INTRODUCTION AND OBJECTIVE: Robot-assisted kidney transplantation (RAKT) has been shown promising results in grafts coming from living donation. However, this technique has two main limitations. First, grafts coming from cadaveric donors, usually reserved to patients with advanced systemic disease who often present iliac artery plaques, are excluded from RAKT because of the lack of intraoperative haptic feedback. For this reason, we introduced 3D imaging reconstruction in RAKT through the augmented reality (AR) in order to intraoperatively guide the surgeon, showing where to put the clamps and perform arteriotomy in the recipient iliac artery. Second, the regional hypothermia during rewarming time is guaranteed by intermittent ice slush insertion in the abdominal cavity, which may be suboptimal and increase the risk of ileus. To overcome this limit, we developed and tested a cold ischemia device (CID) with the aim to maintain a low and constant graft temperature while avoiding ice slush introduction.METHODS: These two projects were conducted according to IDEAL model for surgical innovation. In the first project, iliac artery anatomy together with plaques was represented in a 3D printed model. Firstly, this model was used in open kidney transplantation (OKT) setting in order to test the accuracy of the 3D reconstruction, comparing it with intraoperative tactile feedback. Subsequently, we employed this technology in the AR setting, in two cases without plaques. Finally, we tested AR in a patient with plaques. In the second project, the cooling device was developed and tested in an ex-vivo setting to assess its cooling performances. In phase 2a, the device was used in an in-vivo porcine model to evaluate the feasibility to perform both a complete OKT and RAKT. In phase 2b, CID was employed in 4 patients undergoing OKT or RAKT from living donors. Graft temperature was monitored using a thermal probe.RESULTS: The 3D-AR enabled to clamp the artery in the correct position and to find the right place to perform arteriotomy. Phase 2 demonstrated that both OKT and RAKT can be performed with the support of CID in a clinical setting, without any modification in our standard technique or perceived lengthening of the operative time. Graft temperature never exceeded 20 C. No complications related to the use of both these devices were recorded.CONCLUSIONS: These new tools were designed to overcome RAKT's main limitations, optimizing the graft cooling system and including patients with atheromatic vascular disease, paving the way to expand the indications of RAKT.
INTRODUCTION AND OBJECTIVES: Renal ischaemia reperfusion injury (IRI), is a major source of morbidity and mortality in hospitalised patients. Despite extensive research, there are no effective therapies against renal IRI, and patient outcomes have not improved. Our group have previously demonstrated that zinc (Zn) preconditioning (PC) protects the kidney against renal IRI in a sheep model. However, the mechanisms through which Zn exerts its effect are unknown. There are multiple processes involved in the pathogenesis of renal IRI, and multiple cellular processes affected by Zn. The key putative mechanisms of renal IRI include inflammatory, apoptotic, and oxidative stress pathways. Interleukin-6 (IL-6), Bax & Bak, and glutathione peroxidase-1 (GpX1) are proteins centrally involved in these respective pathways. Our aim was to assess the contribution of these three key mechanisms to Zn's protective effect using transgenic mouse strains with knockout (KO) of these key mediators. Furthermore, dysfunctional cellular metal homeostasis has been suggested as a pivotal mechanism of cellular death due to IRI. We thus investigated the effect of Zn PC on renal metal concentrations in the context of IRI.METHODS: 8-12 week old C57BL/6 mice were preconditioned with intraperitoneal injection of ZnCl2 (10mg/kg) or control 24 hrs & 4 hrs prior to right nephrectomy and 30 mins of left renal ischaemia. Animals were euthanised on the second post-operative day. Blood samples were taken for creatinine and urea. Kidneys were taken for histology and tissue metal analysis. The same protocol was applied to three separate C57BL/6 mouse strains, with genetic KO of IL-6, Bax/Bak, or GpX1.RESULTS: The Zn PC protocol was well tolerated in all strains. Zn-treated mice in all strains had significantly improved renal parameters than saline-treated controls following renal ischaemia suggesting that the protective effect of Zn is not mediated by these three pathways. Significant differences were observed in renal concentrations of Na, Mg, Ca, & Fe as a result of renal IR. Zn PC had no effect on the concentrations of these metals. Renal Zn was 1.46-fold greater in Zn-treated animals (p[<0.01). Total renal Zn concentration was not significantly affected by IR.CONCLUSIONS: Zn PC is preserved despite KO of IL-6, Bax & Bak, or GpX1. Zn thus does not have its effect solely via these mediators, and may act through a number of mechanisms. Renoprotection with Zn PC is associated with increased Zn uptake in the kidney, but is not attributable to effects on other renal metal concentrations.
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