Tolerance protocol of living kidney transplant for developing countries through basic strategy of lymphocyte depletion

End-stage kidney failure(ESKD)is a global issue where kidney replacement therapy imposes enormous economic burden to people of developing countries,in addition to the severe limitations to the availability of hemodialysis and peritoneal dialysis technique.The best option of kidney transplantation also requires lifelong combination immunosuppressive medicines,the cost of which is equally comparable to lifelong dialysis.A strategy of achieving transplant tolerance that requires minimum immunosuppressive medicines,although in experimental stage,also requires state-of-art technology with costly medicines and interventions.This is evidently beyond the reach of ESKD patients of developing countries.Hence,globally in developing countries,a need for an innovative but cost-effective tolerance protocol is a burning need for a successful transplant program.In brief,transplant tolerance is defined as a state of donorspecific unresponsiveness to the allograft antigens without the need for ongoing pharmacologic immunosuppression or with a minimal need.Current state-of-art techniques involves:(1)A state of hematological chimera,for complete tolerance;(2)Prope or partial tolerance where immune-reactive T-lymphocytes are inhibited using monoclonal antibodies;and(3)Chimeric antigen receptor for T-regulatory(T-reg)cell therapy using genetically engineered T-reg cells targeting specific Tlymphocyte receptors for inducing anergy.From our real-world experience in transplant management in post-transplant lympho-proliferative disorders(PTLD),we noticed frequently a drastic reduction in the need of immunosuppressive medicines following lympho-ablative therapy for PTLD.We recently published a case study on a real-world experience transplant case where we explained a partial or prope tolerance that developed after lymphocyte ablation therapy,following which the allograft was maintained with low dose dual standard immunosuppressive medicines.Based on this publication,we propose here an innovative tolerance protocol for living related low risk kidney transplantation for developing countries,in this opinion review.

Laparoscopic vs open donor nephrectomy:Lessons learnt from single academic center experience

AIM To compare laparoscopic and open living donor neph-rectomy, based on the results from a single center during a decade.METHODS This is a retrospective review of all living donor neph-rectomies performed at the Massachusetts General Hospital, Harvard Medical School, Boston, between 1/1998 - 12/2009. Overall there were 490 living donors, with 279 undergoing laparoscopic living donor nephrectomy （LLDN） and 211 undergoing open donor nephrectomy （OLDN）. Demographic data, operating room time, the effect of the learning curve, the number of conversions from laparoscopic to open surgery, donor preoperative glomerular fltration rate and creatinine （Cr）, donor and recipient postoperative Cr, delayed graft function and donor complications were analyzed. Statistical analysis was performed.RESULTSOverall there was no statistically significant differencebetween the LLDN and the OLDN groups regardingoperating time, donor preoperative renal function, donorand recipient postoperative kidney function, delayed graftfunction or the incidence of major complications. Whenthe last 100 laparoscopic cases were analyzed, there wasa statistically significant difference regarding operatingtime in favor of the LLDN, pointing out the importanceof the learning curve. Furthermore, another significantdifference between the two groups was the decreasedlength of stay for the LLDN （2.87 d for LLDN vs 3.6 d for OLDN）.CONCLUSION Recognizing the importance of the learning curve, this paper provides evidence that LLDN has a safety profle comparable to OLDN and decreased length of stay for the donor.