RETRACTED:Predictive Factors of Surgical Complications in the First Year Following Kidney Transplantation

Kidney transplantation and perioperative complications: a prospective cohort study

BACKGROUND

Kidney transplant recipients face complex perioperative challenges due to comorbidities from chronic kidney disease. This study aimed to assess perioperative complications in kidney transplant recipients and evaluate the association between the Charlson Comorbidity Index (CCI) and complication severity using the Clavien-Dindo (CD) classification.

METHODS

A prospective cohort study conducted at a tertiary hospital in South Brazil from September 2020 to March 2022, including 230 adult kidney transplant recipients. Data on demographics, comorbidities, and complications were collected. Complications were categorized using the CD scale, and their relationship with CCI was analyzed using univariate and multivariate Cox regression.

RESULTS

Mean age was 49.2 ± 12.7 years, with 58.7% male recipients. The mean CCI score was 3.65±1.5 points. Intraoperative complications occurred in 10.9% of patients, with notable issues including bleeding and airway difficulties. In the immediate postoperative period, 9.1% required urgent dialysis. In the 30-day follow-up, 57.8% had delayed graft function, 21.7% infections, 11.3% had vascular complications, and the mortality was 1.7%. CCI was not a significant predictor of severe complications; however, congestive heart failure was strongly associated with severe complications (HR = 6.6 95% CI 2.6-6.7, p < 0.001).

CONCLUSIONS

Despite a low overall comorbidity profile, kidney transplant recipients faced significant perioperative challenges. The lack of a significant association between the CCI score and severe complications suggests that traditional risk assessment tools may not fully capture the risks specific to the early postoperative period in kidney transplantation, and future research should focus on developing more refined risk assessment models for chronic kidney disease patients.

Optimizing the kidney donor pool: transplanting donor kidneys after partial nephrectomy of masses or cysts

Background

A limiting factor in expanding the kidney donor pool is donor kidneys with renal tumors or cysts. Partial nephrectomy (PN) to remove these lesions prior to transplantation may help optimize organ usage without recurrence of malignancy or increased risk of complications.

Methods

We retrospectively analyzed all recipients of a living or deceased donor graft between February 2009 and October 2022 in which a PN was performed prior to transplant due to the presence of one or more concerning growths. Donor and recipient demographics, perioperative data, donor allograft pathology, and recipient outcomes were obtained.

Results

Thirty-six recipients received a graft in which a PN was performed to remove suspicious masses or cysts prior to transplant. Majority of pathologies turned out to be a simple renal cyst (65%), followed by renal cell carcinoma (15%), benign multilocular cystic renal neoplasm (7.5%), angiomyolipoma (5%), benign renal tissue (5%), and papillary adenoma (2.5%). No renal malignancy recurrences were observed during the study period (median follow-up: 67.2 months). Fourteen complications occurred among 11 patients (30.6% overall) during the first 6mo post-transplant. Mean eGFR (± standard error) at 36 months post-transplant was 51.9 ± 4.2 ml/min/1.73 m2 (N = 23). Three death-censored graft losses and four deaths with a functioning graft and were observed.

Conclusion

PN of renal grafts with suspicious looking masses or cysts is a safe option to optimize organ usage and decrease the kidney non-use rate, with no observed recurrence of malignancy or increased risk of complications.

The role of anticomplement therapy in the management of the kidney allograft

As the number of patients living with kidney failure grows, the need also grows for kidney transplantation, the gold standard kidney replacement therapy that provides a survival advantage. This may result in an increased rate of transplantation from HLA-mismatched donors that increases the rate of antibody-mediated rejection (AMR), which already is the leading cause of allograft failure. Plasmapheresis, intravenous immunoglobulin therapy, anti-CD20 therapies (i.e., rituximab), bortezomib and splenectomy have been used over the years to treat AMR as well as to prevent AMR in high-risk sensitized kidney transplant recipients. Eculizumab and ravulizumab are monoclonal antibodies targeting the C5 protein of the complement pathway and part of the expanding field of anticomplement therapies, which is not limited to kidney transplant recipients, and also includes complement-mediated microangiopathic hemolytic anemia, paroxysmal nocturnal hemoglobinuria, and ANCA-vasculitis. In this narrative review, we summarize the current knowledge concerning the pathophysiological background and use of anti-C5 strategies (eculizumab and ravulizumab) and C1-esterase inhibitor in AMR, either to prevent AMR in high-risk desensitized patients or to treat AMR as first-line or rescue therapy and also to treat de novo thrombotic microangiopathy in kidney transplant recipients.

Administrative coding of frailty: Its association with clinical outcomes and resource use in kidney transplantation

INTRODUCTION

Although not formalized into current risk assessment models, frailty has been associated with negative postoperative outcomes in many specialties. However, national analyses of the association between frailty and post-transplant outcomes following kidney transplantation (KT) are lacking.

METHODS

This was a retrospective cohort study of adults undergoing KT from 2016 to 2020 in the Nationwide Readmissions Databases. Frailty was defined using the Johns Hopkins Adjusted Clinical Groups frailty indicator.

RESULTS

Of an estimated 95 765 patients undergoing KT during the study period, 4918 (5.1%) were frail. After risk adjustment, frail patients were associated with significantly higher odds of in-hospital mortality (AOR 2.17, 95% CI: 1.33-3.57) compared to their non-frail counterparts. Our findings indicate that frail patients had an average increase in postoperative hospital stay of 1.44 days, a $2300 increase in hospitalization costs, as well as higher odds of developing a major perioperative complication as compared to their non-frail counterparts. Frailty was also associated with greater adjusted risk of non-home discharge.

CONCLUSIONS

Frailty, as identified by administrative coding, is independently associated with worse surgical outcomes, including increased mortality and resource use, in adults undergoing KT. Given the already limited donor organ pool, novel efforts are needed to ensure adequate optimization and timely post-transplantation care of the growing frail cohort undergoing KT.

Frailty and prognosis of patients with kidney transplantation: a meta-analysis

BACKGROUND

The prevalence of frailty among candidates and recipients of kidney transplantation (KT) is well-established, yet the impact of frailty on clinical outcomes following KT remains uncertain. To address this knowledge gap, we conducted a systematic meta-analysis to comprehensively assess the aforementioned relationship.

METHODS

The present study conducted a comprehensive search of PubMed, Embase, and Cochrane Library databases to identify relevant observational studies that compared mortality risk and other clinical outcomes of KT recipients with and without frailty. Two authors independently conducted data collection, literature searching, and statistical analysis. The results were synthesized using a heterogeneity-incorporating random-effects model.

RESULTS

In this meta-analysis, 6279 patients from 13 cohort studies were included, and 1435 patients (22.9%) were with frailty before KT. There were higher mortality rates among frail patients at admission, compared to those without frailty (risk ratio [RR]: 1.97, 95% confidence interval [CI]: 1.57 to 2.47, p < 0.001; I2 = 19%). Subgroup analysis suggested the association between frailty and high mortality risk after KT was consistent in studies of frailty assessed via Physical Frailty Phenotype or other methods, and in studies of follow-up duration < or ≥ 5 years. In addition, frailty was associated with higher incidence of delayed graft function (RR: 1.78, 95% CI: 1.21 to 2.61, p = 0.003; I2 = 0%), postoperative complications (RR: 1.88, 95% CI: 1.15 to 3.08, p = 0.01; I2 = 0%), and longer hospitalization (RR: 1.55, 95% CI: 1.22 to 1.97, p < 0.001; I2 = 0%).

CONCLUSION

Following KT, frail patients are at higher risks for all-cause mortality, delayed graft function, postoperative complications, and longer hospital stays.

Children Are Not Small Adults: Similarities and Differences in Renal Transplantation Between Adults and Pediatrics

Kidney transplantation is the treatment of choice for all patients with end-stage kidney disease, including pediatric patients. Graft survival in pediatrics was lagging behind adults, but now is comparable with the adult cohort. Although many of the protocols have been adopted from adults, there are issues unique to pediatrics that one should be aware of to take care of this population. These issues include recipient size consideration, increased incidence of viral infections, problems related to growth, common occurrence of underlying urological issues, and psychosocial issues. This article addresses the similarities and differences in renal transplantation, from preparing a patient for transplant, the transplant process, to post-transplant complications.

Pretransplant BMI Significantly Affects Perioperative Course and Graft Survival after Kidney Transplantation: A Retrospective Analysis

Background. The number of kidney transplant recipients (KTRs) with overweight and obesity is increasing. It was shown that obesity is related to inferior patient and graft survival. We aimed to analyze intraoperative parameters and postoperative short and long-term course of kidney transplantation (KT) in body mass index (BMI)-stratified cohorts of KTRs. Methods. A retrospective analysis of a prospectively built database of 433 KTRs from 2014 to 2017 from a single transplant center was performed. The objective of the study was to analyze the association between BMI at the time of transplantation with intraoperative parameters, adverse events in early postoperative course, and the overall mortality and graft loss in BMI-stratified cohorts: normal (18.5 and 24.9 kg/m2), overweight (25−29.9 kg/m2) and obese (≥30 kg/m2). Results. Obesity was related to longer total procedure time (p = 0.0025) and longer warm ischemia time (p = 0.0003). The postoperative course in obese patients was complicated by higher incidence of DGF (delayed graft function), early surgical complications (defined as surgical complications <30 days from KT), reoperation rate, vascular complications, incidence of lymphocele and wound dehiscence. There was no difference between the normal weight and overweight KTRs. The one-month kidney function (p = 0.0001) and allograft survival (p = 0.029) were significantly inferior in obese patients with no difference between normal weight and overweight patients. One-year death-censored graft survival was better in patients with BMI < 30 (88.6 vs. 94.8% p = 0.05). BMI was a significant predictor of graft loss in univariate (p = 0.04) but not in multivariate analysis (p = 0.09). Conclusion. Pretransplant obesity significantly affects the intraoperative and postoperative course of kidney transplantation and graft function and survival. The course of transplantation of overweight is comparable to normal BMI KTRs, and presumably pretransplant weight reduction to the BMI < 30 kg/m2 may improve the short-term postoperative course of transplantation as well as may improve graft survival. Thus, pretransplant weight reduction in obese KTRs may significantly improve the results of kidney transplantation. Metabolic surgery may play a role in improving results of KT.