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Background: Recently, continuous nonoxygenated hypothermic machine perfusion (HMP) has been implemented as standard preservation method for deceased donor kidneys in the Netherlands. This study was designed to assess the effect of the implementation of HMP on early outcomes after transplantation., Methods: Kidneys donated in the Netherlands in 2016 and 2017 were intended to be preserved by HMP. A historical cohort (2010-2014) preserved by static cold storage was chosen as the control group. Primary outcome was delayed graft function (DGF). Additional analyses were performed on safety, graft function, and survival up until 2 y after transplantation., Results: Data were collected on 2493 kidneys. Analyses showed significantly more donation after circulatory death, preemptive transplantation, and retransplants in the project cohort. Of the 681 kidneys that were transplanted during the project, 81% were preserved by HMP. No kidneys were discarded due to HMP-related complications. DGF occurred in 38.2% of the project cohort versus 43.7% of the historical cohort (P < 0.001), with a significantly shorter duration within the project cohort (7 versus 9 d, P = 0.003). Multivariate regression analysis showed an odds ratio of 0.69 (95% confidence interval, 0.553-0.855) for the risk of DGF when using HMP compared with cold storage (P = 0.001). There was no significant difference in kidney function, graft survival, and recipient survival up until 2 y posttransplantation., Conclusions: This study showed that HMP as a standard preservation method for deceased donor kidneys is safe and feasible. HMP was associated with a significant reduction of DGF., Competing Interests: The authors declare no funding or conflicts of interest., (Copyright © 2021 The Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Since the start of organ transplantation, hypothermia-forced hypometabolism has been the cornerstone in organ preservation. Cold preservation showed to protect against ischemia, although post-transplant injury still occurs and further improvement in preservation techniques is needed. We hypothesize that hydrogen sulphide can be used as such a new preservation method, by inducing a reversible hypometabolic state in human sized kidneys during normothermic machine perfusion., Methods: Porcine kidneys were connected to an ex-vivo isolated, oxygen supplemented, normothermic blood perfusion set-up. Experimental kidneys (n = 5) received a 85mg NaHS infusion of 100 ppm and were compared to controls (n = 5). As a reflection of the cellular metabolism, oxygen consumption, mitochondrial activity and tissue ATP levels were measured. Kidney function was assessed by creatinine clearance and fractional excretion of sodium. To rule out potential structural and functional deterioration, kidneys were studied for biochemical markers and histology., Results: Hydrogen sulphide strongly decreased oxygen consumption by 61%, which was associated with a marked decrease in mitochondrial activity/function, without directly affecting ATP levels. Renal biological markers, renal function and histology did not change after hydrogen sulphide treatment., Conclusion: In conclusion, we showed that hydrogen sulphide can induce a controllable hypometabolic state in a human sized organ, without damaging the organ itself and could thereby be a promising therapeutic alternative for cold preservation under normothermic conditions in renal transplantation., Competing Interests: The authors have declared that no competing interests exist.

Background: Infected necrotising pancreatitis is a potentially lethal disease and an indication for invasive intervention. The surgical step-up approach is the standard treatment. A promising alternative is the endoscopic step-up approach. We compared both approaches to see whether the endoscopic step-up approach was superior to the surgical step-up approach in terms of clinical and economic outcomes., Methods: In this multicentre, randomised, superiority trial, we recruited adult patients with infected necrotising pancreatitis and an indication for invasive intervention from 19 hospitals in the Netherlands. Patients were randomly assigned to either the endoscopic or the surgical step-up approach. The endoscopic approach consisted of endoscopic ultrasound-guided transluminal drainage followed, if necessary, by endoscopic necrosectomy. The surgical approach consisted of percutaneous catheter drainage followed, if necessary, by video-assisted retroperitoneal debridement. The primary endpoint was a composite of major complications or death during 6-month follow-up. Analyses were by intention to treat. This trial is registered with the ISRCTN registry, number ISRCTN09186711., Findings: Between Sept 20, 2011, and Jan 29, 2015, we screened 418 patients with pancreatic or extrapancreatic necrosis, of which 98 patients were enrolled and randomly assigned to the endoscopic step-up approach (n=51) or the surgical step-up approach (n=47). The primary endpoint occurred in 22 (43%) of 51 patients in the endoscopy group and in 21 (45%) of 47 patients in the surgery group (risk ratio [RR] 0·97, 95% CI 0·62-1·51; p=0·88). Mortality did not differ between groups (nine [18%] patients in the endoscopy group vs six [13%] patients in the surgery group; RR 1·38, 95% CI 0·53-3·59, p=0·50), nor did any of the major complications included in the primary endpoint., Interpretation: In patients with infected necrotising pancreatitis, the endoscopic step-up approach was not superior to the surgical step-up approach in reducing major complications or death. The rate of pancreatic fistulas and length of hospital stay were lower in the endoscopy group. The outcome of this trial will probably result in a shift to the endoscopic step-up approach as treatment preference., Funding: The Dutch Digestive Disease Foundation, Fonds NutsOhra, and the Netherlands Organization for Health Research and Development., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: The incidence and impact of chronic inguinal pain after kidney transplantation is not clearly established. A high incidence of pain after inguinal hernia repair, a comparable surgical procedure, suggests an underexposed problem., Methods: Between 2011 and 2013, 403 consecutive patients who underwent kidney transplantation were invited to complete the Caroline Comfort Scale (CCS) and Visual Analog Scale (VAS) in order to assess the incidence of chronic inguinal pain and movement disabilities, complemented by questions regarding comorbidity during follow-up., Results: The response rate was 58 % (n = 199) with a median follow-up of 22 months (IQR 12-30). In total, 90 patients (45 %) reported a CCS > 0 and 64 patients (32 %) experienced at least mild but bothersome complaints. Most inguinal complaints were reported during bending over and walking with a mean CCS score of 1.1 (SD ± 2.2) and 1.2 (SD ± 2.4), respectively. A high body mass index (BMI), delayed graft function, and the need for a second operation were associated with a higher CCS score on univariate analysis. Using multivariate analysis, only BMI (p = 0.02) was considered an independent risk factor for chronic inguinal pain., Conclusions: The incidence of chronic inguinal pain is a common though underexposed complication after kidney transplantation. More awareness to prevent neuropathic pain seems indicated., Competing Interests: The authors of this manuscript have no conflicts of interest to disclose.

Background: The use of grafts with multiple renal arteries (MRA) in renal transplantation has not been clearly established., Material/methods: A systematic literature review used predefined terms to search PubMed, EMBASE, and the Cochrane Library for all studies since 1985 that included more than 50 MRA grafts. A total of 23 studies, comprising a total of 18,289 patients, were eligible to be included in the meta-analysis., Results: Patients who received an MRA graft compared to single renal artery (SRA) grafts showed significantly higher complication rates (13.8% vs. 11.0%, OR 1.393, p<0.0001), more delayed graft function (10.3% vs. 8.2%, OR 1.333, p=0.022), and had an associated significantly lower 1-year graft survival (93.2% vs. 94.5%, OR 0.819, p=0.034). Both the creatinine level and the warm ischemia time (WIT) were significantly higher in patients with MRA grafts but showed high heterogeneity (I² 98% for WIT and I² 70% for creatinine level). Although MRA grafts were associated with more complications compared to SRA grafts, long-term outcomes were similar for 5-year graft survival (81.4% vs. 81.6%) and 1- and 5-year patient survival (95.4% and 89.6% in MRA group vs. 95.4% and 87.0% in SRA group, respectively)., Conclusions: MRA grafts were associated with a higher risk of complication and delayed graft function but had comparable long-term outcomes for graft and patient survival.

Background: Infected necrotising pancreatitis is a potentially lethal disease that nearly always requires intervention. Traditionally, primary open necrosectomy has been the treatment of choice. In recent years, the surgical step-up approach, consisting of percutaneous catheter drainage followed, if necessary, by (minimally invasive) surgical necrosectomy has become the standard of care. A promising minimally invasive alternative is the endoscopic transluminal step-up approach. This approach consists of endoscopic transluminal drainage followed, if necessary, by endoscopic transluminal necrosectomy. We hypothesise that the less invasive endoscopic step-up approach is superior to the surgical step-up approach in terms of clinical and economic outcomes., Methods/design: The TENSION trial is a randomised controlled, parallel-group superiority multicenter trial. Patients with (suspected) infected necrotising pancreatitis with an indication for intervention and in whom both treatment modalities are deemed possible, will be randomised to either an endoscopic transluminal or a surgical step-up approach. During a 4 year study period, 98 patients will be enrolled from 24 hospitals of the Dutch Pancreatitis Study Group. The primary endpoint is a composite of death and major complications within 6 months following randomisation. Secondary endpoints include complications such as pancreaticocutaneous fistula, exocrine or endocrine pancreatic insufficiency, need for additional radiological, endoscopic or surgical intervention, the need for necrosectomy after drainage, the number of (re-)interventions, quality of life, and total direct and indirect costs., Discussion: The TENSION trial will answer the question whether an endoscopic step-up approach reduces the combined primary endpoint of death and major complications, as well as hospital stay and related costs compared with a surgical step-up approach in patients with infected necrotising pancreatitis.