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Kidney transplantation (KT) is the best therapeutic option for patients with end-stage renal disease in terms of survival, quality of life and cost-effectiveness. The fundamental difference of KT with respect to other therapies is that the process depends on the availability of organs for clinical use, availability that is insufficient to cover the increasing transplantation needs of the population. Another relevant feature of transplantation is that it entails a risk of transmission of diseases from donor to recipient, a risk that can be minimized, but not completely eliminated. Due to its characteristics and its unique nature (the human being), KT requires a specific regulation that guarantees the protection of all those who participate in the process: donors and their families, patients in need of a transplant, recipients of organs and healthcare professionals involved. In this article, we review the ethical-legal standards that regulate the practice of kidney donation and transplantation at the international level and analyze the ethical-legal framework that is applicable in Spain.
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Renal transplantation remains the best treatment option of renal replacement for end-stage chronic kidney disease. Surgical advances in graft quality and implantation techniques have improved transplantation during the last two decades. This has reduced both urologic and vascular complications after implantation. A detailed understanding of renal graft and transplantation anatomy is important to reduce transplantation morbidity. The aim of this article is to provide a detailed anatomic description of the kidney and regions usually involved in human renal transplantation (iliac fossa and left lumbar fossa), to provide basic instructions for the novice transplant surgeon, and to improve the anatomic knowledge of the experienced transplant surgeon.
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Kidney transplantation (KT) is the best treatment for end-stage renal disease. Despite Spain is one of the leading countries in donation, the need for transplantable organs exceeds the available supply.Graft survival depends on the quality of the organ, the damage it suffers during the donation and transplantation process, as well as the risk of rejection. Among the factors that must be controlled and minimized are the ischemia-reperfusion injuries that occurs in the moments surrounding the death of the donor, the procurement and the preservation of the organ until kidney transplantation.Static cold storage is the traditional method of preservation of the organ until the moment of implantation, since it is a technique with wide availability and low cost. The use of perfusion machines in DCD and expanded criteria has shown better short-term results (primary failure, delayed onset of function) without affecting recipient or graft survival.The objective of our article is to review the current situation and the resources available to increase the pool of transplantable organs and their quality.We conducted a systematic review on kidney extraction, donor management, preservation methods and techniques to optimize cadaveric donor kidney donation.
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Urological evaluation is essential to guarantee the success of the kidney transplant. Urologists working within a multidisciplinary team have a crucial role to detect and manage certain recipient urological conditions that could jeopardize the function and survival of the graft. The critical aspects that Urologists should consider in the pre-transplant evaluation would be: - Is renal transplantation surgical technique feasible with assumable risks based on the recipient’s baseline characteristics? age, life expectancy, performance status, physical examination...- Is bladder function adequate to properly ensure the urine storage and voiding?- Is there a potentially treatable urinary flow obstruction?- Are there urological pathologies in the recipient that could lead to post-transplant complications that compromise graft survival: functional, infectious, oncological comorbidities…?- Based on the patient’s cardiovascular risk factors, arteriosclerosis in the aorto-iliac territory colud put at risk the arterial anastomosis?In this chapter, we will try to explain how the pre-transplant urological evaluation should be guided according to the specific recipient characteristics. We will also explain which pre-transplant surgeries are required to avoid some risky that may compromise the recipient and graft survival after renal transplantation, as well as those should be postponed after transplantation.
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Renal biopsy procedure is used prior to insertion and at follow-up on a daily basis. The main donor renal biopsy indication is for evaluation of renal graft with expanded criteria, which have demonstrated their utility for renal transplant decisions.Other indications include evaluation of donors on acute renal failure; indeterminate lesions evaluation on renal parenchyma or evaluation prior to clinical trial evaluation. How the renal biopsy is performed is also important on its evaluation, and evaluation of glomerular lesions, tubule-interstitial and vascular lesions. All those determine renal graft evaluation, survival and chronic renal disease during follow-up. The main indication for renal biopsy on the recipient is the differential diagnosis of rejection when clinically suspicious or on patients with high- immunological risk where subclinical reject is important. In high0risk patients, such as sensitized patients or living-donor recipients with ABO incompatibility, protocol biopsies are evaluated without guideline consensus. For that procedure, an automatic punch 16G needle is used, generally associated with low complication rates.
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Kidney transplantation is the treatment of choice for patients with end-stage renal disease (ESRD) as it has shown a better quality of life and longer survival compared to dialysis. Patients with ESRD have associated vascular pathology in a significant percentage, with abundant calcifications at the level of the aorto-iliac axis. The survival of transplanted patients has also increased so an important number of patients have multiple transplants, patients with an indication for a third, fourth and even fifth transplant.In these cases, in which the iliac fossa is no longer practicable (atheromatosis, vascular abnormalities, occupied iliac fossae for previous kidney transplant…) , orthotopic kidney transplantation offers a viable option with good results.
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OBJECTIVES: Nowadays, Robotic assisted kidney transplantation (RAKT) is considered a less invasive alternative to the Open Kidney Transplantation (OKT) with several advantages such as image magnification, 3D vision and articulated instruments and with a relatively short learning curve for an experienced surgeon. RAKT has shown comparable outcomes with the OKT literature data in terms of surgical and functional results. RAKT may decrease the complication rate, mean hospital stay, postoperative pain, and also improve aesthetic outcomes. The aim of this study was to perform a systematic review of the literature on this novel approach of KT. MATERIALS AND METHODS: A systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The search was conducted using the databases PubMed/Medline, including as outcomes: (1) indications, (2) step-by-step technique for RAKT, (3) RAKT in special cases (4) surgical and functional outcomes, and (5) future perspectives in RAKT. RESULTS: The indications for RAKT are expanding, so that including obese recipients, graft with multiple vessels and graft from deceased donor. To date, the two absolute contraindications to RAKT are patients unfit for pneumoperitoneum and presenting advanced atheromatic plaques where vessel clamping could result challenging. As far as the outcomes, the surgical and functional results are in line with the OKT experience. Complication rate is low in RAKT, particularly in terms of arterial and venous thrombosis (1%), lymphocele (3%), ureteral stricture (2%), and wound infection (0.3%). A robotic assisted kidney auto-transplantation (RAKAT) has been recently described, as novel approach in case of complex proximal benign ureteral stenosis. Despite great advances in this field, some limits still need to be approached such as the modality to maintain the graft to a constant low temperature (< 20 ºC) and to find the proper location of arteriotomy in advanced atheromatic disease without the tactile feedback. CONCLUSION: The present review has confirmed that RAKT is as safe and feasible as OKT with comparable surgical and functional results. Complication rate is lower in RAKT than OKT and the indications are expanding quickly. Furthermore, new technologies are being introduced in order to improve the surgical performances and to expand more the indications for robotic surgery. However, a prospective randomized study in order to compare RAKT versus OKT is still required.
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Living donor kidney transplantation is the best therapeutic option in a patient with end-stage renal failure, because it provides excellent functionality and graft survival. Laparoscopic living donor nephrectomy is the gold-standard for obtaining the graft. In expert hands, different minimally invasive surgeries can be offered with the main advantage of improving the aesthetic results. Although there may be controversy regarding laparoscopic devices for vascular ligation during living donor nephrectomy, both endostaplers and locking clips have proven to be safe as long as the proper technique is performed. Living donor nephrectomy has minimal morbidity and mortality. Age and glomerular filtration rate of the donor candidate are prognostic factor of long-term renal failure. In relation to the implant surgery, robotic kidney transplantation is now probably at the beginning of its development. Published series still do not allow to clearly establish its role compared to conventional open surgery.
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Kidney transplantation (KT) is the best treatment for children in end-stage renal disease. KT has less mortality than dialysis and provides a better quality of life. Thus, the inclusion criteria have been progressively broadened. Histocompatibility and the source of donation are the most relevant factors that influence graft survival. Graft and patient survival have improved dramatically in recent decades, coming close to the results of KT in adults. Some of the specific factors that differentiate it from the adult are: donor-recipient size mismatch, the impact on growth and therapeutic non-compliance. Overall graft survival at 5-years is 90% for living donor KT and 70% for cadaveric donor KT.The most frequent cause of graft loss is chronic rejection. Mortality in the first post-transplant years is less than 6.5%. Infections and cardiovascular complications are the main causes of transplant-related death.Despite the good results, it is imperative to continue investigating how to achieve immunological tolerance. In order to improve the long-term results of the kidney graft is necessary to reduce immunosuppressive treatment and its side effects, such as chronic rejection.
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Kidney transplantation is the renal replacement therapy of choice in patients with end-stage kidney disease. Immunosuppressive drugs are the main pillar of treatment in solid organ transplantation as they reduce rejection rates and increase graft survival. However, they can also cause significant side effects that can complicate transplant progression. The objective of this chapter is to outline the main characteristics of immunosuppressants agents, their mechanisms of action and the side effects.
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Vascular complications remain common after renal transplantation, occurring in 3% to 15% of patients. These complications can compromise graft function, with graft loss rates ranging from 12.6 to 66.7%.Vascular abnormalities of the graft, specifically the presence of multiple vessels, represent the most frequently studied risk factor for the development of vascular complications. Other risk factors identified for the development of vascular complications are linked to the characteristics of the recipient, or thromboembolic disease sharing atherosclerosis and/or hypercoagulant state as pathogenic features. Although the most frequent vascular complication is renal artery stenosis, we will also address the complications according to their early or late onset in order to highlight the potentially more severe complications that may affect graft survival during the follow-up period. Early vascular complications include mainly arterial and venous thrombosis and lacerations or disruptions of artery and/or vein, as well as arterio-venous fistulas or intrarenal pseudoaneurysms. In contrast, late-onset complications include stenosis or kinking of the renal artery -and less commonly of the renal vein-, as well as extrinsic compression as a consequence of the presence of perigraft fluid collections. Finally, extrarenal pseudoaneurysm is a potentially severe complication in the late post-transplant period.Finally, this article explores special transplant situations such as complications derived from the paediatric donor in adult recipients, transplantation in the paediatric recipient and emerging techniques like robotic renal transplantation.
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There are different surgical techniques for reconstruction of the urinary tract in kidney transplant. However, urinary complications are frequent in the postoperative period, being the ureter the frequent location of these complications. This results in high health care costs, increasing patient morbimortality and sometimes graft loss. For this reason, prevention, correct diagnosis and treatment are important.The aim of this review is to describe the surgical techniques most commonly used in kidney transplant for ureteroneocystostomy. To analyze the advantages and disadvantages of each of them and to compare their complications. On the other hand, we summarize the recent literature on the four most frequent urinary complications in the postoperative period after transplantation. The possible causes and treatment of urine leak, ureteric obstruction, hematuria and vesicoureteral reflux are presented.
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OBJECTIVES: Late kidney transplant complication might compromise graft durability, thus the need for early detection and treatment.MATERIAL AND METHODS: A PubMed review including the following MeSH terms was included: kidney transplant¨, ¨complications¨, ¨vascular complications¨, ¨transplant renal artery stenosis¨, ¨ureteral obstruction¨, ¨urologic complications¨, ¨forgotten stent¨, ¨vesicoureteral reflux¨, ¨urinary lithiasis¨ e ¨incisional hernia¨. Metanalysis and systematic review in spanish and English were included from January 2015 till February 2021, as well as relevant selected manuscripts. RESULTS: We defined as late complications those appearing at 3 months from kidney transplant. Those include vascular complications (renal artery stricture), urinary tract (ureteral stricture, permanent double Js, pyelonephritis due to reflux, urinary stones) and abdominal wall (incisional hernia).CONCLUSIONS: Late kidney transplant complications remain high still with advancement on surgical technique and immunotherapy. Those complication might compromise the graft durability and so early detection is or primary importance.
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OBJECTIVE: Cancer is the 3rd cause of death in the Spanish kidney transplant population. The risk of developing a tumour is multifactorial. Improvements in follow-up and increased graft survival have led to an increase in the incidence of de novo tumours in these patients.MATERIAL AND METHODS: We have conducted a systematic review of articles published in online medical databases related to de novo tumours in kidney transplant recipients. We have evaluated the incidence of de novo neoplasms in patients who underwent a kidney transplant at the Hospital Universitario de Cruces from January 2011 to December 2018. RESULTS AND DISCUSSION: Different characteristics have been described within the transplanted population that could promote the development of tumours. The alteration of the antitumor response, the altered ability to respond to infections, drug´s carcinogenic effect, and a greater susceptibility ultraviolet rays damage are some of the most repeated. As a consequence, overall risk of cancer increases two to three times in the transplanted population. Overall, in our analysis, the neoplasms that showed the highest incidence were urological (21.98%), followed by haematological (16.63%) and digestive tract (14.58%).CONCLUSION: There is a higher incidence and risk of de novo tumour development in the kidney transplant population, which probably requires optimizing patient follow-up and developing more precise screening strategies that can be modified depending on geographic and individual variations, to reduce the impact on survival that it may have on our patients.
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OBJECTIVE: Kidney transplantation process involves a series of challenges such as the shortage of organs worldwide for a population waiting for a first and subsequent kidney transplants and the search for the most appropriate graft for each recipient, optimizing the ischemia time as much as possible, minimizing the impact of surgery and subsequent immunosuppressive therapy.METHODS: We carry out a review of the different advances and lines of research in the different areas involved in the kidney transplantation process from strategies focused on increasing the donor pool, enabling the expansion of living donor programs as well as organ preservation strategies previous to transplantation surgery. The arrival of robotic surgery in the field of kidney transplantation has been an important milestone in the last decade, showing improvements compared to traditional open surgery, maintaining satisfactory functional results, although its implementation is currently reduced with technical limitations in the extension to any type of recipient. New immunosuppressive agents that minimize potential side effects or reduce anticalcineurinic drugs doses are also important lines of research.CONCLUSIONS: The future of kidney transplantation involves the search for increasingly global strategies to improve the supply of organs, improvements in the conditioning and preservation of grafts or the global development of minimally invasive surgery in the different areas of kidney transplantation. The weight of biotechnology and gene therapies represent promising tools in the field of tissue generation or targeted immunosuppressive therapies.
