There is no standardization on the timing of the best approach to treat a non-functioning renal graft. We reviewed the literature and performed a proportional meta-analysis of case series of transplantectomy and embolization for a non-functioning renal graft. The groups were compared for mortality and morbidity outcomes. A total of 2421 patients were included in this review. Of these, 2232 patients underwent transplantectomy and 189 underwent percutaneous embolization. The mortality rate in the nephrectomy group was 4% [95% confidence interval [CI], 2-7%; I²=87%] as compared with 0.1% [95% CI, 0.1-0.5%; I²=0%] in the embolization group. The rates of common morbidities were 18% [95% CI, 13-26%, I²=79.7%] for nephrectomy compared with 1.2% [95% CI, 0.7-2.1%, I²=26.4%] for embolization. The incidence of post-embolization syndrome was 68%, and 20% of patients needed post-embolization nephrectomy. Percutaneous embolization was associated with lower mortality and morbidity rates but also with a high rate of post-embolization syndrome. However, in most cases this complication had easily manageable symptoms. Embolization is a new and attractive technique that can be considered in treating non-functioning renal grafts.

/pdf/nephrectomy-versus-embolization-of-non-functioning-renal-4jpwrxuruq.pdf

Nephrectomy Versus Embolization of Non-Functioning Renal Graft: A Systematic Review with a Proportional Meta-Analysis.

Analysis of 4000 kidney transplantations in a single center: Across immunological barriers.

Indications, risks and impact of failed allograft nephrectomy.

Background
Graft nephrectomy is recommended in case of early graft failure. When the graft fails more than 3-6 months after transplantation it is current practice to follow a wait-and-see policy. A common indication for graft removal is the graft intolerance syndrome. We aimed to create a risk prediction model for the occurrence of graft intolerance resulting in graft nephrectomy.

Methods
We collected data of kidney transplantations performed in our centre between 1980 and 2010 that failed at least 6 months after transplantation. We evaluated the association between baseline characteristics and the occurrence of graft nephrectomy because of graft intolerance using a competing risk regression model. Prognostic factors were included in a multivariate prediction model.

Results
In and -exclusion criteria were met in 288 cases. In 48 patients the graft was removed because of graft intolerance. Donor age, the number of rejections and shorter graft survival were predictive factors forgraft nephrectomy because of the graft intolerance syndrome. These factors were included in a prediction rule.

Conclusion
Using donor age, graft survival, and the number of rejections, clinicians can predict the need for graft nephrectomy with a reasonable accuracy.

This article is protected by copyright. All rights reserved.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/tri.13088

Graft intolerance syndrome requiring graft nephrectomy after late kidney graft failure: can it be predicted? A retrospective cohort study.

The clinical significance of human leukocyte antigen (HLA) antibodies (Abs) for hyperacute, acute and chronic antibody-mediated rejection (AMR) of kidney allografts has been clearly demonstrated. AMR occurs in the absence of donorreactive HLA Abs. It is not known how common the problem of AMR by non-HLA Abs is because of lack of suitable assays for their detection. It is believed that the nonHLA Ab population, although heterogenic, is likely to target antigens on donor organ endothelial cells (ECs). We have been involved in the clinical introduction of a flow cytometric (FC) crossmatch (XM) test that permits the detection of Abs reactive with endothelial precursor cells (EPC) isolated from donor peripheral blood. In this context the EPCs may function as surrogates for mature vascular ECs. The work in this thesis describes the adaptation of the EPCXM to detection of complement-fixing HLA and non-HLA Abs using complement fragment-specific antibodies and flow cytometry, describes the outcome of the EPCXM in relation to the conventional lymphocyte XM (LXM), degree of HLA sensitization and transplantation outcome in patients evaluated for living donor (LD) kidney transplantation (Tx), and assesses the long-term renal graft function in patients with a positive EPCXM pre-transplant. In the first paper, we investigated whether EPCs could be used for detection of complement-fixing Abs and if complement factor and IgG deposition on co-purified T and B cells correlated to the outcome of the Tand B-cell complement-dependent cytotoxicity (CDC) XM. Incubation of EPCs with HLA Ab-positive serum samples resulted in deposition of complement factors C3c and C3d, but not C1q nor C4d, on EPCs and co-purified lymphocytes. The amount of C3c deposition and IgG binding on EPCs and T cells, but not B cells, correlated. The specificity and sensitivity for C3d deposition on co-purified T cells vs the T CDC assay were 69% and 72%, while for B cells the sensitivity was considerably lower. In the second paper, we show that 32% of the LD patients had IgG and/or IgM-binding donor EPCs in their pre-Tx sera. Twenty-five percent of the patients were EPCXM IgM+. Of the patients with negative LXM tests, 25% had EPC Abs mainly of IgM class not reactive with HLA. There was no difference in rejection frequency or serum creatinine levels between the EPCXM positive and negative groups, which is in contrast to earlier published results. However, the clinical protocols used in the second paper included Ab pre-Tx treatments such as B cell depletion and Ab removal. The pre-Tx EPCXM positive group had significantly more patients with delayed graft function. In the manuscript we show that the difference in serum creatinine and glomerular filtration rates observed between EPCXM positive and negative groups at three and six months postTx disappears hereafter and during the four-year follow-up. The detection of complement factors on EPCs and lymphocytes by flow cytometry allowing detection of complement-fixing non-HLA and HLA Abs widens the diagnostic repertoire that can be offered patients undergoing kidney transplantation and should thereby improve their clinical management. Prospective studies with appropriate control groups are needed to establish whether pre-treatments aiming at removing anti-EC Abs, as detected by the EPCXM pre-Tx, have a beneficial effect on shortand long-term graft survival. ISBN – 978-91-628-9311-8 Gothenburg, 2015 The clinical importance of non-HLA specific antibodies in kidney

/pdf/the-clinical-importance-of-non-hla-specific-antibodies-in-t6lhzkaw6w.pdf

The clinical importance of non-HLA specific antibodies in kidney transplantation

Introduction Allograft nephrectomy (AN) is associated with a high number of surgical complications. Some authors advocate that early nephrectomy ( Materials and Methods Between January 2000 and October 2012, we performed 104 AN at our institution (32 early and 72 late). Comparisons between early and late AN, and, within the latter, between the 2 different techniques were sought. Statistical analysis was performed for sample description, group comparison and %PRA variation. Results Among the 104 patients with a mean age of 47.9 ± 14.2 years, 54 were men. Age, gender, body mass index, and number of previous transplants were similar between early and late AN and between ICAN and ECAN patients. Late AN was associated with less blood loss (293.4 ± 229.0 vs 414.3 ± 349.5 mL; P = .03), shorter hospital stay (12.8 ± 14.5 vs 26.8 ± 26.5; P  Conclusions Early AN was associated with a greater number of surgical complications. Nevertheless, the number of AN patients returning to the active waiting list was similar between early and late AN groups. ICAN and ECAN had similar surgical and postoperative outcomes, although a bias may be present because some conversions from ECAN to ICAN occurred owing to technical issues. As in other studies, ICAN did not seem to affect allosensitization or jeopardize the chance of being relisted for transplant when compared with ECAN.

Allograft nephrectomy: a single-institution, 10-year experience.

Background Kidney transplantation is the treatment of choice for end-stage renal disease, with improved mortality and quality of life compared with dialysis. Desensitization protocols have allowed kidney transplantation of highly sensitized patients, who have a lower probability to receive a matching kidney from a deceased or living donor. The aim of this work was to analyze the post-transplantation period of highly HLA-sensitized patients with positive flow cytometry crossmatch against donor cells. Methods Following an observational, retrospective design, we investigated 16 highly sensitized patients who underwent kidney or kidney-pancreas transplantation, assessing the impact of desensitization protocols and investigating treatment-related complications, graft function, antibody-mediated rejection (AMR) rate, and graft and patient survivals. Results We studied 16 patients with positive flow cytometry crossmatch, who were divided into 2 groups based on whether they were submitted to a desensitization protocol or not. Patients who were desensitized underwent transplantation in later years, had higher immunologic risk (panel reactive antibody peak 62% vs 33%; P = .038), higher percentage of 2nd kidney transplant (75% vs 25%; P = .066), and higher percentage of donor-specific anti-HLA antibodies identified (P = .028). A majority of patients were desensitized with high-dose intravenous immunoglobulin and plasmapheresis, and 5 patients received rituximab. Acute AMR rate was of 38%, and rituximab was associated with fewer episodes of AMR. Only 1 patient had graft failure, due to chronic humoral rejection, and the remaining maintained good graft function (mean serum creatinine value of 1.33 mg/dL). No patient died and few complications related to immunossupression were observed. Conclusions Desensitization protocols were safe and allowed kidney transplantation in highly sensitized patients that probably would never undergo transplantation and gave the opportunity of living-donor transplant to patients with anti-HLA antibodies against the donor.

Kidney transplantation across a positive crossmatch: a single-center experience.

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Allograft nephrectomy: a single-institution, 10-year experience.

Kidney transplantation across a positive crossmatch: a single-center experience.