Donation after circulatory death (DCD) is a potential source of reducing organ demand. In Italy, DCD requires a 20-min no-touch period that prolongs warm ischemia and increases delayed graft function (DGF) risk and graft loss. We report here our preliminary experience of sequential use of normothermic regional perfusion (NRP), as standard procedure, and hypothermic oxygenated perfusion (HOPE), as an experimental technique of organ preservation, in 10 kidney transplants (KT) from five DCD Maastricht III with extensive functional warm ischemia time (fWIT) up to 325 min. During NRP, renal function tests were evaluated to accept organs which were retrieved according to standard fashion with biopsy. While waiting for pathology and cross-match results, organs were preserved with HOPE through pressure- and temperature-controlled arterial pulsatile flow. All grafts with Karpinski score ≤4 were used for conventional single KT with mean cold ischemia time of 584 ± 167 min and mean fWIT of 151 ± 132 min. At the end of HOPE, lactate levels increased significantly in all cases with DGF (P = 0.0095), which were 3/10 (30%). No primary nonfunctions were recorded, and all patients had sCr < 1.5 mg/dl at 6-month post-KT. NRP and HOPE for DCD may overcome fWIT limits safely, and lactate during HOPE predicts DGF.

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Ureteral obstruction with impaired urine flow is the most common urological complication following renal transplantation. From December 3976 to December 1997,869 kidney grafts were performed by our kidney transplantation group, 96 from living related donors and 773 from cadaver donors (736 first grafts and 37 regrafts). A stricture of the ureter (SU) was observed in 27 cases with a follow-up ranging from 18 months to 18 years after the graft and 11 months to 11 years after the treatment of the SU. In six patients, SU was immediately apparent and limited to the anastomosis: they were obviously technical flaws. In all the other patients, there was a free interval ranging from 2 months to 11 years after surgery; the SU usually involved the entire ureter, suggesting multiple etiologies. Repeated urinary infections could be a cause but immunological problems might be more determinant. In our series, acute rejection was more common than chronic so that the correction of SU was followed in many cases by a good and long lasting result (up to 11 years). In our experience, SU was not a dangerous complication even in patients in whom for different reasons (mainly refusal of treatment) the therapy was delayedeven if anuria occurred, no case of graft loss or serious damage were observed. At the beginning of our experience, the diagnosis of SU was based on urography, and therapy has always been re-operation. For 15 years, the diagnosis of SU has been based on routine echographic surveillance, which was intensified after each rejection, and the first treatment of SU in the last 8 years was re-operation in early technical SU and interventional radiology (balloon dilatation with or without temporary stent) in other cases. When it failed or in case of recurrence, surgicai correction was performed utilizing the native ipsilateral or contralateral ureter for a ureteroureterostomy.

Posttransplant monitoring of anti-HLA antibodies with routine techniques gives unsatisfactory results due to a variety of technical limitations. We investigated how a new alternative technique correlates with posttransplant clinical events. A total of 313 nonselected serum samples from 136 patients were screened by an ELISA utilizing captured soluble HLA class I antigens. We observed the absence of anti-HLA antibody production in acute rejection cases responding to standard antirejection therapy. On the other hand, we showed a clear presence of these antibodies in acute rejection episodes not responding to standard therapy (P<0.0001) and in chronic rejection (P<0.001). We conclude that routine posttransplant monitoring by ELISA offers early risk assessment that is crucial for proper immunosuppression and for antirejection therapy choice.