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EAU Guidelines on Renal Transplantation: Update 2018

EAU Guidelines on Renal Transplantation: Update 2018

The European Association of Urology (EAU) panel on renal transplantation (RT) has released an updated version of the RT guidelines which appeared in the journal European Urology Focus. The main objective is to provide urologists and kidney transplant surgeons with practical guidance on the clinical management of renal transplantation, focusing on the medical and surgical management. Previous guidelines were updated, and levels of evidence and grades of recommendation were assigned. The new abridged EAU guidelines present updated information on the clinical and surgical management of RT for incorporation into clinical practice.

Recommendations and summary of evidence for a single kidney transplant.

  • Use the external or common iliac arteries for an end-to-side arterial anastomosis to the donor renal artery.
  • Use an end-to-end anastomosis to the internal iliac artery as an alternative to the external or common iliac arteries.
  • Check the intima of the donor and recipient arteries prior to commencing the arterial anastomosis to ensure that there is no intimal rupture/flap. If the latter is found, it must be repaired prior to/as part of the arterial anastomosis.
  • Preoperatively plan the surgical approach in third or further transplants to ensure that appropriate arterial inflow and venous outflow exists with adequate space to implant the new kidney.
  • A small RCT (n = 38) comparing end-to-end anastomosis to the internal iliac artery versus end-to-side anastomosis to the external iliac artery found that both techniques showed similar results in the postoperative period and at 3 yr of follow-up.
  • Cohort studies have demonstrated that third or further transplants are a valid therapeutic option with reasonable short- and long-term patient and graft survival.

Recommendations and summary of evidence regarding complications after renal transplantation

  • Perform color Doppler ultrasound in cases of suspected graft arterial or venous thrombosis.
  • Perform color Doppler ultrasound to diagnose an arterial stenosis; in the event of indeterminate results on ultrasound, consider a magnetic resonance or computed tomography angiogram.
  • Perform percutaneous drainage placement as the first treatment for large and symptomatic lymphocele.
  • Manage urine leak by JJ stent and bladder catheter and/or percutaneous nephrostomy tube. Perform surgical repair in cases of failure of conservative management.
  • Manage ureteral strictures <3 cm in length either with surgical reconstruction or endoscopically (percutaneous balloon dilation or antegrade flexible ureteroscopy and holmium laser incision). Treat late stricture recurrence and/or strictures >3 cm in length with surgical reconstruction in appropriate recipients.
  • Perform shockwave lithotripsy or antegrade/retrograde ureteroscopy for stones measuring <15 mm.
  • Perform percutaneous nephrolithotomy for stones measuring >20 mm.
  • Thrombectomy in the case of a viable graft and allograft nephrectomy in the case of a non-viable graft are the treatment options for renal artery thrombosis.
  • Interventional radiology is the first-line treatment option for transplant renal artery stenosis; however, in patients considered unsuitable for radiological angioplasty, surgical treatment may be considered.
  • Surgical repair should be undertaken when conservative management fails or massive urine leak occurs.
  • For strictures >3 cm in length or those which have recurred following a primary endourological approach, surgical reconstruction should be performed.
  • Extracorporeal shockwave lithotripsy should be considered as the first-line treatment option for stones <15 mm.

Recommendations and summary of evidence for follow-up after renal transplant.

  • Provide lifelong regular post-transplant follow-up by an experienced and trained RT specialist at least every 6–12 mo.
  • Advise patients on appropriate lifestyle changes, potential complications and the importance of adherence to their immunosuppressive regimen.
  • Regularly monitor (approximately every 4–8 wk) serum creatinine, estimated glomerular filtration rate, blood pressure, urinary protein excretion, immunosuppression, and complications after RT. Changes in these parameters over time should trigger further diagnostic work-up, including renal biopsy, a search for infectious causes and anti-HLA antibodies.
  • Perform an ultrasound of the graft in cases of graft dysfunction in order to rule out obstruction and renal artery stenosis.
  • In patients with interstitial fibrosis and tubular atrophy undergoing CNI therapy and/or with histological signs suggestive of CNI toxicity (eg, arteriolar hyalinosis, striped fibrosis) consider CNI reduction or withdrawal
  • In patients with interstitial fibrosis and tubular atrophy undergoing CNI therapy and/or with histological signs suggestive of CNI toxicity (eg, arteriolar hyalinosis, striped fibrosis) consider CNI reduction or withdrawal
  • Initiate appropriate medical treatment, (eg, tight control of hypertension, diabetes, proteinuria, cardiac risk factors, infections, and other complications, according to current guidelines).
  • Regular long-term follow-up by experienced transplant physicians is essential in order to detect complications or graft dysfunction early and ensure adherence to the immunosuppressive regimen.
  • Annual screening should include a dermatological examination, cardiovascular history and exam, tumor screening (including a nodal examination, fecal occult screening, chest x-ray, gynecological and urological examination) and abdominal ultrasound, including an ultrasound of the native and transplanted kidney. If appropriate, further diagnostic tests should be prompted to treat or slow the progression of any identified complication.
  • In patients diagnosed early with interstitial fibrosis/tubular atrophy, particularly if there is evidence for CNI toxicity, disease progression may be slowed by conversion to a CNI-free regimen. If the risk of rejection seems too high, another option is the substantial reduction of CNI under the protection of MPA.
  • Supportive measures should aim to adequately treat the consequences of chronic kidney disease (eg, anemia, acidosis, bone disease).

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Source: With inputs from European Urology Focus

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