BackgroundWhether overweight or obese end stage renal disease (ESRD) patients are suitable for renal transplantation (RT) is often debated. The objective of this review and meta-analysis was to systematically investigate the outcome of low versus high BMI recipients after RT.MethodsComprehensive searches were conducted in MEDLINE OvidSP, Web of Science, Google Scholar, Embase, and CENTRAL (the Cochrane Library 2014, issue 8). We reviewed four major guidelines that are available regarding (potential) RT recipients. The methodology was in accordance with the Cochrane Handbook for Systematic Reviews of Interventions and written based on the PRISMA statement. The quality assessment of studies was performed by using the GRADE tool. A meta-analysis was performed using Review Manager 5.3. Random-effects models were used.ResultsAfter identifying 5,526 studies addressing this topic, 56 studies were included. We extracted data for 37 outcome measures (including data of more than 209,000 RT recipients), of which 26 could be meta-analysed. The following outcome measures demonstrated significant differences in favour of low BMI (<30) recipients: mortality (RR = 1.52), delayed graft function (RR = 1.52), acute rejection (RR = 1.17), 1-, 2-, and 3-year graft survival (RR = 0.97, 0.95, and 0.97), 1-, 2-, and 3-year patient survival (RR = 0.99, 0.99, and 0.99), wound infection and dehiscence (RR = 3.13 and 4.85), NODAT (RR = 2.24), length of hospital stay (2.31 days), operation duration (0.77 hours), hypertension (RR = 1.35), and incisional hernia (RR = 2.72). However, patient survival expressed in hazard ratios was in significant favour of high BMI recipients. Differences in other outcome parameters were not significant.ConclusionsSeveral of the pooled outcome measurements show significant benefits for ‘low’ BMI (<30) recipients. Therefore, we postulate that ESRD patients with a BMI >30 preferably should lose weight prior to RT. If this cannot be achieved with common measures, in morbidly obese RT candidates, bariatric surgery could be considered.Electronic supplementary materialThe online version of this article (doi:10.1186/s12916-015-0340-5) contains supplementary material, which is available to authorized users.

BackgroundPeritoneal dialysis is an effective treatment for end-stage renal disease. Key to successful peritoneal dialysis is a well-functioning catheter. The different insertion techniques may be of great importance. Mostly, the standard operative approach is the open technique; however, laparoscopic insertion is increasingly popular. Catheter malfunction is reported up to 35% for the open technique and up to 13% for the laparoscopic technique. However, evidence is lacking to definitely conclude that the laparoscopic approach is to be preferred. This review and meta-analysis was carried out to investigate if one of the techniques is superior to the other.MethodsComprehensive searches were conducted in MEDLINE, Embase and CENTRAL (the Cochrane Library 2012, issue 10). Reference lists were searched manually. The methodology was in accordance with the Cochrane Handbook for interventional systematic reviews, and written based on the PRISMA-statement.ResultsThree randomized controlled trials and eight cohort studies were identified. Nine postoperative outcome measures were meta-analyzed; of these, seven were not different between operation techniques. Based on the meta-analysis, the proportion of migrating catheters was lower (odds ratio (OR) 0.21, confidence interval (CI) 0.07 to 0.63; P = 0.006), and the one-year catheter survival was higher in the laparoscopic group (OR 3.93, CI 1.80 to 8.57; P = 0.0006).ConclusionsBased on these results there is some evidence in favour of the laparoscopic insertion technique for having a higher one-year catheter survival and less migration, which would be clinically relevant.

Peritoneal dialysis (PD) is an effective treatment for end-stage renal disease. There are several configurations of PD catheter design that may impact catheter function, such as the shape of the intraperitoneal segment, the number of cuffs, and the subcutaneous configuration. This review and meta-analysis was carried out to determine whether there is a clinical advantage for one of the catheter types or configurations. Comprehensive searches were conducted in MEDLINE, Embase, and CENTRAL (the Cochrane Library 2012, issue 10). The methodology was in accordance with the Cochrane Handbook for Interventional Systematic Reviews and written based on the PRISMA statement. The initial search yielded 682 hits from which 13 randomized controlled trials were identified. Outcomes of interest were as follows: catheter survival, drainage dysfunction, migration, leakage, exit-site infections, peritonitis, and catheter removal. Comparing straight vs. swan neck and single vs. double-cuffed catheters, no differences were found when results were pooled. Comparison of straight vs. coiled-tip catheters demonstrated that survival was significantly different in favor of straight catheters (hazard ratio 2.05; confidence interval 1.10-3.79, P=0.02). For surgically inserted catheters, the removal rate and survival at 1 year after insertion were significantly in favor of straight catheters. Our meta-analysis clearly demonstrates benefits for catheters with a straight intraperitoneal segment.

As the organ shortage increases, inherently the demand for donor kidneys continues to rise. Thus, live kidney donation is essential for increasing the donor pool. In order to create successful expansion, extended criteria live kidney donors should be considered. This review combines current guidelines with all available literature in this field, trying to seek and establish the optimal extended criteria. Comprehensive searches were carried out in major databases until November 2013 to search for articles regarding older age, overweight and obesity, hypertension, vascular anomalies/multiplicity, nulliparous women, and minors as donors. Of the 2079 articles found, 152 fell within the scope of the review. Five major guidelines were included and reviewed. Based on the literature search, live kidney donation in older donors (up to 70 years of age) seems to be safe as outcome is comparable to younger donors. Obese donors have comparable outcome to lean donors, in short- and mid-term follow-up. Since little literature is available proving the safety of donation of hypertensive donors, caution is advised. Vascular multiplicity poses no direct danger to the donor and women of childbearing age can be safely included as donors. Although outcome after donation in minors is shown to be comparable to adult donors, they should only be considered if no other options exist. We conclude that the analyzed factors above should not be considered as absolute contraindications for donation.

Implanting a ureteric stent during ureteroneocystostomy reduces the risk of leakage and ureteral stenosis after kidney transplantation (KTx), but it may also predispose to urinary tract infections (UTIs). The aim of this study is to determine the optimal timing for ureteric stent removal after KTx. Searches were performed in EMBASE, MEDLINE Ovid, Cochrane CENTRAL, Web of Science, and Google Scholar (until November 2017). For this systematic review, all aspects of the Cochrane Handbook for Interventional Systematic Reviews were followed and it was written based on the PRISMA-statement. Articles discussing JJ-stents (double-J stents) and their time of removal in relation to outcomes, UTIs, urinary leakage, ureteral stenosis or reintervention were included. One-thousand-and-forty-three articles were identified, of which fourteen articles (three randomised controlled trials, nine retrospective cohort studies, and two prospective cohort studies) were included (describing in total n = 3612 patients). Meta-analysis using random effect models showed a significant reduction of UTIs when stents were removed earlier than three weeks (OR 0.49, CI 95%, 0.33 to 0.75, p = 0.0009). Regarding incidence of urinary leakage, there was no significant difference between early (<3 weeks) and late stent removal (>3 weeks) (OR 0.60, CI 95%, 0.29 to 1.23, p = 0.16). Based on our results, earlier stent removal (<3 weeks) was associated with a decreased incidence of UTIs and did not show a higher incidence of urinary leakage compared to later removal (>3 weeks). We recommend that the routine removal of ureteric stents implanted during KTx should be performed around three weeks post-operatively.

BackgroundWhether vascular multiplicity should be considered as contraindication and therefore ‘extended donor criterion’ is still under debate.MethodsData from all live kidney donors from 2006–2013 (n = 951) was retrospectively reviewed. Vascular anatomy as imaged by MRA, CTA or other modalities was compared with intraoperative findings. Furthermore, the influence of vascular multiplicity on outcome of donors and recipients was studied.ResultsIn 237 out of 951 donors (25%), vascular multiplicity was present. CTA had the highest accuracy levels regarding vascular anatomy assessment. Regarding outcome of donors with vascular multiplicity, warm ischemia time (WIT) and skin-to-skin time were significantly longer if arterial multiplicity (AM) was present (5.1 vs. 4.0 mins and 202 vs. 178 mins). Skin-to-skin time was significantly longer, and complication rates were higher in donors with venous multiplicity (203 vs. 180 mins and 17.2% vs. 8.4%). Outcome of renal transplant recipients showed a significantly increased WIT (30 vs. 26.7 minutes), higher rate of DGF (13.9% vs. 6.9%) and lower rate of BPAR (6.9% vs. 13.9%) in patients receiving a kidney with AM compared to kidneys with singular anatomy.ConclusionsWe conclude that vascular multiplicity should not be a contra-indication, since it has little impact on clinical outcome in the donor as well as in renal transplant recipients.

In this era of organ donor shortage, live kidney donation has been proven to increase the donor pool; however, it is extremely important to make careful decisions in the selection of possible live donors. A body mass index (BMI) above 35 is generally considered as a relative contraindication for donation. To determine whether this is justified, a systematic review and meta-analysis were carried out to compare perioperative outcome of live donor nephrectomy between donors with high and low BMI. A comprehensive literature search was performed in MEDLINE, Embase, and CENTRAL (the Cochrane Library). All aspects of the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement were followed. Of 14 studies reviewed, eight perioperative donor outcome measures were meta-analyzed, and, of these, five were not different between BMI categories. Three found significant differences in favor of low BMI (29.9 and less) donors with significant mean differences in operation duration (16.9 min (confidence interval (CI) 9.1-24.8)), mean difference in rise in serum creatinine (0.05 mg/dl (CI 0.01-0.09)), and risk ratio for conversion (1.69 (CI 1.12-2.56)). Thus, a high body mass index (BMI) alone is no contraindication for live kidney donation regarding short-term outcome.

SummaryIschemic postconditioning may improve outcome after kidney transplantation. We performed a pilot study to assess feasibility and safety of ischemic postconditioning in human donation-after-circulatory-death kidney transplantation. Twenty patients were included. Primary outcome was rate of serious adverse events. Secondary outcomes were incidence of DGF and renal function at 3 months. Data were compared to a historical control group (n = 40). Furthermore, we performed a paired kidney analysis using the contralateral kidney (n = 11). Donor age and serum creatinine were higher in the experimental group compared with historical control: 57.7 (20-71) vs. 51.5 (24-74) years (P = 0.01) and 79 (40-156) lmol/l vs. 64 (25-115) lmol/l (P = 0.047). Postconditioning could be applied all times. One complication, a venous tear, occurred related to postconditioning. The experimental group experienced more DGF (85% vs. 63%) (P = 0.07). Serum creatinine at month 3 was 166 (109-331) lmol/l vs. 159 (81-279) lmol/l (P = 0.71). Paired kidney analysis showed no significant differences in DGF (72.2% vs. 54.5%, P = 0.66) and serum creatinine 199 (90-473) lmol/l vs. 184 (117-368) lmol/l (P = 0.76). This is the first report of applying IPoC in human kidney transplantation. Although IPoC is feasible and appears to be safe, no benefit in terms of reduced DGF or better renal function was observed (Dutch trial registry number NTR 3117).