[CamiCon study: Evaluation of a new tool for automated and connected voiding calendar]

INTRODUCTION

A voiding diary (VD) is a key element in the evaluation of patients with overactive bladder (OAB) at initial presentation and during treatment to assess its effectiveness. In order to be clinically relevant, it must be performed over 3 days according to the International Continence Society (ICS). Unfortunately, some patients find it cumbersome. We aimed to evaluate the reliability and patient satisfaction when using a connected tank device.

MATERIAL AND METHOD

We conducted a single-center prospective study including 41 patients. Each patient completed a paper voiding diary and then a diary with Diary Pod® (DP) or inversely depending on the study arm. Data from 34 patients were collected. After completion of both diaries, patients completed a satisfaction questionnaire sent by email via GoogleForm. Study statistics were performed with Jamovi® and Excel® software.

RESULT

Data from 34 patients were analyzed. There was a statically significant difference (P=0.046) between the mean volume calculated from the paper VD and that calculated from the connected VD (DP). There was no statistically significant difference (P=0.112) between the mean number of daytime voids, mean number of nighttime voids (P=0.156), mean water intake (P=0.183) reported on the paper VD and the connected VD. Thirteen (42%) paper VD and 1 connected VD did not include documentation of the presence or absence of urine leakage or urgency. There was no statistically significant difference between the two calendars regarding the presence or absence of urine leakage (P=0.180) and urinary urgency (P=0.564). Eighty-four percent (26/31) preferred the connected tank to the usual method (paper/pen), while 55% (17/31) and 29% (9/31) of the participants respectively answered that the DP was "very definitely" or "definitely" an aid for performing VD. Nevertheless, 39% (12/31) and 55% (17/31) considered its price to be high or fair and only 22% (7/31) were inclined to buy it.

CONCLUSION

This study showed that the Diary connected reservoir Pod® is a reliable and innovative tool for voiding schedules. It facilitates data collection for the majority of patients (83%) and could, through better patient compliance, provide better quality data and help their interpretation by the physician. These factors could encourage the implementation of the connected voiding diary as a diagnostic tool. It would also be used for the assessment of treatment effectiveness in daily clinical practice as well as in research. Its cost remains a major obstacle, judged by 39% of patients to be too high, and could therefore be proposed in specific situations requiring precise data.

Volumetric and functional outcomes at 1-year between percutaneous-ablation and partial-nephrectomy for T1b renal tumors

INTRODUCTION

Indication for percutaneous-ablation (PA) is gradually expanding to renal tumors T1b (4-7cm). Few data exist on the alteration of renal functional volume (RFV) post-PA. Yet, it is a surrogate marker of post partial-nephrectomy (PN) glomerular filtration rate (GFR) impairment. The objective was to compare RFV and GFR at 1-year post-PN or PA, in this T1b population.

METHODS

Patients with unifocal renal tumor≥4cm treated between 2014 and 2019 were included. Tumor, homolateral (RFVh), contralateral RFV, and total volumes were assessed by manual segmentation (3D Slicer) before and at 1 year of treatment, as was GFR. The loss of RFV, contralateral hypertrophy, and preservation of GFR were compared between both groups (PN vs. PA).

RESULTS

144 patients were included (87PN, 57PA). Preoperatively, PA group was older (74 vs. 59 years; P<0.0001), had more impaired GFR (73 vs. 85mL/min; P=0.0026) and smaller tumor volume(31.1 vs. 55.9cm3; P=0.0007) compared to PN group. At 1 year, the PN group had significantly more homolateral RFV loss (-19 vs. -14%; P=0.002), and contralateral compensatory hypertrophy (+4% vs. +1,8%; P=0.02, respectively). Total-RFV loss was similar between both (-21.7 vs. -19cm3; P=0.07). GFR preservation was better in the PN group (95.9 vs. 90.7%; P=0.03). In multivariate analysis, age and tumor size were associated with loss of RFVh.

CONCLUSION

For renal tumors T1b, PN is associated with superior compensatory hypertrophy compared with PA, compensating for the higher RFVh loss, resulting in similar ΔRFV-total between both groups. The superior post-PN GFR preservation suggests that the preserved quantitative RFV factor is insufficient. Therefore, the underlying quality of the parenchyma would play a major role in postoperative GFR.

External Validation of a Predictive Model to Estimate Renal Function After Living Donor Nephrectomy

BACKGROUND

Transplantation from living donor nephrectomy (LDN) is the best treatment for end-stage renal disease but observed decrease in donor renal function is a major concern. The aim of this study was to externally validate a predictive model to estimate 1-y postdonation estimated glomerular filtration rate (eGFR) and risk of chronic kidney disease (CKD) in living donors.

METHODS

All LDN performed at Necker Hospital from January 2006 to May 2018 were retrospectively included. Observed eGFR (using CKD-EPI formula) at 1-y post LDN was compared with the predicted eGFR calculated with a formula developed at Toulouse-Rangueil and based on predonation eGFR and age. Pearson correlation, receiver operating characteristics curve (ROC curve), and calibration curve were used to assess external validity of the proposed prognostic model to predict postoperative eGFR and occurrence of CKD in donors.

RESULTS

Four hundred donors were evaluated with a mean postoperative eGFR of 62.1 ± 14 mL/min/1.73m2. Significant correlation (Pearson r = 0.66; P < 0.001) and concordance (Bradley-Blackwood F = 49.189; P < 0.001) were observed between predicted and observed 1-y eGFR. Area under the receiver operating characteristic curve of the model relevant accuracy was 0.86 (95% CI, 0.82-0.89).

CONCLUSIONS

This study externally validated the formula to predict 1-y postdonation eGFR. The calculator could be an accurate tool to improve the selection of living kidney donor candidate.

What is the evidence for oxygenation during kidney preservation for transplantation in 2021? A scoping review

PURPOSE

The main objective of static cold storage is to reduce cellular metabolic demands to extend the period of ischaemia prior to transplantation. Hypothermia does not halt metabolism and the absence of oxygen causes a cellular shift toward anaerobic respiratory pathways. There is emerging evidence that the introduction of oxygenation during organ preservation may help ameliorate the degree of ischaemia reperfusion injury and improve post-transplantation outcomes. This review aims to appraise and summarise all published literature that utilises oxygenation to improve kidney preservation for purposes of transplantation.

METHODS

We performed a scoping review of the literature using the bibliographic databases Embase and MEDLINE. The final date for searches was 20 March 2021. All research studies included were those that reported oxygen delivery during kidney preservation as well as providing a description of the oxygenation technique.

RESULTS

17 human and 48 animal studies met the inclusion criteria. The oxygen delivery methods investigated included hypothermic oxygenated machine perfusion (HOPE), oxygen carriers, two-layer method, venous systemic persufflation, hyperbaric oxygenation, normothermic machine perfusion and sub-normothermic machine perfusion. The COMPARE trial was the only study carried out with the most methodological robustness being a randomised, double blind, controlled, phase III trial that investigated the efficacy of HOPE versus HMP.

CONCLUSION

A variety of studies reflect the evolution of oxygenation with useful lessons and encouraging outcomes. The first in human studies investigating HOPE and oxygen carriers are most robustly investigated strategies for oxygenation during kidney preservation and are, therefore, the best clinical references.

Management of long ureteral stenosis: Alternatives to indwelling ureteral stents

OBJECTIF

Evaluate kidney autotransplantation (KAT) and ileal ureter substitution (IUS) practice and outcome as alternatives to indwelling ureteral stents for the management of long ureteral stenosis (US).

MATERIAL

We included all patients treated for US with KAT or IUS in 5 French university urology centers between 2010 and 2018. We excluded US due to urothelial carcinoma. Primary endpoint was the preservation of ipsilateral kidney and renal function without any urinary diversion.

RESULTS

22 patients were treated with KAT (n=8, 36.4%) and IUS (n=14, 63.6%). Mean US length was 4.6cm and 6cm (P=0.52) in KAT and IUS groups respectively. US etiologies were lithiasis, iatrogenic, retroperitoneal fibrosis or extrinsic compression. US level was varied. The surgery was described as difficult because of peritoneal adhesions or major peri-ureteral fibrosis. Mean operating time and hospital stay were 336 and 346minutes (P=0.87) and 8 and 15 days respectively (P=0.001). Postoperative complications were mostly Clavien ≤2 (n=17, 77.3%). Revision surgery was required in the KAT group in 3 cases (37.5%), for textiles, renal vein thrombosis and anastomotic leak, none in the IUS group. The mean follow-up was 15.7 months. All but one (in the KAT group) ipsilateral kidneys were preserved, without renal function impairment (Δcreat +2.1 vs. +2.4μmol/l respectively, P=0.67), nor urinary diversion.

CONCLUSION

KAT and IUS are safe alternatives whose indication depends on surgeons expertise. Our study pointed out the scarcity of this practice suggesting the need to refer patients to expert centers.

LEVEL OF EVIDENCE

3.

Apalutamide, darolutamide and enzalutamide in nonmetastatic castration-resistant prostate cancer: a meta-analysis

Aim: Comparison of the efficacy/safety/health-related quality of life of apalutamide, enzalutamide and darolutamide in Phase III clinical trials involving patients with nonmetastatic castration-resistant prostate cancer was performed. Materials & methods: Relevant studies were identified by searching PubMed as well as conference abstracts reporting updated overall survival. Three pivotal trials were identified, SPARTAN (apalutamide), PROSPER (enzalutamide) and ARAMIS (darolutamide), and form the basis of this analysis. Results: All three drugs significantly prolonged metastasis-free survival, prostate-specific antigen response and overall survival versus placebo, and were generally well tolerated. Conclusion: Drug selection will likely be influenced by tolerability/safety and other factors, such as the propensity for drug-drug interactions and the presence of comorbidities, that affect the risk-benefit balance in individual patients.

Deciphering the Prognostic and Predictive Value of Urinary CXCL10 in Kidney Recipients With BK Virus Reactivation

BK virus (BKV) replication increases urinary chemokine C-X-C motif ligand 10 (uCXCL10) levels in kidney transplant recipients (KTRs). Here, we investigated uCXCL10 levels across different stages of BKV replication as a prognostic and predictive marker for functional decline in KTRs after BKV-DNAemia. uCXCL10 was assessed in a cross-sectional study (474 paired urine/blood/biopsy samples and a longitudinal study (1,184 samples from 60 KTRs with BKV-DNAemia). uCXCL10 levels gradually increased with urine (P-value < 0.0001) and blood BKV viral load (P < 0.05) but were similar in the viruria and no BKV groups (P > 0.99). In viremic patients, uCXCL10 at biopsy was associated with graft functional decline [HR = 1.65, 95% CI (1.08–2.51), P = 0.02], irrespective of baseline eGFR, blood viral load, or BKVN diagnosis. uCXL10/cr (threshold: 12.86 ng/mmol) discriminated patients with a low risk of graft function decline from high-risk patients (P = 0.01). In the longitudinal study, the uCXCL10 and BKV-DNAemia trajectories were superimposable. Stratification using the same uCXCL10/cr threshold at first viremia predicted the subsequent inflammatory response, assessed by time-adjusted uCXCL10/cr AUC (P < 0.001), and graft functional decline (P = 0.03). In KTRs, uCXCL10 increases in BKV-DNAemia but not in isolated viruria. uCXCL10/cr is a prognostic biomarker of eGFR decrease, and a 12.86 ng/ml threshold predicts higher inflammatory burdens and poor renal outcomes.

[Renal transplantation on vascular prosthesis]

INTRODUCTION

In front of a very calcified aortoiliac axis, renal transplantation with implantation of the artery on vascular prosthesis can be proposed. This rare intervention is considered difficult and morbid. The main objective of this work was to evaluate the overall and specific survival of the transplant in this situation. The secondary objective was the study of the complications and the evolution of the transplant's renal function.

MATERIAL AND METHODS

From a multicenter retrospective data collection of the DIVAT cohort (6 centers) added with data from 4 other transplant centers, we studied transplants with prosthetic arterial anastomosis.

RESULTS

Thirty four patients was included. The median duration of follow-up was 2.5 years. 4 patients died in the month following transplantation, 16 were hemodialysis and 9 were transfused. The median survival of the transplant was 212 days. Functional arrests of the transplant were mostly associated with nephrological degradation and return to dialysis (about 80%) while 10% were related to a death of the recipient directly attributable to renal transplantation. The surgical complications of the transplantation were marked by one arterial stenosis, one fistula and 4 urinary stenoses.

CONCLUSION

Thus, renal transplantation with arterial anastomosis on vascular prosthesis, on selected patients, offers an alternative to dialysis. A national compendium of transplanted patients on vascular prosthesis would allow a long-term follow-up of transplant's survival and define selection criteria prior to this kind of surgery.

LEVEL OF EVIDENCE

3.

Performing an early systematic Doppler-ultrasound fails to prevent hemorrhagic complications after complex partial nephrectomy

Background:

The aim of this work was to assess the clinical relevance of a systematic postoperative Doppler-ultrasound (DU) after complex partial nephrectomy (PN).

Materials and methods:

All patients who underwent open, laparoscopic or robotic PN from 2014 to 2017 at our institution were included. Postoperative hemorrhagic complications (HCs) were defined as the occurrence of blood transfusion, hemorrhagic shock, arterial embolization, or re-hospitalization for hematoma. DU was systematically performed between post-op day 4 and 7 for every complex tumor (RENAL score ⩾ 7). DU was considered positive in the presence of pseudoaneurysm (PA) or arteriovenous fistula (AVF).

Results:

Among 194 patients, 117 underwent DU (60.3%). We reported 22 HCs (11.3%) requiring 8 selective embolization procedures (4.1%). HCs occurred during the hospital stay in 17 patients (77.3%), thus directly diagnosed on a computed tomography scan. Among the five patients (22.7%) with HC occurring after hospital discharge, between day 7 to 15, four had a previously negative systematic DU. Overall, systematic DU was positive in only five patients (4.3%) with only one patient of 194 (0.5%) undergoing preventive embolization of a PA-AVF. The negative predictive values (NPVs) and positive predictive values of DU were respectively 96.5% and 5%, with 20% sensitivity and 96.5% specificity.

Conclusions:

Our results may suggest offering systematic DU in patients under antiplatelet therapies, with high tumor size (>T1b), or early postoperative hemoglobin variations. A high NPV of DU might be counterbalanced by its low sensibility. Since all secondary HCs occurred between postoperative day 7 to 15, our results may suggest differing DU in selected cases.

CARMENA: Cytoreductive nephrectomy followed by sunitinib versus sunitinib alone in metastatic renal cell carcinoma—Results of a phase III noninferiority trial

LBA3

Background: Cytoreductive nephrectomy (CN) has been the standard of care in mRCC in the past twenty years, supported by randomized and large retrospective studies. However the efficacy of targeted therapies has challenged this standard. CARMENA was designed to answer the question of whether upfront CN should continue to be performed before sunitinib. Methods: CARMENA was a randomized phase III trial. Patients (pts) with synchronous mRCC, amenable to CN, were enrolled after confirmation of clear cell histology on biopsy if PS 0-1, absence of symptomatic brain metastasis, acceptable organ function and eligible for sunitinib therapy. Pts were randomized 1:1 to either CN followed by sunitinib (arm A) or sunitinib alone (arm B), and stratified by MSKCC risk groups. Sunitinib was given at 50 mg/d, 4/6wk with dose adaptation to routine practice. In arm A, sunitinib had to start 4 to 6 wk after surgery. Primary endpoint was overall survival (OS). A total of 576 pts had to be enrolled to demonstrate non inferiority hypothesis (H0: λE/λC > 1.20), with 80% power at a 1-sided significance level of 5%. Results: 450 pts were included from 9/09 to 9/17, 226 and 224 in arm A and B, respectively. Median age was 62, ECOG-PS was 0 in 56% and 1 in 44%. MSKCC risk groups were intermediate/poor in 55.6/44.4% (arm A) and in 58.5/41.5% (arm B). In arm A, 6.7% did not have CN and 22.5% never received sunitinib. In arm B, 4.9 % never received sunitinib and 17% had secondary nephrectomy. At the time of the analysis, 326 deaths have been observed with a median follow-up of 50.9 mo. OS was not inferior in arm B, overall as well as by MSKCC risk groups (table). No difference in response rate and PFS was observed. Safety of sunitinib was as expected in both arms. Conclusions: Sunitinib alone is not inferior to CN followed by sunitinib in synchronous mRCC both in intermediate and poor MSKCC risk groups. CN should not be anymore the standard of care when medical treatment is required. Clinical trial information: NCT00930033. [Table: see text]

Nephron sparing surgery in tumours greater than 7cm

INTRODUCTION

Partial nephrectomy (PN) is the gold standard treatment for renal cell carcinomas under 4cm. No robust data exists to recommend PN for tumours>7cm (cT2). The objective of this work is to evaluate the results of PN for cT2 tumours.

PATIENTS AND METHODS

All patients who underwent PN or radical nephrectomy (RN) for cT2 tumours between 2000 and 2013 at our institution have been included. Patient demographics, postoperative data including renal function, morbidity, mortality and oncologic outcomes were reviewed retrospectively and compared using χ² test, Mann-Whitney test, Kaplan-Meier method and log rank test.

RESULTS

We included 130 patients, 49 (38%) in the PN group and 81 (62%) in the RN group, with a median follow-up of 42 months [19-69]. Variation of postoperative renal function at day 5 and last recorded value was significantly different between the groups (P=0.03 and P<0.001). The PN group had a significantly higher complication rate as compared with RN group (37% versus 14%, P=0.002). There were no significant differences between the two groups for overall, recurrence free and specific survival (P=0.55, P=0.55, P=0.24, respectively). In univariate analysis, the type of surgery (PN versus RN) was not associated with a significant difference of oncologic outcome (margins, survival).

CONCLUSION

PN can be offered for cT2 tumours with oncological outcomes similar to RN. Despite an increased morbidity, it remains acceptable with the demonstrated advantage of preservation of renal function.

LEVEL OF EVIDENCE

4.

[Sporadic kidney cancer of young subjects: Study of the clinical and pathological features of a bicentric cohort]

INTRODUCTION

The epidemiology of kidney cancer is evolving with a net increase in the incidence of renal tumors, globally, and in young people in particular.

OBJECTIVE

To evaluate the incidence and clinical and pathological characteristics of sporadic renal tumors in young subjects and their risk factors.

MATERIAL AND METHODS

A retrospective study aimed at collecting clinical, epidemiological and anatomopathological information from the 118 patients aged 18 to 40 treated for a sporadic kidney tumor in two Parisian university hospital centers between 2003 and 2013.

RESULTS

Our study showed a very significant increase in the incidence of renal tumors in our 11 years of decline (P=6.10^-15). The mode of discovery also seems to have evolved with a majority of tumors (67 %), due to the considerable growth of imaging in recent decades. We also showed a different pathological distribution compared to the literature with a significant increase in the number of papillary tumors (16.9 %) and chromophobes (15.2 %), in addition to a decrease in the number of carcinomas (43.2 %) as well as the appearance of a new pathological entity of particular clinical severity: renal carcinoma related to translocation Xp11.2 (15.3 %) (P<10^-5). Among the risk factors, hypertension seems to be a definite risk factor while tobacco and obesity do not have a significant influence.

CONCLUSION

Our study showed a marked increase in the incidence of renal tumors with specific clinical and epidemiological features in a population of young subjects. The role and importance of oncogenetic management as well as the study of environmental factors could lead to the identification of new risk factors and corollary to their prevention.

LEVEL OF EVIDENCE

4.

Immunothérapie dans les cancers de la prostate

IMMUNOTHERAPY IN URO-ONCOLOGY

Immunotherapy is moving forward in prostate cancer. The autologous vaccine, Sipuleucel-T has been the first vaccine to be approved by FDA. First results with GVAX, tasquinimob or anti-PD-1 have been disappointing. Ipilimumab seen to be more active at an earlier stage of prostate disease. Identifying predictive factor or surrogate markers of activity of immunotherapy and which agents are clinically effective alone or in combination with others therapies such as hormonal or bone targeted therapies are warranted.

[Chronic kidney disease and kidney transplantation]

OBJECTIVES

To report epidemiology and characteristics of end-stage renal disease (ESRD) patients and renal transplant candidates, and to evaluate access to waiting list and results of renal transplantation.

MATERIAL AND METHODS

An exhaustive systematic review of the scientific literature was performed in the Medline database (http://www.ncbi.nlm.nih.gov) and Embase (http://www.embase.com) using different associations of the following keywords: "chronic kidney disease, epidemiology, kidney transplantation, cost, survival, graft, brain death, cardiac arrest, access, allocation". French legal documents have been reviewed using the government portal (http://www.legifrance.gouv.fr). Articles were selected according to methods, language of publication and relevance. The reference lists were used to identify additional historical studies of interest. Both prospective and retrospective series, in French and English, as well as review articles and recommendations were selected. In addition, French national transplant and health agencies (http://www.agence-biomedecine.fr and http://www.has-sante.fr) databases were screened using identical keywords. A total of 3234 articles, 6 official reports and 3 newspaper articles were identified; after careful selection 99 publications were eligible for our review.

RESULTS

The increasing prevalence of chronic kidney disease (CKD) leads to worsen organ shortage. Renal transplantation remains the best treatment option for ESRD, providing recipients with an increased survival and quality of life, at lower costs than other renal replacement therapies. The never-ending lengthening of the waiting list raises issues regarding treatment strategies and candidates' selection, and underlines the limits of organ sharing without additional source of kidneys available for transplantation.

CONCLUSION

Allocation policies aim to reduce medical or geographical disparities regarding enrollment on a waiting list or access to an allotransplant.

[Deceased donation in renal transplantation]

OBJECTIVES

To review epidemiologic data's and medical results of deceased donation in renal transplantation.

MATERIAL AND METHODS

Relevant publications were identified through Medline (http://www.ncbi.nlm.nih.gov) and Embase (http://www.embase.com) database using the following keywords, alone or in association, "brain death; cardiac arrest; deceased donation; organ procurement; transplantation". Articles were selected according to methods, language of publication and relevance. The reference lists were used to identify additional historical studies of interest. Both prospective and retrospective series, in French and English, as well as review articles and recommendations were selected. In addition, French national transplant and health agencies (http://www.agence-biomedecine.fr and http://www.has-sante.fr) databases were screened using identical keywords. A total of 2498 articles, 8 official reports and 17 newspaper articles were identified; after careful selection 157 publications were eligible for our review.

RESULTS

Deceased donation may involve either brain death or non-heartbeating donors (NHBD). Organ shortage led to the procurement of organs from expanded-criteria donors, with an increased age at donation and extended vascular disease, leading to inferior results after transplantation and underlining the need for careful donor management during brain death or cardiac arrest. Evolution of French legislation covering bioethics allowed procurement from Maastricht categories II and recently III non-heartbeating donors.

CONCLUSION

The increase of organ shortage emphasizes the need for a rigorous surgical technique during procurement to avoid loss of transplants. A history or current neoplasm in deceased-donors, requires attention to increase the pool of organs without putting the recipients at risk for cancer transmission. French NHBD program, especially from Maastricht category III, may stand for a potential source of valuable organs.

[Conservative management of upper tract urinary fistulae using ureteral trans-vesico-parietal stent]

OBJECTIVES

Ureteral stents and ureteral catheters externalized through the urethra are not ideal solutions to manage complicated upper urinary tract fistulae. We sought an effective method of drainage, minimally invasive, reproducible allowing a rapid patient's discharge.

PATIENTS AND METHODS

Between November 2013 and February 2015, an ureteral stent was exteriorized in trans-vesico-parietal by an endoscopic and percutaneous access in patients with complicated upper urinary tract fistulae. Monitoring of tolerance, complications and urinary fistula healing was performed.

RESULTS

Nine consecutive patients had an ureteral stent exteriorized in trans-vesico-parietal to manage complicated upper urinary tract fistulae. There was no failure in introducing the catheter, or postoperative complication. Catheters were left in place on average 36.1days (24-55). The patients were able to return home with the catheter in place in 77.8% of cases. The tolerance of the catheter was good. All fistulae were able to be treated conservatively at the end of the drainage period.

CONCLUSION

Trans-vesico-parietal ureteral catheters enable efficient and reproducible conservative treatment of upper tract urinary fistulae regardless of their cause.

LEVEL OF EVIDENCE

5.

Prospective assessment of the adherent perinephric fat in partial nephrectomies: Predictors and impact on peri-operative outcomes

543

Background: The surgical complexity of partial nephrectomy (PN) can be partly anticipated using renal morphometric scores that do not consider patient related issues such as obesity or perirenal fat. Our primary objective was to prospectively assess the predictive factors for adherent perinephric fat (APF) and its impact on the onset of complications. The secondary objective was to correlate the surgical appraising with the histological reality of APF. Methods: Fifty consecutive patients undergoing robotic or open PN were prospectively included from November 2014 to March 2015. The previously published Mayo adhesive probability score (MAP score) was calculated and compared to the per-operative surgical assessment of APF using a 0 to 3 scale (APF being defined by a score ≥ 2). Fat was analyzed histologically for fibrosis (HES staining and picrosirius red) and inflammatory infiltrate of macrophages (immunohistochemistry using anti-CD68 antibody). Results: APF was present in 18 patients (36%), with no impact on surgical approach (31.3% vs 38.9 robotic way, without surgical conversion). APF was associated with longer operating time (169 min vs. 146 min, p = 0.036) and increased blood loss (469 mL vs 179 mL, p = 0.014). Duration of clamping, rate of positive margins, blood transfusion and the Clavien-Dindo score were not different (Table 1). In multivariate analysis, only male gender (p = 0.044), age (p = 0.014) and MAP score (p = 0.00057) were significant predictors of APF. Histologically, APF was characterized by a marked fibrosis but no macrophage infiltrate. Conclusions: APF can be accurately predicted using radio-clinical data as the MAP score, combined with age and gender. APF is associated with increased operative time and blood loss without impacting the rate of complications. Histological analysis of APF demonstrates significant fibrosis without inflammatory infiltrate. [Table: see text]

A 16-gene assay to predict recurrence after surgery in localised renal cell carcinoma: development and validation studies

BACKGROUND

The likelihood of tumour recurrence after nephrectomy in localised clear cell renal cell carcinoma is well characterised by clinical and pathological parameters. However, these assessments can be improved and personalised by the addition of molecular characteristics of each patient's tumour. We aimed to develop and validate a prognostic multigene signature to improve prediction of recurrence risk in clear cell renal cell carcinoma.

METHODS

In the development stage, we investigated the association between expression of 732 genes, measured by reverse-transcription PCR, and clinical outcome in 942 patients with stage I-III clear cell renal cell carcinoma who had undergone a nephrectomy at the Cleveland Clinic (OH, USA). 516 genes were associated with recurrence-free interval. 11 of these genes were selected by further statistical analyses, and were combined with five reference genes (ie, 16 genes in total), from which a recurrence score algorithm was developed. The recurrence score was then validated in an independent cohort of 626 patients from France with stage I-III clear cell renal cell carcinoma who had also undergone nephrectomy. The association between the recurrence score and the risk of recurrence and cancer-specific survival in the first 5 years after surgery was assessed using Cox proportional hazard regression, stratified by tumour stage (stage I vs stage II vs III).

FINDINGS

In our primary univariate analysis, the continuous recurrence score (median 37, IQR 31-45) was significantly associated with recurrence-free interval (hazard ratio 3·91 [95% CI 2·63-5·79] for a 25-unit increase in score, p<0·0001). In multivariable analyses, the recurrence score was significantly associated with the risk of tumour recurrence (hazard ratio per 25-unit increase in the score 3·37 [95% CI 2·23-5·08], p<0·0001) after stratification by stage and adjustment for tumour size, grade, or Leibovich score. The recurrence score was able to identify a clinically significant number of both high-risk stage I and low-risk stage II-III patients. A heterogeneity study on separate samples showed little to no intratumoural variability among the 16 genes.

INTERPRETATION

Our findings validate the recurrence score as a predictor of clinical outcome in patients with stage I-III clear cell renal cell carcinoma, providing a more accurate and individualised risk assessment beyond existing clinical and pathological parameters.

FUNDING

Genomic Health Inc and Pfizer Inc.

Urinary C-X-C Motif Chemokine 10 Independently Improves the Noninvasive Diagnosis of Antibody-Mediated Kidney Allograft Rejection

Urinary levels of C-X-C motif chemokine 9 (CXCL9) and CXCL10 can noninvasively diagnose T cell-mediated rejection (TCMR) of renal allografts. However, performance of these molecules as diagnostic/prognostic markers of antibody-mediated rejection (ABMR) is unknown. We investigated urinary CXCL9 and CXCL10 levels in a highly sensitized cohort of 244 renal allograft recipients (67 with preformed donor-specific antibodies [DSAs]) with 281 indication biopsy samples. We assessed the benefit of adding these biomarkers to conventional models for diagnosing/prognosing ABMR. Urinary CXCL9 and CXCL10 levels, normalized to urine creatinine (Cr) levels (CXCL9:Cr and CXCL10:Cr) or not, correlated with the extent of tubulointerstitial (i+t score; all P<0.001) and microvascular (g+ptc score; all P<0.001) inflammation. CXCL10:Cr diagnosed TCMR (area under the curve [AUC]=0.80; 95% confidence interval [95% CI], 0.68 to 0.92; P<0.001) and ABMR (AUC=0.76; 95% CI, 0.69 to 0.82; P<0.001) with high accuracy, even in the absence of tubulointerstitial inflammation (AUC=0.70; 95% CI, 0.61 to 0.79; P<0.001). Although mean fluorescence intensity of the immunodominant DSA diagnosed ABMR (AUC=0.75; 95% CI, 0.68 to 0.82; P<0.001), combining urinary CXCL10:Cr with immunodominant DSA levels improved the diagnosis of ABMR (AUC=0.83; 95% CI, 0.77 to 0.89; P<0.001). At the time of ABMR, urinary CXCL10:Cr ratio was independently associated with an increased risk of graft loss. In conclusion, urinary CXCL10:Cr ratio associates with tubulointerstitial and microvascular inflammation of the renal allograft. Combining the urinary CXCL10:Cr ratio with DSA monitoring significantly improves the noninvasive diagnosis of ABMR and the stratification of patients at high risk for graft loss.

Robustness of the 16-gene signature for prediction of recurrence-free interval in localized clear cell renal cell carcinoma

455

Background: The Renal Cancer assay is a clinically validated RT-PCR assay developed to estimate the risk of recurrence in stage I-III clear cell renal cell carcinoma (ccRCC) patients (pts) treated with nephrectomy. The assay measures expression of 16 genes that are combined to calculate the Recurrence Score result (RS). The RS is associated with recurrence, renal cancer-specific survival and overall survival (all p<0.001) (Escudier, ASCO 2014). The performance of the RS in clinically relevant subgroups, compared to the Leibovich score, and its within-patient variability was examined. Methods: The algorithm, endpoints, methods, and analysis plan were pre-specified prior to merging clinical and molecular data. RT-PCR of RNA from fixed paraffin-embedded ccRCC tissue was performed without knowledge of clinical data. Recurrence-free internval (RFI) was analyzed using Cox regression stratified by stage with data censored at 5 years, and Kaplan-Meier methods. Multivariable models incorporating the Leibovich score were used to assess the additional contribution of the RS to prediction of recurrence. Within- and between-tumor block reproducibility was assessed in an independent study using two separate tumor blocks from 8 pts, where each block was analyzed at 3 depths. Results: RS was generated in 626/645 pts (97%): 398 stage I, 54 stage II, 174 stage III. Median follow up was 5.5 yrs. The RS was significantly associated with risk of recurrence after adjustment for the Leibovich score (HR=4.20, p<0.001). Additionally, the performance of RS was similar across age groups (<60, 60-70 or ≥70), gender, nephrectomy type, tumor size (≤4, 4-7 or >7cm), grade, and presence/absence of invasion (all interaction p>0.29). Within-patient variability in the score (std. dev. of 1.73 and 4.74 RS units for within- and between-tumor block, respectively) was lower than patient-to-patient variability (std. dev. of 15.6 in validation study). Conclusions: The 16-gene signature remains strongly associated with risk of recurrence after adjustment for the Leibovich score and performs consistently across clinically relevant subgroups. Examination of within-patient and between-patient variability indicates that the score is robust to tumor heterogeneity.

[Single procedure treatment of complex nephrolithiasis: about a modern series of anatrophic nephrolithotomy]

PURPOSE

Advances in endourology have significantly reduced indications of open surgery in the treatment of staghorn calculi. However, in our experience, open surgery is still the treatment of choice in some cases. This study presents the results of a series of selected patients and discusses the results in terms of efficacy and morbidity.

MATERIALS

A cohort of 26 patients underwent anatrophic nephrolithotomy by lombotomy to treat a complex staghorn calculus.

RESULTS

The mean stone size was 68,5mm, 70% were complete staghorn calculi. The operative time was 100minutes. Blood loss was 225mL, with a postoperative transfusion rate of 15.4%. The hospital stay was 8.4 days. The stone free rate following the procedure was 92%. The creatinine clearance (MDRD) at 3 months was improved from 5.9mL/min/m(2) on average over the entire series.

CONCLUSION

There are clearly still indications for open surgery in staghorn stones management, with good results in this contemporary series on both stone removal and nephronic preservation. Yet, it appears that this technique is no longer taught.

LEVEL OF EVIDENCE

5.

Nephron sparing surgery for De Novo kidney graft tumor: results from a multicenter national study

Nephron sparing surgery (NSS) results in the transplanted population remain unknown because they are only presented in small series or case reports. Our objective was to study renal sparing surgery for kidney graft renal cell carcinomas (RCC) in a multicenter cohort. Data were collected from 32 French transplantation centers. Cases of renal graft de novo tumors treated as RCC since the beginning of their transplantation activity were included. Seventy-nine allograft kidney de novo tumors were diagnosed. Forty-three patients (54.4%) underwent renal sparing surgery. Mean age of grafted kidneys at the time of diagnosis was 47.5 years old (26.1-72.6). The mean time between transplantation and tumor diagnosis was 142.6 months (12.2-300). Fifteen tumors were clear cell carcinomas (34.9%), and 25 (58.1%) were papillary carcinomas. Respectively, 10 (24.4%), 24 (58.3%) and 8 (19.5%) tumors were Fuhrman grade 1, 2 and 3. Nine patients had postoperative complications (20.9%) including four requiring surgery (Clavien IIIb). At the last follow-up, 41 patients had a functional kidney graft, without dialysis and no long-term complications. NSS is safe and appropriate for all small tumors of transplanted kidneys with good long-term functional and oncological outcomes, which prevent patients from returning to dialysis.

Factors impacting survival in patients with upper tract urothelial carcinoma undergoing radical nephroureterectomy

INTRODUCTION

This study aims to assess the influence of different prognostic factors on survival of upper tract urothelial carcinoma (UTUC) managed by nephroureterectomy and to investigate whether these factors have an independent prognostic significance.

MATERIALS AND METHODS

A retrospective review of institutional databases from two teaching hospitals identified 269 consecutive patients with UTUC managed with nephroureterctomy between 1985 and 2005. Mean follow up was 80.6 months (median 70.3 months). Follow up was completed until January 2009. Tumor location and other clinicopathological variables were analyzed regarding survival. Data accrued included age, gender, tumor characteristics (pT stage, grade, lymph node status), tumor location, use of chemotherapy and period of diagnosis. Tumor location was divided into two groups (renal pelvis and ureter) based on the location of the tumor.

RESULTS

Five year and 10 year overall survival estimates for this cohort were 71.3% and 40.0% respectively. According to tumor location, survival was 73.6% and 47.0% for the renal pelvis versus 67.8% and 32.3% for the ureter, respectively (log rank test: p = 0.027). In multivariate analysis, among the clinicopathological variables, T stage was the most significant prognostic factor (p < 0.001). Nodal involvement (p = 0,005), high grade (p < 0.001), first period of diagnosis (p < 0.001) and ureteral tumor location (p = 0.003) were significantly associated with lower survival rates. Prognosis of UTUC improved over time: survival was significantly better during the last period of diagnosis (2001-2005) (p < 0.002).

CONCLUSIONS

Tumor location and diagnostic period should be considered as an independent prognostic factor for upper tract transitional cell carcinoma.

Interstitial fibrosis evolution on early sequential screening renal allograft biopsies using quantitative image analysis

Screening renal biopsies (RB) may assess early changes of interstitial fibrosis (IF) after transplantation. The aim of this study was to quantify IF by automatic color image analysis on sequential RB. We analyzed RB performed at day (D) 0, month (M) 3 and M12 from 140 renal transplant recipients with a program of color segmentation imaging. The mean IF score was 19 ± 9% at D0, 27 ± 11% at M3 and 32 ± 11% at M12 with a 8% progression during the first 3 months and 5% between M3 and M12. IF at M3 was correlated with estimated glomerular rate (eGFR) at M3, 12 and 24 (p < 0.02) and IF at M12 with eGFR at M12 and 48 (p < 0.05). Furthermore, IF evolution between D0 and M3 (ΔIFM3-D0) was correlated with eGFR at M24, 36 and 48 (p < 0.03). IF at M12 was significantly associated with male donor gender and tacrolimus dose (p = 0.03). ΔIFM3-D0 was significantly associated with male donor gender, acute rejection episodes (p = 0.04) and diabetes mellitus (p = 0.02). Thus, significant IF is already present before transplantation. IF evolution is more important during the first 3 months and has some predictive ability for change in GFR. Intervention to decrease IF should be applied early, i.e. before 3 months, after transplantation.

Significance of C4d Banff scores in early protocol biopsies of kidney transplant recipients with preformed donor-specific antibodies (DSA)

The significance of C4d-Banff scores in protocol biopsies of kidney transplant recipients with preformed donor-specific antibodies (DSA) has not been determined. We reviewed 157 protocol biopsies from 80 DSA+ patients obtained at 3 months and 1 year post-transplant. The C4d Banff scores (1,2,3) were associated with significant increments of microcirculation inflammation (MI) at both 3 months and 1 year post-transplant, worse transplant glomerulopathy and higher class II DSA-MFI (p < 0.01). Minimal-C4d had injury intermediate between negative and focal, while focal and diffuse-C4d had the same degree of microvascular injury. A total of 54% of patients had variation of C4d score between 3 months and 1 year post-transplant. Cumulative (3 month + 1 year) C4d scores correlated with long-term renal function worsening (p = 0.006). However, C4d staining was not a sensitive indicator of parenchymal disease, 55% of C4d-negative biopsies having evidence of concomitant MI. Multivariate analysis demonstrated that the presence of MI and class II DSA at 3 months were associated with a fourfold increased risk of progression to chronic antibody-mediated rejection independently of C4d (p < 0.05). In conclusion, the substantial fluctuation of C4d status in the first year post-transplant reflects a dynamic humoral process. However, C4d may not be a sufficiently sensitive indicator of activity, MI and DSA being more robust predictors of bad outcome.

Kidney transplantation at Necker Hospital: the most recent 5-year period (2004-2009)

The results of our last 5 years activity in kidney transplantation clearly show that it is possible to perform high-risk transplantations with very acceptable results: ECD kidneys, dual transplantation, recipients with DSAs. In depth statistical analysis of these data should allow a clearer definition of the best strategies to use in these situations.

Donor-estimated GFR as an appropriate criterion for allocation of ECD kidneys into single or dual kidney transplantation

It has been suggested that dual kidney transplantation (DKT) improves outcomes for expanded criteria donor (ECD) kidneys. However, no criteria for allocation to single or dual transplantation have been assessed prospectively. The strategy of DKT remains underused and potentially eligible kidneys are frequently discarded. We prospectively compared 81 DKT and 70 single kidney transplant (SKT) receiving grafts from ECD donors aged >65 years, allocated according to donor estimated glomerular filtration rate (eGFR): DKT if eGFR between 30 and 60 mL/min, SKT if eGFR greater than 60 mL/min. Patient and graft survival were similar in the two groups. In the DKT group, 13/81 patients lost one of their two kidneys due to hemorrhage, arterial or venous thrombosis. Mean eGFR at month 12 was similar in the DKT and SKT groups (47.8 mL/min and 46.4 mL/min, respectively). Simulated allocation of kidneys according to criteria based on day 0 donor parameters such as those described by Remuzzi et al., Andres et al. and UNOS, did not indicate an improvement in 12-month eGFR compared to our allocation based on donor eGFR.

Incidence, risk factors and clinical consequences of neutropenia following kidney transplantation: a retrospective study

Neutropenic episodes in kidney transplant patients are poorly characterized. In this retrospective study, neutropenia was experienced by 112/395 patients (28%) during the first year posttransplant. The only factor found to be significantly associated with the occurrence of neutropenia was combined tacrolimus-mycophenolate therapy (p < 0.001). Neutropenic patients experienced more bacterial infections (43% vs. 32%, p = 0.04). Grade of neutropenia correlated with the global risk of infection. Discontinuation of mycophenolic acid (MPA) due to neutropenia was associated with an increased incidence of acute rejection (odds ratios per day 1.11, 95% confidence intervals 1.02-1.22) but not with reduced renal function at 1 year. The time from onset of neutropenia to MPA discontinuation correlated with the duration of neutropenia. Granulocyte colony-stimulating factor (G-CSF) administration was safe and effective in severely neutropenic kidney graft recipients, with absolute neutrophil count >1000/microL achieved in a mean of 1.5+/-0.5 days. Neutropenia is an important and frequent laboratory finding that may exert a significant influence on outcomes in kidney transplantation. As well as leading to an increased incidence of infection, it is associated with a higher rate of allograft rejection if MPA is discontinued for >6 days (p = 0.02). G-CSF accelerates recovery of neutropenia and may be a good therapeutic alternative for severely neutropenic patients.

Renal ischemic preconditioning improves recovery of kidney function and decreases alpha-smooth muscle actin expression in a rat model

PURPOSE

We determined the role of ischemic preconditioning on renal function and histology in a rat model.

MATERIALS AND METHODS

A total of 34 Sprague-Dawley rats (Janvier Laboratories, Le Genet-St-Isle, France) were divided into 6 groups, including sham operation, ischemic preconditioning alone (5 minutes of bilateral ischemia followed by 5 minutes of reperfusion for 3 cycles), ischemia alone (60 minutes of bilateral renal pedicle clamping), ischemic preconditioning before bilateral ischemia, ischemic preconditioning before ischemia in left nephrectomized rats and ischemic preconditioning of the left kidney alone before 60 minutes of bilateral warm ischemia to assess the effect of left kidney preconditioning on the contralateral kidney. Serum creatinine and malondialdehyde levels were recorded at days 0, 1, 3, 11 and 15. Kidneys were harvested at day 15 for histological study and alpha-smooth muscle actin typing.

RESULTS

At days 1 and 3 serum creatinine and malondialdehyde levels were significantly lower in the ischemic preconditioning group compared to levels in the ischemia alone group. At days 11 and 15 creatinine and malondialdehyde levels were similar in all groups and comparable to levels at day 0. At day 15 ischemic preconditioning kidneys showed significantly decreased fibrosis and alpha-smooth muscle actin expression than ischemia alone kidneys.

CONCLUSIONS

Ischemic preconditioning improves the ability of rat kidney to tolerate subsequent ischemic injury in the first 3 days after reperfusion. Moreover, fibrosis and alpha-smooth muscle actin expression are decreased in ischemic preconditioning kidneys 15 days after reperfusion, suggesting a potential interest of ischemic preconditioning in surgical situations that expose kidneys to prolonged warm ischemia.

Impact of Surgical Procedures and Complications on Outcomes of Third and Subsequent Kidney Transplants

BACKGROUND

Surgical procedures and complications have rarely been described in patients receiving a third or subsequent renal transplant.

METHODS

Data from 61 consecutive third (n=56), fourth (n=4), and fifth (n=1) renal transplants performed during 1974 to 2005 were analyzed retrospectively.

RESULTS

Actuarial graft survival was 91%, 74%, and 57% at one, five, and 10 years, respectively. Technical failure accounted for the loss of three grafts (5%). A transperitoneal approach was necessary in 41% of patients. Technical difficulties occurred in half of the procedures, mainly due to atheroma or vascular calcifications. Overall, there were 45 surgical complications in 30 patients, of urological (n=11), vascular (n=6), infectious (n=9), hemorrhagic (n=12), digestive (n=3), or wound origin (n=4). The rate of surgical revision was 16%. Univariate analysis showed that among surgical complications, only vascular complications were associated with a poor graft outcome (P=0.02). Urological complications did not influence long-term graft outcome. Multivariate analysis of all surgical procedures and complications that might have influenced graft survival showed that only vascular complications were associated with a poorer graft outcome (relative risk=6.13, P=0.015).

CONCLUSIONS

Despite a high rate of surgical complications and revisions, third and subsequent kidney transplantations may be performed safely by experienced surgeons without surgical complications influencing long-term graft outcome.