Transplant;Failure,Kidney Clinical Trial
Official title:
Minimally Invasive Kidney Transplantation: Surgical Stress and Kidney Injury
This study aims to investigate the effect of robot-assisted laparoscopic kidney transplantation on kidney injury by measuring biomarkers of kidney injury which are found in blood and urine to establish if there is a significant difference between robotic and open surgery. The study will also investigate the potential benefits of minimally invasive surgery on the surgical trauma associated with open surgery by assessing the surgical stress response between groups of kidney transplant patients receiving either open or minimally invasive kidney transplants and by comparing wound healing with patients undergoing donor nephrectomy.
1. Introduction
1.1 Background
Living donor kidney transplantation is the optimal treatment for end stage renal disease
(ESKD). This process involves a mandatory period of warm and cold ischaemia before the donor
kidney is reperfused. The reperfusion injury causes damage to the transplanted kidney that
may affect its long term outcome. In living donor kidney transplantation this period of
ischaemia is kept to a minimum. However, minimally invasive kidney transplantation (MIKT) has
been shown to increase the warm ischaemia time for these patients due to the prolonged
anastomosis time and the graft and patient are exposed to pneumoperitoneum for a significant
amount of time. It is not clear if these events affect graft outcomes.
Biomarkers of acute kidney injury are of interest in transplantation as they may be used to
assess the severity of graft injury and predict the likely clinical outcomes at an early
stage. There is evidence that they can predict delayed graft function after kidney
transplantation.
MIKT also has the potential in reducing the surgical trauma associated with open surgery due
to smaller incisions; this may reduce infections and improve wound healing. Evidence from
laparoscopic donor nephrectomy shows clear benefits to patients.
1.2 Rationale
A key issue arising from MIKT is its effect on the kidney allograft. The robotic kidney
transplant technique prolongs the re-warming time due to the longer anastomosis time. Results
suggest that this may reduce the glomerular filtration rate (eGFR) in the early
post-transplant period when compared to open kidney transplant with no difference in function
at 1 and 2 year follow-up. The long-term consequences for the graft beyond this period are
unknown. The effects of pneumoperitoneum on the transplant kidney have also been questioned
with suggestions that higher intra-abdominal pressures may reduce allograft perfusion during
surgery with negative consequences for the allograft based on experience with other studies
of both human and animal models. There is unpublished data that suggests that the effects on
longer term graft outcomes are not significant.
MIKT promises to offer significant benefits to kidney transplant recipients including less
manipulation of the graft during surgery and a reduction in surgical site infections which
has already been noted in obese patients undergoing robotic MIKT. Smaller incisions with
reduced analgesia requirement are a key benefit which may affect length of stay and
associated co-morbidity, hospital costs and the patient experience which has been
demonstrated with the donor nephrectomy operation.
The expression of several biomarkers of kidney injury has been demonstrated to reflect damage
to the graft and subsequent kidney function in living donor kidney transplantation. These
biomarkers, including Kidney Injury Molecule 1 (KIM-1), neutrophil gelatinase associated
lipocalin (NGAL) and interleukin 18 (IL-18) are expressed in both serum and urine. Changes in
their expression can predict some outcomes after transplantation. These biomarkers offer an
advantage over traditional means of assessing kidney injury and function after
transplantation such as serum creatinine measurement, urine output and kidney biopsy in that
they can be detected early in the spectrum of acute kidney injury.
Patients with ESRD usually have multiple co-morbidities and are less able to withstand the
stress of major surgery compared to other patients leading to greater mortality and
complications. MIKT may reduce the surgical stress burden for these patients, compared with
open surgery, but this is currently uncertain. Evidence from other fields of surgery has
shown that the changes in the metabolic stress response to open and minimally invasive
surgery can be quantified.
We therefore propose to perform this study to assess the impact of minimally invasive kidney
transplantation on the transplant kidney and the recipient by observing the expression of
biomarkers and establishing their relationship to outcomes after transplantation.
2 Study Objectives, Design and Statistics 2.1. Study Objectives
This study aims to investigate the effect of the warm ischaemia time and pneumoperitoneum on
kidney injury by measuring biomarkers of acute kidney injury which are found in blood and
urine to establish if there is a significant difference between robotic and open surgery. The
study will also investigate the potential benefits of minimally invasive surgery on the
surgical trauma associated with open surgery by assessing the surgical stress response and
wound healing between groups of kidney transplant patients receiving either open or minimally
invasive kidney transplants. Wound healing will also be compared with patients undergoing a
different minimally invasive surgical technique (laparoscopic donor nephrectomy) as they will
have a similar incision.
The primary outcome measure is the difference in expression of plasma and serum biomarkers of
kidney injury and surgical stress in the recipient groups. The secondary outcomes will
include clinical outcomes such as infection, graft function and acute rejection, evidence of
wound healing as assessed by ultrasound scan and quality of life outcomes assessed by
questionnaire.
2.2 Study Design & Flowchart The study will be conducted on an observational case-control
basis comparing groups of patients receiving standard care in three arms: open living donor
kidney transplantation, robotic living donor kidney transplantation and laparscopic donor
nephrectomy. Biomarkers of kidney injury and the surgical stress response will be measured in
plasma and urine of the recipients only.
Participants will receive information leaflets during education sessions prior to
transplantation or donor surgery. Information about the study will be given during this
period and they will also be approached in clinic prior to surgery to gain their informed
consent after they have had the time to consider the information about the study.
Participants will have blood samples collected for the study at the same time as their
routine clinical samples are taken wherever possible. These samples will be collected on the
day of surgery and all post-operative days until day seven after surgery if they are
inpatients. Additional samples will be collected at non-routine times in the first 24 hours
after transplant surgery only.
Urine samples will be collected from the catheter during surgery and each post-operative day
up till day seven after surgery if they are inpatients.
All participants will be offered the opportunity of undergoing an optional bedside ultrasound
scan of their abdominal wall incision at day three post-surgery.
Final blood and urine samples will be collected at the time of the participant's routine
post-operative visit at 1 month.
Biomarkers will be measured using Luminex and ELISA techniques as appropriate. The biomarkers
to be measured will include Kidney injury molecule 1 (KIM-1), Neutrophil
gelatinase-associated lipocalin (NGAL) and Interleukin-18 (IL-18).
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