highest-quality publications, we kindly request that authors refrain from submitting mini-reviews and case reports for this Special Issue. Instead, we seek in-depth research articles and comprehensive reviews that present novel findings and insights into kidney transplantation.

By bringing together leading experts and researchers in the field, this Special Issue aims to foster interdisciplinary discussions and promote collaborations to address the pressing issues faced in kidney transplantation. We believe that this collection of articles will serve as a valuable resource for clinicians and researchers involved in improving patient outcomes and advancing the field of kidney transplantation.

Dr. Alberto Piana
Dr. Angelo Territo
Guest Editors

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Keywords

kidney transplantation
urologic cancers
organ preservation
surgical challenges
donor selection
long-term out-comes
complications
post-transplant care
technology

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Published Papers (9 papers)

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Research

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14 pages, 697 KiB

Open AccessArticle

The Role of Vitamin D Metabolism Genes and Their Genomic Background in Shaping Cyclosporine A Dosage Parameters after Kidney Transplantation

by Katarzyna Kotowska, Bartosz Wojciuk, Jerzy Sieńko, Anna Bogacz, Iga Stukan, Sylwester Drożdżal, Bogusław Czerny, Karol Tejchman, Grzegorz Trybek, Bogusław Machaliński and Maciej Kotowski

J. Clin. Med. 2024, 13(16), 4966; https://doi.org/10.3390/jcm13164966 - 22 Aug 2024

Viewed by 750

Abstract

Background: Kidney transplantation is followed by immunosuppressive therapy involving calcineurin inhibitors (CNIs) such as cyclosporin A. However, long-term high CNIs doses can lead to vitamin D deficiency, and genetic variations influencing vitamin D levels can indirectly impact the necessary CNIs dosage. This study investigates the impact of genetic variations of vitamin D binding protein (DBP) rs2282679 and CYP2R1 hydroxylase rs10741657 polymorphisms on the cyclosporin A dosage in kidney transplant recipients. Additional polymorphisims of genes that are predicted to influence the pharmacogenetic profile were included. Methods: Gene polymorphisms in 177 kidney transplant recipients were analyzed using data mining techniques, including the Random Forest algorithm and Classification and Regression Trees (C&RT). The relationship between the concentration/dose (C/D) ratio of cyclosporin A and genetic profiles was assessed to determine the predictive value of DBP rs2282679 and CYP2R1 rs10741657 polymorphisms. Results: Polymorphic variants of the DBP (rs2282679) demonstrated a strong predictive value for the cyclosporin A C/D ratio in post-kidney transplantation patients. By contrast, the CYP2R1 polymorphism (rs10741657) did not show predictive significance. Additionally, the immune response genes rs231775 CTLA4 and rs1800896 IL10 were identified as predictors of cyclosporin A response, though these did not result in statistically significant differences. Conclusions:DBP rs2282679 polymorphisms can significantly predict the cyclosporin A C/D ratio, potentially enhancing the accuracy of CNI dosing. This can help identify patient groups at risk of vitamin D deficiency, ultimately improving the management of kidney transplant recipients. Understanding these genetic influences allows for more personalized and effective treatment strategies, contributing to better long-term outcomes for patients. Full article

(This article belongs to the Special Issue Kidney Transplantation: Current Challenges and Future Perspectives)

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7 pages, 194 KiB

Open AccessArticle

Comparison of Percutaneous Core Needle Biopsy Results in Patients Who Previously Underwent Open and Robot-Assisted Kidney Transplantation

by Fatih Gokhan Akbay, Zeki Toprak and Mithat Eksi

J. Clin. Med. 2024, 13(15), 4518; https://doi.org/10.3390/jcm13154518 - 2 Aug 2024

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Abstract

Objective: The objective of this study was to investigate the safety and efficacy of percutaneous graft biopsy, specifically in patients who have undergone robotic kidney transplantation, a topic that has received limited attention in the existing literature. While percutaneous graft biopsy is well established in patients who have undergone open transplantation, its application in robotic transplantation remains relatively unexplored. Material and Methods: A retrospective analysis was conducted on patient records spanning from 2013 to 2024, focusing on those who underwent graft biopsy due to acute graft dysfunction. The cohort was bifurcated into two distinct groups: individuals who underwent open kidney transplantation and those who underwent robotic kidney transplantation. Results: The study encompassed a total of 89 patients, with 64 having undergone open kidney transplantation and 25 having undergone robot-assisted kidney transplantation. The mean age of the patients was 40.61 (±12.26) years, with 60 (67.4%) being male and 29 (32.6%) being female. Comparative analysis revealed no significant disparities in age, gender distribution, body mass index, donor type (cadaveric versus living), or rates of graft loss between the two groups. Furthermore, examination of the total complication rates did not uncover any noteworthy differences between the cohorts. Conclusions: Ultrasound-assisted percutaneous needle biopsy is a reliable method in patients who have undergone robot-assisted kidney transplantation in cases of both indication-based and protocol biopsies. This study underscores the reliability of ultrasound-assisted percutaneous needle biopsy as a viable method for patients who have undergone robot-assisted kidney transplantation. By shedding light on the safety and efficacy of percutaneous graft biopsy in the context of robotic transplantation, this research contributes to the expanding body of knowledge in the field, providing valuable insights for clinical practice and future research endeavors. Full article

(This article belongs to the Special Issue Kidney Transplantation: Current Challenges and Future Perspectives)

22 pages, 3107 KiB

Open AccessArticle

Long-Term Outcome after Early Mammalian Target of Rapamycin Inhibitor-Based Immunosuppression in Kidney Transplant Recipients

by Lutz Liefeldt, Johannes Waiser, Friederike Bachmann, Klemens Budde, Frank Friedersdorff, Fabian Halleck, Nils Lachmann, Robert Peters, Birgit Rudolph, Sinem Ünlü, Kaiyin Wu and Petra Glander

J. Clin. Med. 2024, 13(15), 4305; https://doi.org/10.3390/jcm13154305 - 23 Jul 2024

Viewed by 763

Abstract

Background: The use of mammalian target of rapamycin inhibitors (mTORis) in kidney transplantation increases the risk of donor-specific human leukocyte antigen (HLA) antibody formation and rejection. Here, we investigated the long-term consequences of early mTORi treatment compared to calcineurin inhibitor (CNI) treatment. Methods: In this retrospective single-center analysis, key outcome parameters were compared between patients participating in randomized controlled immunosuppression trials between 1998 and 2011, with complete follow-up until 2018. The outcomes of eligible patients on a CNI-based regimen (n = 384) were compared with those of patients randomized to a CNI-free mTORi-based regimen (n = 81) and 76 patients randomized to a combination of CNI and mTORi treatments. All data were analyzed according to the intention-to-treat (ITT) principle. Results: Deviation from randomized immunosuppression for clinical reasons occurred significantly more often and much earlier in both mTORi-containing regimens than in the CNI treatment. Overall patient survival, graft survival, and death-censored graft survival did not differ between the treatment groups. Donor-specific HLA antibody formation and BPARs were significantly more common in both mTORi regimens than in the CNI-based immunosuppression. Conclusions: The tolerability and efficacy of the mTORi treatment in kidney graft recipients are inferior to those of CNI-based immunosuppression, while the long-term patient and graft survival rates were similar. Full article

(This article belongs to the Special Issue Kidney Transplantation: Current Challenges and Future Perspectives)

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21 pages, 1399 KiB

Open AccessArticle

Does Timepoint of Surgical Procedure Affect the Outcome in Simultaneous Pancreas–Kidney Transplantation? A Retrospective Single-Center Analysis over 20 Years

by Hans Michael Hau, Nora Jahn, Christos Vlachos, Tim Eichler, Andri Lederer, Antonia Geisler, Uwe Scheuermann, Daniel Seehofer, Sylvia Köppen, Sven Laudi, Robert Sucher and Sebastian Rademacher

J. Clin. Med. 2024, 13(13), 3688; https://doi.org/10.3390/jcm13133688 - 25 Jun 2024

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Abstract

Background: Sleep deprivation and disturbances in circadian rhythms may hinder surgical performance and decision-making capabilities. Solid organ transplantations, which are technically demanding and often begin at uncertain times, frequently during nighttime hours, are particularly susceptible to these effects. This study aimed to assess how transplant operations conducted during daytime versus nighttime influence both patient and graft outcomes and function. Methods: simultaneous pancreas–kidney transplants (SPKTs) conducted at the University Hospital of Leipzig from 1998 to 2018 were reviewed retrospectively. The transplants were categorized based on whether they began during daytime hours (8 a.m. to 6 p.m.) or nighttime hours (6 p.m. to 8 a.m.). We analyzed the demographics of both donors and recipients, as well as primary outcomes, which included surgical complications, patient survival, and graft longevity. Results: In this research involving 105 patients, 43 SPKTs, accounting for 41%, took place in the daytime, while 62 transplants (59%) occurred at night. The characteristics of both donors and recipients were similar across the two groups. Further, the rate of (surgical) pancreas graft-related complications and reoperations (daytime 39.5% versus nighttime 33.9%; p = 0.552) were also not statistically significant between both groups. In this study, the five-year survival rate for patients was comparable for both daytime and nighttime surgeries, with 85.2% for daytime and 86% for nighttime procedures (p = 0.816). Similarly, the survival rates for pancreas grafts were 75% for daytime and 77% for nighttime operations (p = 0.912), and for kidney grafts, 76% during the day compared to 80% at night (p = 0.740), indicating no significant statistical difference between the two time periods. In a multivariable model, recipient BMI > 30 kg/m², donor age, donor BMI, and cold ischemia time > 15 h were independent predictors for increased risk of (surgical) pancreas graft-related complications, whereas the timepoint of SPKT (daytime versus nighttime) did not have an impact. Conclusions: The findings from our retrospective analysis at a big single German transplant center indicate that SPKT is a reliable procedure, regardless of the start time. Additionally, our data revealed that patients undergoing nighttime transplants have no greater risk of surgical complications or inferior results concerning long-term survival of the patient and graft. However, due to the small number of cases evaluated, further studies are required to confirm these results. Full article

(This article belongs to the Special Issue Kidney Transplantation: Current Challenges and Future Perspectives)

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11 pages, 2434 KiB

Open AccessArticle

Exploring Thyroid Function after Kidney Transplantation: The Complex Interplay Unacknowledged in Post-Transplant Care

by Ita Jelić Pranjić, Lidija Orlić, Ana Carević, Tea Vrdoljak Margeta, Jelena Šimić and Ivan Bubić

J. Clin. Med. 2024, 13(12), 3559; https://doi.org/10.3390/jcm13123559 - 18 Jun 2024

Cited by 1 | Viewed by 1097

Abstract

Background/Objectives: The interplay between thyroid function and kidney graft function following kidney transplantation remains incompletely understood. Thyroid disorders are more prevalent in kidney transplant recipients than in the general population and are associated with poorer outcomes. Methods: This prospective, single-center study was designed to estimate thyroid function (thyroid-stimulating hormone (TSH), triiodothyronine (T3), free triiodothyronine (FT3), thyroxine (T4), free thyroxine (FT4), as well as anti-thyroid peroxidase antibody (anti-TPO), anti-thyroglobulin antibody (anti-Tg), and thyroid-stimulating immunoglobulin (TSI)) and its influence on kidney graft function among a cohort of 23 kidney transplant recipients during a follow-up period of 12 months. Results: Significantly increased levels of T4 and T3 were observed 12 months post-transplantation, with FT3 levels increasing significantly after 6 months. The prevalence of immeasurably low anti-Tg antibodies rose during follow-up. Initially, 8% of patients showed positive TSI, which turned negative for all after 6 months. A statistically significant correlation was found between the initial TSH and the estimated glomerular filtration rate (eGFR) value 6 months after transplantation (p = 0.023). The graft function was stable. Proteinuria was statistically significantly lower 12 months after transplantation. Conclusions: Identifying additional risk factors, understanding their impact on kidney graft function, and recognizing cardiovascular comorbidities could enhance patient care. Notably, this study marks the first prospective investigation into thyroid function after kidney transplantation in Croatia, contributing valuable insights to the global understanding of this complex interplay. Full article

(This article belongs to the Special Issue Kidney Transplantation: Current Challenges and Future Perspectives)

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14 pages, 261 KiB

Open AccessArticle

Effect of Different Induction Immunosuppression on the Incidence of Infectious Complications after Kidney Transplantation—Single Center Study

by Matej Vnučák, Karol Graňák, Monika Beliančinová, Patrícia Kleinová, Tímea Blichová, Vladimír Doboš and Ivana Dedinská

J. Clin. Med. 2024, 13(8), 2162; https://doi.org/10.3390/jcm13082162 - 9 Apr 2024

Cited by 1 | Viewed by 1074

Abstract

Background/Objectives: Potent immunosuppression lowers the incidence of acute graft rejection but increases the risk of infections. In order to decrease either infectious complications or acute rejection, it is necessary to identify risk groups of patients profiting from personalized induction immunosuppressive treatment. The aim of our analysis was to find whether there were higher incidences of infectious complications after kidney transplantation (KT) in groups with different induction immunosuppressive treatment and also to find independent risk factors for recurrent infections. Materials: We retrospectively evaluated all patients with induction treatment with basiliximab after kidney transplantation from 2014 to 2019 at our center relative to age- and sex-matched controls of patients with thymoglobulin induction immunosuppression. Results: Our study consisted of two groups: basiliximab (39) and thymoglobulin (39). In the thymoglobulin group we observed an increased incidence of recurrent infection in every observed interval; however, acute rejection was seen more often in the basiliximab group. A history of respiratory diseases and thrombocytopenia were identified as independent risk factors for recurrent bacterial infections from the first to sixth month after KT. Decreased eGFR from the first month, infections caused by multi-drug-resistant bacteria, and severe infections (reflected by the need for hospitalization) were identified as independent risk factors for recurrent bacterial infections from the first to the twelfth month after KT. Conclusions: We found that in the group of patients with thymoglobulin induction immunosuppressive treatment, infectious complications occurred significantly more often during the entire monitored period with decreased incidence of acute humoral and cellular rejection occurred more often. Full article

(This article belongs to the Special Issue Kidney Transplantation: Current Challenges and Future Perspectives)

11 pages, 401 KiB

Open AccessArticle

The Minimisation of Cardiovascular Disease Screening for Kidney Transplant Candidates

by Michael Corr, Amber Orr and Aisling E. Courtney

J. Clin. Med. 2024, 13(4), 953; https://doi.org/10.3390/jcm13040953 - 7 Feb 2024

Cited by 1 | Viewed by 1181

Abstract

Background: There is increasing evidence that cardiac screening prior to kidney transplantation does not improve its outcomes. However, risk aversion to perioperative events means that, in practice, testing remains common, limiting the availability of ‘real-world’ data to support any change. Our objective was to assess perioperative and 1-year post-transplant cardiovascular events in a kidney transplant candidate cohort who received minimal cardiovascular screening. Methods: The retrospective cohort study included all adult kidney-only transplant recipients in a single UK region between January 2015 and December 2021. Kidney transplant recipients asymptomatic of cardiac disease, even those with established risk factors, did not receive cardiac stress testing. The perioperative and 1-year post-transplant cardiovascular event incidences were examined. Logistic regression was used to identify variables of statistical significance that predicted cardiovascular or cerebrovascular events. Results: A total of 895 recipients fulfilled the inclusion criteria. Prior to transplantation, 209 (23%) recipients had an established cardiac diagnosis, and 193 (22%) individuals had a diagnosis of diabetes. A total of 18 (2%) patients had a perioperative event, and there was a 5.7% incidence of cardiovascular events 1 year post-transplantation. The cardiovascular mortality rate was 0.0% perioperatively, 0.2% at 3 months post-transplant, and 0.2% at 1 year post-transplant. Conclusions: This study demonstrates comparable rates of cardiovascular events despite reduced screening in asymptomatic recipients. It included higher risk individuals who may, on the basis of screening results, have been excluded from transplantation in other programmes. It provides further evidence that extensive cardiac screening prior to kidney transplantation is unlikely to be offset by reduced rates of cardiovascular events. Full article

(This article belongs to the Special Issue Kidney Transplantation: Current Challenges and Future Perspectives)

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Review

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25 pages, 10683 KiB

Open AccessReview

Surgical Strategies for Renal Transplantation: A Pictorial Essay

by Dorin Novacescu, Silviu Constantin Latcu, Marius Raica, Flavia Baderca, Cristina-Stefania Dumitru, Liviu Daminescu, Razvan Bardan, Vlad Dema, Alexei Croitor, Talida Georgiana Cut and Alin Adrian Cumpanas

J. Clin. Med. 2024, 13(14), 4188; https://doi.org/10.3390/jcm13144188 - 17 Jul 2024

Viewed by 1783

Abstract

This pictorial essay aims to navigate through the complexities and challenges of renal transplantation (RT), by weaving together visual imagery with clinical insights within a comprehensive illustrative surgical guide. Herein, we provide a detailed visual exploration of the intricate anatomy and surgical processes necessary for both renal graft retrieval from the donor and also for an adequate implantation in the recipient. Regarding graft retrieval, after reviewing the relevant retroperitoneal surgical anatomy, and donor nephrectomy techniques, graft preservation and optimal backbench graft dissection principles were meticulously analyzed. Thereafter, the recipient surgical strategy for graft implantation was addressed, focusing on preoperative preparations, the site of implantation selection, exposure, operative bed dissection, graft revascularization, and urinary tract reconstruction. Careful donor and recipient selection, meticulous surgical execution, and rigorous postoperative management clearly hold a pivotal role in optimizing patient outcomes. Fostering a deeper understanding of the surgical nuances and clinical management practices that contribute to successful results post-RT, we hope to provide a useful practical tool for clinicians about to embark on the treacherous road of RT surgery. Innovative technologies and surgical practices that have already significantly improved the safety and effectiveness of RT stand testament to the importance of further scientific inquiry, conceptual developments, and clinical integration. Moving forward, it is essential that the medical community continues to refine these strategies and advocate for equitable access to transplantation, ensuring that advancements in the field translate into real-world benefits for all patients grappling with ESRD. The collaborative efforts of multidisciplinary teams are essential in addressing the complex clinical challenges associated with RT, with the ultimate goal of improving patient survival, enhancing graft longevity, and reducing healthcare disparities. Full article

(This article belongs to the Special Issue Kidney Transplantation: Current Challenges and Future Perspectives)

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10 pages, 969 KiB

Open AccessReview

Robotic-Assisted Nephrectomy for Living Kidney Donation—Single Center Initial Experience (Case Series) and Review of the Literature

by Karolina Kędzierska-Kapuza, Inga Łopuszyńska, Agnieszka Mizerska, Marta Matejak-Górska, Krzysztof Safranow and Marek Durlik

J. Clin. Med. 2024, 13(13), 3754; https://doi.org/10.3390/jcm13133754 - 27 Jun 2024

Viewed by 799

Abstract

Background: Robotic-assisted nephrectomy for living kidney-donation (RANLD) has the potential of becoming the leading technique of harvesting kidney, if expertise is available. The aim of this work is to present our initial experience with robotic technique with additional hand-assistance. Materials and Methods: We initiated RANLD at our clinic using the DaVinci System in September 2022, since then harvesting six kidneys, four left and two right; in two cases, multiple arteries existed. The renal vessels were ligated using vascular staplers. All the operations included a hand-assist with the use of Gelport. The mean operation time was 119.2 min (SD 12 min). Results: There were no conversions or donors’ post-operative complications. Time of discharge from the hospital was 4.5 days post-operatively. Total hospital length of stay was 7.8 days. All the harvested kidneys were transplanted, five of them with adequate function, three with initially delayed function, and one needed to be removed due to thrombotic complications. Post-operative was pain assessed on the VAS scale and overall pain was assessed according to the NRS scale. At the discharge day, donors’ performance status was about 87.5% according to the Karnofsky scale. The donors resumed their normal life activity within 15.7 days and returned to work within 45.2 days. The serum mean creatinine level before the donation was 0.85 mg/dL (SD 0.1 mg/dL), and mean eGFR (MDRD) = 91.8 mL/min/1.73 m² (SD 16.1 mL/min/1.73 m²). Conclusions: Further development of RANLD could lead to an increase in the number of living kidney donors, particularly in Poland where the number is currently lower than that of deceased donors. Prolonged operation time, longer warm ischemic time, and high equipment costs are significant drawbacks of RANLD. Full article

(This article belongs to the Special Issue Kidney Transplantation: Current Challenges and Future Perspectives)

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