Michael McCabe

Background.: The ongoing organ shortage and aging global population necessitate the utilization of older donors. However, the transplantability of donation after circulatory death (DCD) grafts from septuagenarian donors remains uncertain. Methods.: Adult DCD donors in the United Network for Organ Sharing database between 2020 and 2024 were stratified on the basis of age 70 y or older (septuagenarian donors) and younger than 70 y. The utilization and posttransplant outcomes were analyzed. Results.: There were 24 258 DCD donors, of whom 195 (0.8%) were septuagenarians. Among 364 recovered kidneys, 58 livers, and 8 lungs from septuagenarian donors, 61 (16.7%) kidneys, 50 (86.2%) livers, and 6 (75%) lungs were transplanted. There was no significant difference in 1-y graft survival for either kidney (92.9 versus 91.6%, P = 0.99) or liver (92.3 versus 90.1%, P = 0.82) recipients. There was heterogeneity across regions in septuagenarian donor practices: 2 (3.6%) of 55 organ procurement organizations recovered 33.8% of all septuagenarian donors, whereas 4 (1.8%) of 218 centers transplanted 34.8% of all septuagenarian grafts used. Conclusions.: Septuagenarian DCD grafts achieved favorable graft survival after kidney or liver transplantation. Although significant variation exists across organ procurement organizations and transplant centers, aggressive exploration of septuagenarian DCD donors is warranted to resolve the organ shortage.

Key Points: Terminal renal resistance added prognostic value to kidney donor profile index (KDPI), especially in KDPI >0.85 kidneys. Its effect was modest in KDPI ≤0.85 kidneys. Terminal renal resistance was found to be useful in guiding the acceptance of KDPI >0.85 kidneys on the basis of estimated post-transplant survival. Terminal renal resistance ≥0.3 triggered kidney nonuse regardless of KDPI, but KDPI ≤0.85 kidneys should not be declined on the basis of resistance alone. Background: Elevated terminal renal resistance on hypothermic machine perfusion is widely regarded as a marker of kidney quality and a trigger for kidney nonuse for transplantation, yet large-scale evidence is limited on whether terminal renal resistance adds prognostic value beyond kidney donor profile index (KDPI). Methods: Adult kidney-only transplants performed using hypothermic machine perfusion ( n =36,490) in the Organ Procurement and Transplantation Network database between March 31, 2015, and December 31, 2023, were included. Terminal renal resistance was categorized as 0.85) kidneys. Utilization analyses were performed in a separate donor cohort of 15,524 kidneys recovered using hypothermic machine perfusion from eight organ procurement organizations. Results: Higher renal resistance was independently associated with worse 5-year graft survival (hazard ratio for graft loss=1.49 [≥0.4] versus P < 0.001). The effect was modest in KDPI 0.85 grafts. Renal resistance thresholds that were associated with better survival of using KDPI >0.85 kidneys differed on the basis of candidate estimated post-transplant survival (EPTS; renal resistance <0.2 for EPTS <0.35, <0.3 for EPTS 0.35–0.85, and 0.85). Utilization dropped sharply beyond a terminal renal resistance of 0.3 across all KDPI strata, disproportionate to the actual graft risk. Utilization of KDPI ≤0.85 grafts with renal resistance ≥0.30 could have yielded an estimated 357 (95% confidence interval, 304 to 377) additional transplants per year. Conclusions: Terminal renal resistance was associated with long-term graft and patient survival, but this effect was clinically meaningful only in high-KDPI kidneys.

Introduction: Robotic-assisted kidney autotransplantation (RAKAT) is a minimally invasive approach to managing complex renal pathologies. While increasingly utilized, experience with RAKAT in patients with prior renal surgery remains limited. Methods: We present a case of recurrent nutcracker syndrome (NCS) in a 29-year-old female who had previously undergone left renal vein transposition. Due to recurrent symptoms, she underwent RAKAT with extracorporeal vascular reconstruction using cryopreserved allografts to manage the foreshortened renal vessels. The surgical technique involved a multiport robotic approach with a hand-assist device, extracorporeal bench surgery, and repositioning for the autotransplantation phase. Results: The procedure was completed successfully with a total operative time of 779 minutes and estimated blood loss was 100 mL. The cold ischemic time was 90 minutes. Postoperative complications included urinary tract infections requiring intravenous antibiotics (Clavien-Dindo grade II). At 7 months follow-up, the patient had excellent graft function and no evidence of recurrent NCS. Conclusion: This case demonstrates the feasibility of RAKAT with extracorporeal vascular reconstruction using allografts as a salvage therapy for recurrent NCS after prior open surgery. This approach requires advanced robotic and vascular expertise and careful preoperative planning.

Introduction: Urologic complications are thought to be the most common surgical complication of renal transplantation. Ureteral pathology, including stenosis, urine leak, and vesicoureteral reflux, predominates. Although endourologic and interventional radiological management may be utilized, failure rates remain relatively high and surgical reconstruction remains the definitive management. Robotic ureteral reconstruction has been demonstrated to provide patient benefit in nontransplant populations, but the literature on transplant reconstruction is very limited. This study reports an additional series of patients with a focus on surgical technique, as well as reviews the available evidence for robotic reconstruction for post-transplant ureteral complications. Methods: All institutional patients undergoing robotic-assisted reconstruction for post-transplant ureteral complications for the years 2019–2022 were included. Intra- and postoperative variables, patient demographics, and follow-up data were obtained retrospectively from parsing of patient records. Statistics were tabulated descriptively. Results: Eleven patients underwent ureteral reconstruction. Of the 11, 9 (81%) were male with a mean age of 51.9 years (16–70) and BMI of 33.8 (24.3–49.1). The most common (10/11) indication for reconstruction was stricture; the most common (10/11) technique used was Lich-Gregoir reimplantation. Mean operative time was 288 minutes (143–500). There were no intra- or immediate postoperative complications. Median length of stay was 2 days (1–22). There were two incidences of mortality at 2 and 5 months postoperatively unrelated to surgery. There were four readmissions within 30 days, three for urinary tract infection (UTI) and one for a pelvic abscess which required washout. The remainder of the cohort has been followed for a mean of 14.6 months (6–41) without any incidences of graft loss or recurrence of ureteral pathology. Conclusions: Robotic-assisted ureteral reconstruction is a technically challenging but highly feasible technique that may provide the benefits of minimally invasive surgery while still allowing definitive reconstruction. Centers with extensive robotic capabilities should consider the technique.

Open transplant nephrectomy for failed renal allograft is an invasive procedure associated with significant perioperative morbidity and mortality. Minimally invasive surgical approaches have improved a variety of patient outcomes for many surgeries. Thus, ...

Introduction: Despite strong public support, organ donor registration rates (RR) continue to lag while need only grows. In the United States, the traditional registration site is the Department of Motor Vehicles (DMV), however Primary care provider (PCP) offices have been considered as alternate locations for increasing RR. Methods: Twelve PCP offices across 2 New York Counties were subjected to a control week where participants received only a registration opportunity and an intervention week with the addition of a motivational poster and informational brochure. Zip code level sociodemographic data were obtained for each site. RR from the DMV over the same period served as historical control. Results: There were 1292 participants in the control phase and 1099 in the experimental phase. New registration rate for the control was 33.8% (289/897); experimental phase 7.88% (61/769); DMV registration 21.02% (1902/9050). The intervention was associated with a significant decrease in registrations (OR 0.181 (95% CI 0.135-0.244, P < 0.001)). Offices were clustered based on sociodemographic factors and regressed in 2 clusters. Lower educational attainment was associated with lower registration in the first but not second cluster (OR = 0.948 (0.923-0.974, P < 0.001)). Conclusions: This study provided evidence that PCP offices were a feasible site for organ donor registration and calls into question the efficacy of written materials-only interventions for increasing organ donor RR. It reiterated the negative effect of lower educational attainment on registration and suggested future studies focus on more active methods of engagement.