Transplantation of Reconstructed Renal Allografts Following Ex-Vivo Partial Nephrectomy

Exclusion Criteria

• •For Donors:
• •Known familial RCC syndrome
• •Functional considerations:
• •o \< 50 years of age
• •* Preoperative GFR \< 80 ml/min/1.73 m2
• •* Proteinuria on urine dipstick or urinalysis (≥1+ considered positive)
• •* Predicted new baseline GFR (NBGFR) following radical nephrectomy would be \< 45
• •* NBGFR would be calculated using previously described equation based on split renal function (SFR) and renal functional compensation (RFC)
• •* NBGFR = global GFR x (SRFcontralateral from PVA) x 1.25 (average amount of RFC)2
• •Comorbidities with risk of deteriorating renal function:
• •* Hypertension requiring three or more anti-hypertensives
• •* Diabetes mellitus requiring insulin or with end organ damage
• •* Morbid obesity
• •* History of nephrolithiasis or other
• •Tumor characteristics on pre-operative cross-sectional imaging:
• •o Tumor has infiltrative features
• •* Tumor is \> 4cm (does not meet criteria for cT1a stage)
• •* Regional lymphadenopathy, branch or main renal vein invasion, or other imaging findings suggestive of locally advanced disease
• •Kidney characteristics on pre-operative cross-sectional imaging:
• •* More than one renal artery unless can be readily and safely reconstructed
• •* More than one renal vein unless can be readily and safely reconstructed
• •* Duplicated collecting system unless can be readily and safely reconstructed
• •High-risk features on renal mass biopsy (if obtained) or intraoperative pathology
• •o Malignant non-RCC pathology
• •o Rhabdoid or sarcomatoid differentiation
• •o Grade 4
• •o Positive or concerning margins during tumor excision
• •Must be deemed appropriate living donor candidate per the standard living donor selection process at the Cleveland Clinic o All altruistic living donors undergo a complete evaluation by medical providers and social workers ensuring that they are appropriate candidates to undergo this procedure. This evaluation includes direct query into any history of psychiatric comorbidities and/or substance abuse. If present, this prompts a formal evaluation by psychiatry prior to confirmation of donor candidacy.
• •For Recipients:
• •Traditional contraindications to kidney transplantation at the Cleveland Clinic would apply, including the following directly from the Transplant Care Pathway:
• •Active, untreated bacterial, fungal, or viral infections. Once treated, patients may be reconsidered. Patients with human immunodeficiency virus (HIV)14 or chronic hepatitis15 infections will be evaluated on an individual basis.
• •Active malignancy, except non-melanoma skin cancer and other selected low-grade, low-stage cancers (e.g., bladder, kidney, prostate). The American Society of Transplant (AST) clinical practice guidelines published in 2001 are dated. Improved methods of cancer prognostication are available on a cancer-specific basis.16 An acceptable disease-free waiting period may be needed prior to transplantation depending on the cancer type (stage/grade) and treatment modality. Expert opinion from an oncological specialist may be needed to facilitate decisions about wait-listing or performance of a transplant.
• •Medical non-adherence, substance abuse or behaviors leading to a failure to achieve a therapeutic physician/transplant team-patient alliance.
• •Life expectancy of less than five years independent of renal disease.
• •Advanced circulatory disease (cardiac, cerebral, peripheral), pulmonary disease or other non-renal conditions such that transplantation would pose a significant risk for morbidity/mortality.
• •Obesity with body mass index (BMI) \> 38, or an abdominal wall configuration that in the judgment of the evaluating surgeon poses undue complication risk.
• •Active nicotine abuse (in any form).
• •Poor functional status independent of renal disease.
• •Considering the average waiting times for a deceased donor kidney is more than 3 years, only transplant candidates 72 years or younger will be accepted for evaluation. Suitable candidates may remain on the waiting list up to the age of 75-year-old. They will be delisted if no transplantation has occurred.
• •Cumulative burden of disease defined as multiple medical conditions that on their own may not preclude listing but that in combination are deemed not suitable by the transplant selection committee.