Living donor renal transplantation with incidental renal cell carcinoma from donor allograft

Pathological features and outcomes of incidental renal cell carcinoma in candidate solid organ donors

Background

We report the findings of a single Italian center in the evaluation of renal lesions in deceased donors from 2001 to 2017. In risk evaluation, we applied the current Italian guidelines, which include donors with small (< 4 cm, stage pT1a) renal carcinomas in the category of non-standard donors with a negligible risk of cancer transmission.

Methods

From the revision of our registries, 2,406 donors were considered in the Emilia Romagna region of Italy; organs were accepted from 1,321 individuals for a total of 3,406 organs.

Results

The evaluation of donor safety required frozen section analysis for 51 donors, in which a renal suspicious lesion was detected by ultrasound. Thirty-two primary renal tumors were finally diagnosed 26 identified by frozen sections and 6 in discarded kidneys. The 32 tumors included 13 clear cell renal cell carcinomas (RCCs), 6 papillary RCCs, 6 angiomyolipomas, 5 oncocytomas, 1 chromophobe RCC, and 1 papillary adenoma. No cases of tumor transmission were recorded in follow-up of the recipients.

Conclusion

Donors with small RCCs can be accepted to increase the donor pool. Collaboration in a multidisciplinary setting is fundamental to accurately evaluate donor candidate risk assessment and to improve standardized protocols for surgeons and pathologists.

Increasing kidney grafts for transplantation

INTRODUCTION

The current pool of organs available for transplantation does not cover requirements, for this reason non-standard risk donors need to be incorporated into the pool. In this way, donors with small renal tumour are considered for transplantation after bench tumour excision. The aim of our study was to analyse our experience in using these grafts for transplantation.

MATERIALS AND METHODS

Retrospective analysis from our prospective accrued database of donors with incidental renal mass used for kidney transplantation between January 2007 and August 2018.

RESULTS

Twenty kidney transplantations were performed, thirteen cases received the affected kidney (after tumour removal) and seven the contralateral kidney; from six living and eleven deceased donors. Donor and recipient median age was 58 years (range 22-82) and 56.5 years (range 38-74), respectively. Mean tumour diameter was 12.7 mm (SD 9.5). Tumours resulted in two benign lesions and fifteen renal cell carcinoma. Surgical margins were negative. Two cases presented with bleeding after reperfusion was solved without repercussion. One case presented with immediate vein thrombosis. None of them present delayed graft function. After a 69 month follow-up none of the donors or the recipients presented tumour recurrence.

CONCLUSIONS

Kidneys with small incidental tumours seem to be a good option for kidney transplantation in selected patients after bench surgery excision with good functional and oncologic results. More studies and longer follow-up are needed to confirm these results.

Long-term outcome of kidney transplant by using restored kidney grafts after tumour ex vivo excision - a prospective study

The aim of this study is to report long-term outcomes of kidney transplantation by using the kidney graft after a small tumour ex vivo excision. A structured programme was established to use the restored kidney graft from urological referral after radical nephrectomy. The criteria were defined as tumour size ≤3 cm, margin clear on frozen section and recipients aged ≥60 years or those on the urgent list for transplantation as a result of imminent lack of dialysis access. The recipients were followed up regularly for surveillance of tumour recurrence. Between February 2007 and February 2018, 28 recipients had kidney transplantation by using the restored kidney grafts. The tumour size was 2.6 ± 0.7 cm. The follow-up was median 7 years without evidence of tumour recurrence. The patient and graft survival was satisfactory. Kidney transplantation by using restored kidneys after a small tumour excision is a novel source for selected recipients. The long-term patient and graft survival is satisfactory. Although there is a risk of tumour recurrence, it is rare event. Together with literature review, we would support use of kidney graft after a small tumour excision for selected recipients.

Transplantation of Renal Allograft After Removal of Renal Cell Carcinoma: Case Report and Review of the Literature

With the rising incidence of end-stage renal disease in the United States, patients needing renal transplants are waiting longer for increasingly scarce grafts. Formerly, the general practice was to avoid organs with tumors for transplant because of the risk of malignancy transmission to the recipient. However, with comprehensive donor selection and a small-sized primary tumor, the positive outcomes of transplant outweigh the risks of transmission after a partial nephrectomy. In our case, a 31-year-old woman, the daughter of the recipient, underwent a laparoscopic nephrectomy with an existing 8-mm tumor later confirmed as renal cell carcinoma. An ex vivo tumor enucleation was performed before the allograft was transplanted into the 69-year-old patient with endstage renal disease. At last follow-up, graft function has remained excellent with no evidence of local recurrence or metastasis in both the donor and recipient. Here, we describe our case and perform a literature review on the incidence and management of renal allografts with incidentally detected renal cell carcinoma during transplant.

Transplanting kidneys from donors with small renal masses - a strategy to expand the donor pool

INTRODUCTION

Renal transplantation is the optimal treatment for end-stage renal disease, but organ demand continues to outstrip supply. The transplantation of kidneys from donors with small renal masses (SRMs) represents a potential avenue to expand the donor pool. We reviewed all published cases of transplants from donors with SRMs and we present followup data, best practices, and outline an actionable series of steps to guide the implementation of such transplants at individual centers.

METHODS

A detailed literature search of the MEDLINE/PubMed and SCOPUS databases was performed. Thirty unique data sets met inclusion criteria and described the transplantation of tumor-ectomized kidneys; nine data sets described the transplantation of contralateral kidneys from donors with SRMs.

RESULTS

A total of 147 tumorectomized kidneys have been transplanted. Pathology revealed 120 to be renal cell carcinomas (RCCs), of which 116 were stage T1a (0.3-4 cm). The mean followup time was 44.2 months (1-200). A single suspected tumor recurrence occurred in one patient nine years post-transplantation and it was managed with active surveillance. Twenty-seven kidneys have been transplanted from deceased donors with contralateral renal masses. Pathology revealed 25 to be RCCs, of which 19 were confirmed to be stage T1 (<7 cm). The mean followup time was 46.7 months (0.5-155). One recipient developed an RCC and underwent curative allograft nephrectomy.

CONCLUSIONS

Careful use of kidneys from donors with SRMs is feasible and safe, with an overall recurrence rate of less than 1.5%. The use of such kidneys could help alleviate the organ shortage crisis.

Case series: Transplantation of kidneys from donors with renal artery aneurysm

INTRODUCTION

With the present disparity between organ availability and recipient demands, we reported our experience in transplanting kidneys with renal artery aneurysm after back-table reconstruction.

METHODS

Four patients were identified. The repair consisted of excision of the aneurysm with ostial closure, and for one of the cases, an ovarian vein patch was used. We reviewed the safety and outcomes of this procedure. All donors were asymptomatic before surgery and were diagnosed incidentally during living donor evaluation. The nephrectomies performed were hand-assisted laparoscopic approaches. All recipients had followup renal function and ultrasound duplex of renal artery at six and 12 months and then annually.

RESULTS

The mean age of the recipients was 28.7 years (range 3-45). The mean size of the aneurysm was 7.4 ± 2.7 mm. All patients had immediate graft function with median serum creatinine of 1.9 ± 1.5 mg/dL at discharge. The average length of hospital stay was 6.25 ± 2.6 days. They also maintained good renal function with an average estimated glomerular filtration rate (eGFR) of 102.8 mL/min/1.73m² (range 53.4-199 mL/min/1.73m²) and patent vessels at one year. One patient suffered from acute antibody-mediated rejection and lost his graft (medication non-compliance). One patient had two simultaneous benign renal cysts that were resected. Three of the kidneys were right-sided and one left. Mean cold ischemia time was 86 ± 18 minutes. No deaths have been recorded.

CONCLUSIONS

Transplanting kidneys with a renal artery aneurysm after ex-vivo repair is safe and the outcomes are encouraging. Also, it may play an important role in expanding the donor pool in the face of current organ shortage.

Algorithm for Bosniak 2F Cyst in Kidney Donation

Patient: Female, 54

Final Diagnosis: Multilocular cystic renal cell carcinoma with clear cells

Symptoms: None

Medication: —

Clinical Procedure: Hand-assisted retroperitoneal donor nephrectomy

Specialty: Transplantology

Transplantation of Restored Kidneys From Unrelated Donors After Resection of Renal Cell Carcinoma: Results From 10 Patients

PURPOSE

To relieve the chronic shortage of donor kidneys, we conducted a prospective kidney transplantation trial using kidneys removed from 10 unrelated patients (51 to 79 years of age) who had undergone nephrectomy for small renal cell carcinoma (1.5 to 3.9 cm) of low-to-moderate complexity based on RENAL (radius, exophytic/endophytic properties, nearness of tumor to the collecting system or sinus in millimeters, anterior/posterior location relative to polar lines) nephrometry (objective description helpful for operative indication and planning).

METHODS

Donors were selected from among 15 patients who opted to undergo nephrectomy for small renal cell carcinoma. A total of 76 dialysis patients 34 to 85 years of age who agreed to undergo restored kidney transplantation were recruited as transplant candidates.

RESULTS

In stage 1 (5 cases), high-risk patients were selected without human leukocyte antigen testing, and accelerated acute rejection occurred in 4 of 5 recipients. This trial was subsequently extended with human leukocyte antigen testing, and an additional 5 patients were enrolled in stage 2. Eight recipients, including 4 recipients with a history of renal transplantation, experienced rejection; 1 patient resumed dialysis 35 months after transplantation. The most recent serum creatinine levels ranged from 1.10 to 3.19 mg/dL in the 9 recipients with functioning grafts and from 0.84 to 4.68 mg/dL in the 10 donors. No tumor recurrence was noted at 32 to 58 months after surgery in either the recipients or the donors.

CONCLUSIONS

Restored kidney transplantation using kidneys with a small renal tumor seems suitable for carefully selected high-risk recipients and, in particular, elderly kidneys can also function well. Avoiding cancer transmission, fair recipient selection, close follow-up, and a well-organized tracking system warrant further study.

Ten-Year Follow-up of a Reused Kidney Graft for Transplant Using Sirolimus for Maintenance Immunosuppression

Reused kidney grafts have been transplanted with successful outcomes, though not widely performed in the Unites States. We present the case of a reused kidney graft with 10-year follow-up. The first donation was from a patient who died from a cerebrovascular accident and whose organs were used for a simultaneous pancreas and kidney transplant. After 5 years, the patient died and kidney was considered for donation and reuse. The patient had a virtual crossmatch with the first donor and a complement-dependent and flow-dependent crossmatch with the second donor. Long-term immune suppression was kept with a calcineurin-inhibitor-free regimen with sirolimus to prevent further damage from the first recipient. Control kidney biopsy showed steady progression of previous CNI toxicity without further damage. We describe the immunological basis of reused graft, the technical aspects of procurement and transplantation, as well as the use of Mammalian target of rapamycin for maintenance immunosuppression with good long-term results. Reused kidney grafts can be a good source of kidney grafts when adequate selection between donor and recipients is made and immunosuppression protocol is tailored to the preexisting damage to the original graft.