Reasons and effects of the decline of willing related potential living kidney donors

BACKGROUND Although the availability of related living donors(LDs)provides a better chance for receiving kidney transplantation(KT),the evaluation protocols for LD selection remain a safeguard for the LD’s safety.These protocols are variable from one center to another,resulting in variable rates of decline of the potential LDs(PLDs).The decline of willing PLDs may occur at any stage of evaluation,starting from the initial contact and counseling to the day of operation.AIM To identify the causes of the decline of PLDs,the predictors of PLD candidacy,and the effect on achieving LDKT.METHODS A retrospective study was performed on the willing PLDs who attended our outpatient clinic for kidney donation to their related potential recipients between October 2015 and December 2022.The variables influencing their candidacy rate and the fate of their potential recipients were studied.Two groups of PLDs were compared:Candidate PLDs after a completed evaluation vs non-candidate PLDs with a complete or incomplete evaluation.A multivariate logistic regression was performed to assess the factors contributing to the achievement of PLD candidacy.RESULTS Of 321 willing PLDs,257 PLDs(80.1%)accessed the evaluation to variable extents for 212 potential recipients,with a mean age(range)of 40.5±10.4(18-65)years,including 169 females(65.8%).The remaining 64 PLDs(19.9%)did not access the evaluation.Only 58 PLDs(18.1%)succeeded in donating,but 199 PDLs(62.0%)were declined;exclusion occurred in 144 PLDs(56.0%)for immunological causes(37.5%),medical causes(54.9%),combined causes(9.7%),and financial causes(2.1%).Regression and release occurred in 55 PLDs(17.1%).The potential recipients with candidate PLDs were not significantly different from those with non-candidate PLDs,except in age(P=0.041),rates of completed evaluation,and exclusion of PLDs(P<0.001).There were no factors that independently influenced the rate of PLD candidacy.Most patients who failed to have KT after the decline of their PLDs remained on hemodialysis for 6 mo to 6 years.CONCLUSION The rate of decline of willing related PLDs was high due to medical or immunological contraindications,release,or regression of PLDs.It reduced the chances of high percentages of potential recipients in LDKT.

Changing landscape in living kidney donation in Greece

Patients with end-stage renal disease in Greece are facing long waiting times to receive a kidney transplant from a deceased donor.Living kidney donation offers a valuable alternative that provides optimal outcomes and significantly expands the donor pool but still remains relatively underutilised.Developments around the world in the field of kidney transplantation mandate a change in current practice to include additional options for living donation through paired exchange,antibody-incompatible transplantation and other strategies,following careful consideration of the cultural and ethical factors involved in these complex clinical decisions.An increase in living donation rates may be achieved in several ways,including targeted campaigning to overcome potential barriers.Educating clinicians on transplantation will prove as equally important as informing patients and prospective donors but requires training and resources.Adoption of established practices and implementation of new strategies must be tailored to the needs of the Greek donor and recipient population.Local beliefs about donation,perception of associated risk and other social characteristics must be considered in the design of future strategies.Facilitating living donation in a safe environment with appropriate donor and recipient education will form the solid foundation of a new era of kidney transplantation in Greece.

Hypertension and obesity in living kidney donors

Over the past few decades,the shortage in the kidney donor pool as compared to the increasing number of candidates on the kidney transplant waitlist led to loosening of kidney donors’acceptance criteria.Hypertension and obesity represent risk factors for chronic kidney disease,both in native kidneys and those in kidney transplant recipients.While great progress has been made in kidney transplantation from living donors to benefit the recipient survival and quality of life,progress has been slow to fully risk-characterize the donors.This review critically reassesses the current state of understanding regarding the risk of endstage kidney disease in those donors with obesity,hypertension or both.Accurate risk assessment tools need to be developed urgently to fully understand the risk glomerular filtration rate compensation failure in the remaining kidney of the donors.

Living kidney donor assessment:Kidney length vs differential function

BACKGROUND The key question in living kidney donor assessment is how best to determine the contribution of each kidney to overall renal function and guide selection of which kidney to donate,ensuring safety of procedure and good outcome for both recipient and donor.It is thought that a length difference>2 cm may indicate significant difference in function and therefore need for measurement of differential function.AIM To determine the effect of using kidney length to decide which kidney to donate in a retrospective cohort of potential donors.METHODS All 333 potential living kidney donors between January 2009 and August 2018 who completed assessment were retrospectively evaluated.Donor assessment was performed as per United Kingdom guidelines.Data included age,sex,kidney length(cranio-caudal)obtained by computed tomography/ultrasonography,51-chromium ethylenediamine tetraacetatic acid measured glomerular filtration rate,mercapto acetyl tri glycine split function and vascular anatomy.There were 48 exclusions due to inadequate data or incomplete investigations.Statistical analysis was performed using Excel pivot tables and GraphPad Prism.Correlation between kidney length and differential function was determined with Pearson’s correlation coefficient.RESULTS Of 285 potential donors included in the study,there were 144 males(mean age 49.9±14.75)and 141 females(mean age 51.2±11.23).Overall,the Pearson’s correlation between differences in length and divided function of kidney pairs was 0.1630,P=0.0058.Of 73 with significant difference(>10%)in divided function,18(24.7%)had no difference in kidney length;54(74%)had a difference of<2 cm and only one of>2 cm.Using a length difference of>1 cm would only predict significant difference in divided function in 8/34(23.5%)of cases.Using a difference of>2 cm as cut off for performing split function would lead to false reassurance in 72 patients(6 had>20%difference in divided function whereas 66 had 10%-20%difference).CONCLUSION Length difference between kidney pairs alone is not sufficient to replace measurement of divided function.This issue requires a randomised controlled trial to resolve it.

Pros and cons of live kidney donation in prediabetics: A critical review and way forward

There is shortage of organs,including kidneys,worldwide.Along with deceased kidney transplantation,there is a significant rise in live kidney donation.The prevalence of prediabetes(PD),including impaired fasting glucose and impaired glucose tolerance,is on the rise across the globe.Transplant teams frequently come across prediabetic kidney donors for evaluation.Prediabetics are at risk of diabetes,chronic kidney disease,cardiovascular events,stroke,neuropathy,retinopathy,dementia,depression and nonalcoholic liver disease along with increased risk of all-cause mortality.Unfortunately,most of the studies done in prediabetic kidney donors are retrospective in nature and have a short follow up period.There is lack of prospective long-term studies to know about the real risk of complications after donation.Furthermore,there are variations in recommendations from various guidelines across the globe for donations in prediabetics,leading to more confusion among clinicians.This increases the responsibility of transplant teams to take appropriate decisions in the best interest of both donors and recipients.This review focuses on pathophysiological changes of PD in kidneys,potential complications of PD,other risk factors for development of type 2 diabetes,a review of guidelines for kidney donation,the potential role of diabetes risk score and calculator in kidney donors and the way forward for the evaluation and selection of prediabetic kidney donors.

Unspecified live kidney donation by urological patients

BACKGROUND Individuals with benign kidney disorders undergoing nephrectomy have three possibilities:Autotransplantation,with a certain risk of complications,but without a clear benefit;discarding the kidney;or living kidney donation.AIM To investigate whether patients with benign kidney disorders and a medical indication for nephrectomy are suitable as unspecified live kidney donors.METHODS We searched all clinical data from 1994-2019 for unspecified donors and their transplant recipients(n=160).Nine of these 160 donors had pre-existing kidney disorders necessitating nephrectomy and had decided to donate their kidney anonymously after discussing the possibility of kidney donation.We studied the clinical course of these nine donating patients and their transplant recipients.RESULTS Seven of nine donating patients indicated unbearable loin pain as the main complaint,one donating patient refused ureterocutaneostomy and one had two aneurysms of the renal artery.Postoperatively,seven donating patients described absence of pain and one a significant reduction after the nephrectomy.The average 1-year creatinine level in the donating patients was 88μmol/L and after a median of 6.9 years the average creatinine level was 86.6μmol/L.In the transplant recipients,one major complication occurred which led to death and in one transplant recipient graft function failed to normalize at first but has been stable for nine years now.Currently,all transplant recipients are off dialysis.CONCLUSION Our data show that patients undergoing nephrectomy as part of treatment in selected kidney disorders can function as live kidney donors.

Epstein-Barr virus-associated smooth muscle tumors in immunocompromised patients:Six case reports

BACKGROUND Epstein-Barr virus associated smooth muscle tumor(EBV-SMT)is a rare oncological entity.However,there is an increasing incidence of EBV-SMTs,as the frequency of organ transplantation and immunosuppression grows.EBV-SMT diagnosis relies on histopathology and immunochemical staining to distinguish it from post-transplant lymphoproliferative disorder(PTLD).There is no clear consensus on the treatment of EBV-SMTs.However,surgical resection,chemotherapy,radiation therapy,and immunosuppression reduction have been explored with varying degrees of success.CASE SUMMARY Our case series includes six cases of EBV-SMTs across different age groups,with different treatment modalities,adding to the limited existing literature on this rare tumor.The median latency time between immunosuppression and disease diagnosis is four years.EBV-SMTs present with variable degrees of aggressiveness and seem to have worse clinical outcomes in patients with tumor multiplicity and worse immunocompetency.CONCLUSION It is imperative to continue building on this knowledge and keeping EBV-SMTs on the differential in immunocompromised individuals.

Translational research and innovation in modern transplant practice:Paradigms from Greece and around the world

The continuous clinical and technological advances,together with the social,health and economic challenges that the global population faces,have created an environment where the evolution of the field of transplantation is essentially necessary.The goal of this special issue is to provide a picture of the current status of transplantation in Greece as well as in many other countries in Europe and around the world.Authors from Greece and several other countries provide us with valuable insight into their respective areas of transplant expertise,with a main focus on the field of translational research and innovation.The papers that are part of this Special Issue“Translational Research and Innovation and the current status of Transplantation in Greece”have presented innovative and meaningful approaches in modern transplant research and practice.They provide us with a clear overview of the current landscape in transplantation,including liver transplantation in the context of a major pandemic,the evolution of living donor kidney transplantation or the evolution of the effect of hepatitis C virus infection in transplantation,while at the same time explore more recent challenges,such as the issue of frailty in the transplant candidate and the changes brought by newer treatments,such as immunotherapy,in transplant oncology.Additionally,they offer us a glimpse of the effect that technological innovations,such as virtual reality,can have on transplantation,both in terms of clinical and educational aspects.Just as critical is the fact that this Special Issue emphasizes the multidisciplinary,collaborative efforts currently taking place that link transplant research and innovation with other cutting-edge disciplines such as bioengineering,advanced information technology and artificial intelligence.In this Special Issue,in addition to the clinical and research evolution of the field of transplantation,we are witnessing the importance of interdisciplinary collaboration in medicine.