Publishing type：Research paper (scientific journal)   Publisher：MDPI AG  

Background/Objectives: Limited research exists on risk factors for urinary tract infections (UTIs) in kidney transplant recipients, particularly in high-risk groups such as ABO-incompatible or donor-specific antibody (DSA)-positive cases. Early UTIs, especially within the first month post-transplant, impact on acute rejection and long-term graft outcomes, highlighting the need for risk factor identification and management. Methods: Among 157 living donor kidney transplant cases performed at our institution between 2009 and 2024, 128 patients were included after excluding cases with >72 h of perioperative prophylactic antibiotics or urological complications. UTI was defined as the presence of pyuria and a positive urine culture, accompanied by clinical symptoms requiring antibiotic treatment, occurring within one month post-transplantation. Results: The median onset of UTI was postoperative day 8 (interquartile range, IQR: 6.8–9.3). No subsequent acute rejection episodes were observed. The median serum creatinine at 1 month postoperatively was 1.3 mg/dL (IQR: 1.1–1.7), and this was not significantly different from those who did not develop UTI. In univariate analysis, low or high BMI (<20 or >25), longer dialysis duration (>2.5 years), desensitization therapy (plasmapheresis + rituximab), elevated preoperative neutrophil-to-lymphocyte ratio (NLR) (≥3), and longer warm ischemic time (WIT) (≥7.8 min) were significantly associated with an increased infection risk of UTI (p = 0.010, 0.036, 0.028, 0.015, and 0.038, respectively). Multivariate analyses revealed that abnormal BMI, longer dialysis duration, desensitization therapy, and longer WIT were independent risk factors for UTI (p = 0.012, 0.031, 0.008, and 0.033, respectively). The incidence of UTI increased with the number of risk factors: 0% (0/16) for zero, 10% (5/48) for one, 31% (16/51) for two, 45% (5/11) for three, and 100% (2/2) for four risk factors. Conclusions: Desensitization therapy, BMI, dialysis duration, and WIT were identified as independent risk factors for perioperative UTI. In patients with risk factors, additional preventive strategies should be considered, with extended antibiotic prophylaxis being one potential option.

DOI： 10.3390/jcm14176102

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BACKGROUND: Although the long-term survival of kidney transplant recipients has significantly improved, malignant neoplasms remain one of the leading causes of death in this population. The recipients face a 1.8-fold increased risk of developing malignant neoplasms compared with the general population. This risk increases with time after transplantation. Tacrolimus (TAC) is preferred over cyclosporine A (CyA) in terms of efficacy against organ rejection, but evidence on the risk of malignant neoplasms is lacking. We aimed to describe the incidence and types of malignant neoplasms in kidney transplant recipients and evaluate the association between malignant neoplasms development and the type of prescribed CNI. METHODS: This retrospective cohort study was conducted using the Japanese National Database of Health Insurance Claims, including data covering 99% of kidney transplant patients in Japan. Patients who underwent kidney transplantation and were prescribed TAC or CyA between April and June 2011 were included. The primary outcome included the incidence of malignant neoplasms, and secondary outcomes included overall survival and graft survival. RESULTS: A total of 7,590 patients were included, with 11.0% developing malignant neoplasms during the follow-up period. The most common malignant neoplasms were in the digestive organs and urinary tract. No statistically significant difference in malignant neoplasms incidence was observed between TAC and CyA users (hazards ratio: 0.97, 95% CI: 0.84 to 1.12; estimated average treatment effect: -24.05, 95% CI: -184.90 to 136.80). The patient and graft survival rates were also comparable between the groups. CONCLUSIONS: This large study suggests that TAC is not associated with an increased risk of malignant neoplasms compared to CyA in the late post-transplant period. CLINICAL TRIAL NUMBER: Not applicable.

DOI： 10.1186/s12882-025-04405-8

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BACKGROUND: No direct cost comparison has been conducted between percutaneous cryoablation (PCA) and robot-assisted partial nephrectomy (RAPN) for clinical T1a renal cell carcinoma (RCC) in Japan. This study aimed to compare their costs. METHODS: We retrospectively analyzed data from 212 PCAs (including 155 with transcatheter arterial embolization) and 119 RAPN cases performed between December 2017 and May 2022. RESULTS: PCA patients were older with higher American Society of Anesthesiologists scores, Charlson Comorbidity Index, and history of previous RCC treatment, cardiovascular disease, and antithrombotic drug use than RAPN patients. PCA was associated with a significantly shorter procedure time and hospitalization duration with fewer major complications than those associated with RAPN. While PCA incurred a slightly lower total cost (1,123,000 vs. 1,155,000 yen), it had a significantly higher procedural cost (739,000 vs. 693,000 yen) and markedly worse total (- 93,000 vs. 249,000 yen) and procedural income-expenditure balance (- 189,000 vs. 231,000 yen) than those of RAPN. After statistical adjustment, PCA demonstrated significantly higher total (difference: 114,000 yen) and procedural costs (difference: 72,000 yen), alongside significantly worse total (difference: - 358,000 yen) and procedural income-expenditure balances (difference: - 439,000 yen). The incremental cost-effectiveness ratio was more favorable for PCA than for RAPN. CONCLUSION: For high- risk patients, PCA demonstrated a safer option with shorter hospitalization duration than those of RAPN. Although PCA was more cost-effective, its higher procedural cost and unfavorable income-expenditure balance require careful evaluation, especially for large tumors that require three or more needles.

DOI： 10.1007/s10147-025-02783-5

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Immune checkpoint inhibitors (ICIs) are a key component of first-line treatment for metastatic renal cell carcinoma (mRCC). However, predicting treatment-related adverse events (TRAEs) remains challenging. This study investigated the utility of eosinophil-related biomarkers as predictors of Common Terminology Criteria for Adverse Events grade ≥ 3 TRAEs in mRCC patients undergoing ICI combination therapy. In this retrospective analysis across 21 hospitals in Japan, we examined 180 patients treated with ICI/ICI therapy and 216 patients treated with ICI/tyrosine kinase inhibitor (TKI) therapy. Grade ≥ 3 TRAEs occurred in 39.4% and 31.9% of patients in the ICI/ICI and ICI/TKI groups, respectively. An elevated eosinophil proportion of ≥ 2.0% (odds ratio [OR]: 2.36; 95% CI [confidence interval] 1.23-4.54, p = 0.01) and a low neutrophil/eosinophil ratio (NER) of ≤ 40.0 (OR: 2.78, 95% CI 1.39-5.53, p = 0.004) were significant predictors of severe TRAEs in the ICI/ICI group. However, no significant associations were found in the ICI/TKI group. These findings may help identify patients who suffer from grade ≥ 3 TRAEs and help determine individualized treatment strategies in patients with mRCC.

DOI： 10.1038/s41598-025-08767-9

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BACKGROUND/AIM: This study investigated the correlation between body mass index (BMI, kg/m2) and clinical outcomes in patients with advanced renal cell carcinoma (RCC) treated with ipilimumab and nivolumab. PATIENTS AND METHODS: A total of 113 patients with advanced RCC, treated with first-line ipilimumab and nivolumab were analyzed. Patients were divided into two groups based on their BMI at treatment initiation: the high BMI (BMI ≥25) and the low BMI group (BMI <25). The objective response rate (ORR), overall survival (OS), progression-free survival (PFS), and duration of response (DOR) were analyzed to compare the two groups. RESULTS: Patient characteristics for the high BMI (n=30) and the low BMI (n=83) were as follows: median age at treatment initiation (70 years for both groups), percentage of male patients (77% vs. 82%), International Metastatic RCC Database Consortium (IMDC) poor-risk category (23% vs. 33%), the presence of liver metastasis (7% vs. 8%). The ORR was 53% (16/30) in the high BMI and 37% (29/77) in the low BMI (p=0.01). The median OS was not estimated in the high BMI and 33 months in the low BMI (p=0.049). Multivariable analysis identified IMDC poor-risk status with a hazard ratio (HR) of 2.31 and the presence of liver metastasis with an HR of 4.83 as independent factors affecting OS. CONCLUSION: A higher ORR for the combination of ipilimumab and nivolumab was observed in patients with high BMI compared to those with low BMI. IMDC poor risk and the presence of liver metastasis significantly influenced the prognosis of patients with advanced RCC treated with the combination.

DOI： 10.21873/anticanres.17635

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Major guidelines for living-donor kidney transplantation underscore the need for pre-donation evaluation of renal function, hypertension, obesity, diabetes mellitus, and albuminuria to minimize the risk of donation from marginal donors. However, validity is yet to be established. We retrospectively investigated the relationship between clinical characteristics and histological indices in baseline renal biopsies (0-h biopsies) and whether these parameters could predict renal function in living kidney donors one year post-donation. Seventy-six living kidney donors were recruited for this study. In histological analyses, glomerulosclerosis, arteriosclerosis, arteriolosclerosis, arteriolar hyalinosis, and interstitial fibrosis and tubular atrophy scores/indices were evaluated. Post-donation serum creatinine levels in kidney donors with arteriolar hyalinosis were significantly higher than those in individuals without arteriolar hyalinosis. There was a significant correlation between baseline serum uric acid levels and the arteriolar hyalinosis index, with baseline uric acid level identified as an independent factor for hyalinosis in multiple regression analysis. Additionally, the serum uric acid level was a significant prognostic factor for post-donation serum creatinine after adjustment for baseline clinical parameters. These data demonstrate that pre-donation serum uric acid levels are associated with arteriolar hyalinosis in the kidney and could predict a decline in renal function during the first year after donation in living kidney donors.

DOI： 10.1371/journal.pone.0320482

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For small renal tumors, nephron-preserving treatment, including partial nephrectomy or ablation therapy, is recommended. According to major guidelines, ablation therapies are advised for patients who are deemed not suitable to undergo surgery due to an advanced age or the presence of comorbidities. However, compared with surgery, ablation therapy can result in superior safety and functional outcomes. The present review discusses the factors affecting decision-making as regards treatment options for small renal tumors. When determining an appropriate treatment option, tumor locations, as well as the condition and preferences of the patient, are considered. Scoring systems, such as the RENAL Nephrometry Score can assist in guiding treatment decisions. However, surgery may be the preferred approach for tumors near major vessels and collecting systems. For endophytic tumors, partial nephrectomy can be challenging due to the difficulty in visualizing intra-parenchymal tumors during the procedure, whereas ablation therapies may be inferior to partial nephrectomy. Although treatment selection for small renal tumors can be affected by tumor location, partial nephrectomy remains the gold standard for numerous cases.

DOI： 10.3892/mi.2025.247

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BACKGROUND/AIM: This study assessed the accuracy of preoperative contrast-enhanced computed tomography (CECT) scans in staging small-sized, locally advanced (cT3a) renal cell carcinoma (RCC) and identified predictors of pathological downstaging following surgery. PATIENTS AND METHODS: Seventy-six patients who underwent radical nephrectomy for cT3aN0M0 RCC with tumors ≤7 cm were analyzed. Preoperative CECT evaluated features such as venous, peritumoral, or renal sinus fat, and urinary tract invasion, predictive values, and concordance index between radiological and pathological findings were calculated for these categories. The study also examined the impact of clinicopathologic factors on downstaging. RESULTS: Of 76 patients with cT3 RCC, 37% were down-staged to pT1. Down-staged cases had a higher proportion of male patients and non-clear cell carcinoma (86% vs. 58%, 32% vs. 6%; p=0.02, p=0.007, respectively). Multiple cT3a factors were less common in down-staged cases (4% vs. 23%, p=0.04). Non-clear cell carcinoma was significantly associated with downstaging compared to clear cell carcinoma (75% vs. 30%, p=0.006). Multivariate analysis confirmed non-clear cell carcinoma as an independent predictor (odds ratio=8.2, p=0.01). For venous invasion, CECT sensitivity and positive predictive value were high (73.5% and 83.3%, respectively) and the degree of agreement was substantial (κ=0.62). CONCLUSION: The accuracy of preoperative CECT was acceptable for detecting venous invasion. The downstaging to pT1 occurred in 37% of cT3a RCC cases in the final pathology, with non-clear cell carcinoma being a significant predictor.

DOI： 10.21873/invivo.14077

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BACKGROUND/AIM: Immune checkpoint inhibitors (ICIs) have improved survival in metastatic renal cell carcinoma (mRCC), with nivolumab (NIVO) plus ipilimumab (IPI) showing benefits in intermediate- and poor-risk patients. Despite first-line efficacy, progression is common, requiring second-line therapies. Tyrosine kinase inhibitors (TKIs) are commonly administered after ICIs; however, the relationship between progression-free survival (PFS) in first- and second-line settings is not well defined. This study examined the correlation of PFS in patients with mRCC treated with ICIs followed by TKIs. PATIENTS AND METHODS: This retrospective multicenter study analyzed 66 patients with mRCC who received NIVO + IPI as first-line therapy and subsequent TKIs between September 2018 and February 2023. Patients were stratified according to the International Metastatic RCC Database Consortium (IMDC) risk classification. RESULTS: Median PFS for second-line TKIs was 6.9 months, and overall survival was 17.7 months. While no significant correlation was observed between first- and second-line PFS in the overall cohort or the IMDC intermediate-risk subgroup, a significant positive correlation was found in the poor-risk group (Spearman's rho=0.677, p=0.002). CONCLUSION: Treatment outcomes in poor-risk patients may exhibit a predictable response pattern across therapy lines, potentially informing personalized treatment strategies.

DOI： 10.21873/cdp.10488

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OBJECTIVES: This study aimed to compare the clinical outcomes of robot-assisted partial nephrectomy (RAPN) and image-guided percutaneous cryoablation (IG-PCA) for clinical T1 renal cell carcinoma. MATERIALS AND METHODS: We conducted a retrospective analysis of 679 patients with clinical T1 renal cell carcinoma treated with RAPN or IG-PCA between 2012 and 2021. Propensity scores were calculated via logistic analysis to adjust for imbalances in baseline characteristics. We compared oncological and functional outcomes between the 2 treatment groups. RESULTS: Following the matching process, 108 patients were included in each group. No patient in the RAPN group developed local recurrence. In the IG-PCA group, three patients experienced local tumor progression. The patients underwent salvage thermal ablations by the secondary technique; 2 underwent IG-PCA and 1 underwent microwave ablation, resulting in a local control rate of 100%. The Kaplan-Meier analysis showed no statistically significant differences between the groups in terms of 5-year recurrence-free survival, metastasis-free survival, and overall survival (log-rank test; P = 0.11, P = 0.64, and P = 0.17, respectively). No significant differences were observed in the 2 treatments in major and overall complication rates (P = 0.75 and P = 0.82, respectively). Both groups showed similar rates of less than 10% estimated glomerular filtration rate decline at 12 months post-treatment and 5-year renal function preservation rates (P = 0.88 and P = 0.38, respectively). CONCLUSIONS: IG-PCA demonstrated oncological outcomes comparable to those of RAPN. RAPN addressed the disadvantages of conventional procedures and allowed for safety outcomes comparable to IG-PCA.

DOI： 10.1016/j.urolonc.2024.09.012

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PURPOSE: Immune checkpoint inhibitor (ICI)-based combination therapy is a standard systemic treatment for metastatic renal cell carcinoma (mRCC). Although differential pharmacologic action between ICI+ICI and ICI+tyrosine kinase inhibitor (TKI) combinations may affect outcomes, comparative studies using real-world data are few. METHODS: We retrospectively analyzed the records of 447 mRCC patients treated with 1st-line ICI-based combinations at multiple institutions between January 2018 and August 2023, and selected 320 patients diagnosed with clear cell RCC (ccRCC) for further study. Cohorts were matched using one-to-one propensity scores based on IMDC risk classification. Overall survival (OS), progression-free survival (PFS), objective response rates (ORRs), and treatment-related adverse events (TrAE) were compared. RESULTS: The matching process yielded 228 metastatic ccRCC patients treated with ICI+ICI (n = 114) or ICI+TKI (n = 114). Median OS was 53 months (95%CI: 33-NA) in patients treated with ICI+ICI and was not reached (95%CI: 43-NA) with ICI+TKI (P = 0.24). Median PFS was significantly shorter for ICI+ICI (13 months, 95%CI: 7-25) than for ICI+TKI (25 months, 95%CI: 13-NA) (P = 0.047). There were no differences in second-line PFS for sequential therapy after 1st-line combinations of ICI+ICI or ICI+TKI (6 vs. 8 months, P = 0.6). There were no differences in ORR between the 2 groups (ICI+ICI: 51% vs. ICI+TKI: 55%, P = 0.8); the progressive disease (PD) rate was significantly higher in patients treated with the ICI+ICI combination (24% vs. 11%, P = 0.029). The rate of any grade TrAE was significantly higher in patients treated with ICI+TKI (71% vs. 85%, P = 0.016), but we found no differences in severe TrAE between the 2 groups (39% vs. 36%, P = 0.8). CONCLUSIONS: In a matched cohort of real-world data, we confirmed comparable OS benefits between ICI+ICI and ICI+TKI combinations. However, differential clinical behaviors in terms of PFS, PD rates, and TrAE between ICI-based combinations may enrich clinical decision-making.

DOI： 10.1016/j.urolonc.2024.06.013

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INTRODUCTION: Concomitant medications can affect the efficacy of immune checkpoint inhibitors. The association between histamine-2 receptor antagonists (H2RAs), major antacids similar to proton pump inhibitors (PPIs), and the efficacy of pembrolizumab for metastatic urothelial carcinoma (mUC) treatment has been poorly evaluated. We evaluated the impact of PPIs and H2RAs on oncological outcomes in mUC patients treated with pembrolizumab. PATIENTS AND METHODS: This retrospective multicenter study included patients with mUC treated with pembrolizumab. Patients prescribed PPIs or H2RAs within 30 days before and after the initial administration were extracted. The overall survival (OS), cancer-specific survival (CSS), progression-free survival (PFS), and objective response rates (ORR) were assessed. Kaplan-Meier survival curve analysis and multivariable Cox proportional hazard models were employed to assess the association between PPIs or H2RAs and survival outcomes. RESULTS: Overall, 404 patients were eligible for this study; 121 patients (29.9%) used PPIs, and 34 (8.4%) used H2RAs. Kaplan-Meier analysis showed significantly worse OS, CSS, and PFS in patients using PPIs compared to no PPIs (P = .010, .018, and .012, respectively). In multivariable analyses, the use of PPIs was a significant prognostic factor for worse OS (HR = 1.42, 95% CI 1.08-1.87, P = .011), CSS (HR = 1.45, 95% CI 1.09-1.93, P = .011), and PFS (HR = 1.35, 95% CI 1.05-1.73, P = .020). PPIs were not associated with ORRs. The use of H2RAs was not associated with survival or ORRs. CONCLUSION: PPIs were significantly associated with worse survival of patients with mUC treated with pembrolizumab, and H2RAs could be an alternative during administration. Both the oncological and gastrointestinal implications should be carefully considered when switching these antacids.

DOI： 10.1016/j.clgc.2024.102097

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This review presents the latest insights on robot-assisted kidney autotransplantation (RAKAT). RAKAT is a minimally invasive surgical procedure and represents a promising alternative to conventional laparoscopic nephrectomy followed by open kidney transplantation for the treatment of various complex urological and vascular conditions. RAKAT can be performed either extracorporeally or intracorporeally. Additionally, a single-port approach can be performed through one small incision without the need to reposition the patient. Of 86 patients undergoing RAKAT, 8 (9.3%) developed postoperative > Grade 2 Clavien-Dindo (CD) complications. Although the feasibility of RAKAT was established in 2014, the long-term efficacy and safety along with outcomes of this surgical approach are still being evaluated, and additional studies are needed. With improvements in the technology of RAKAT and as surgeons gain more experience, RAKAT should become increasingly used and further refined, thereby leading to improved surgical outcomes and improved patients' quality of life.

DOI： 10.1111/iju.15426

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PURPOSE: Radiological tumor burden has been reported to be prognostic in many malignancies in the immunotherapy era, yet whether it is prognostic in patients with metastatic urothelial carcinoma (mUC) treated with pembrolizumab remains uninvestigated. We sought to assess the predictive and prognostic value of radiological tumor burden in patients with mUC. METHODS: We performed a retrospective analysis of 308 patients with mUC treated with pembrolizumab. Radiological tumor burden was represented by baseline tumor size (BTS) and baseline tumor number (BTN). Optimal cut-off value of BTS was determined as 50 mm using the Youden index (small BTS: n = 194, large BTS: n = 114). Overall (OS), cancer-specific (CSS), progression-free survival (PFS), and objective response rate (ORR) were compared. Non-linear associations between BTS and OS and CSS were evaluated using restricted cubic splines. RESULTS: Patients with large BTS were less likely to have undergone the surgical resection of the primary tumor (P = 0.01), and more likely to have liver metastasis (P < 0.001) and more metastatic lesions (P < 0.001). On multivariable analyses controlling for the effects of confounders (resection of primary tumor, metastatic site, number of metastases and lactate dehydrogenase level), large BTS and high BTN were independently associated with worse OS (HR 1.52; P = 0.015, and HR 1.69; P = 0.018, respectively) and CSS (HR 1.59; P = 0.01, and HR 1.66; P = 0.031, respectively), but not PFS. Restricted cubic splines revealed BTS was correlated with OS and CSS in linear relationships. Additionally, large BTS was significantly predictive of lower ORR and complete response rate on univariable analyses (P = 0.041 and P = 0.032, respectively), but its association disappeared on multivariable analyses. CONCLUSION: Radiological tumor burden has independent prognostic value with a linear relationship in pembrolizumab-treated patients with mUC and might help drive the earlier introduction of second-line pembrolizumab and/or switching to subsequent therapies.

DOI： 10.1016/j.urolonc.2023.11.009

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One-third of renal cell carcinomas (RCCs) without metastases develop metastatic disease after extirpative surgery for the primary tumors. The majority of metastatic RCC cases, along with treated primary lesions, involve limited lesions termed "oligo-recurrent" disease. The role of metastasis-directed therapy (MDT), including stereotactic body radiation therapy (SBRT) and metastasectomy, in the treatment of oligo-recurrent RCC has evolved. Although the surgical resection of all lesions alone can have a curative intent, SBRT is a valuable treatment option, especially for patients concurrently receiving systemic therapy. Contemporary immune checkpoint inhibitor (ICI) combination therapies remain central to the management of metastatic RCC. However, one objective of MDT is to delay the initiation of systemic therapies, thereby sparing patients from potentially unnecessary burdens. Undertaking MDT for cases showing progression under systemic therapies, known as "oligo-progression", can be complex in considering the treatment approach. Its efficacy may be diminished compared to patients with stable disease. SBRT combined with ICI can be a promising treatment for these cases because radiation therapy has been shown to affect the tumor microenvironment and areas beyond the irradiated sites. This may enhance the efficacy of ICIs, although their efficacy has only been demonstrated in clinical trials.

DOI： 10.3390/cancers15245873

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Language：Japanese   Publisher：一般社団法人 日本移植学会  

【緒言】COVID-19感染症は2023年5月に2類から5類感染症へ変更となったが、その後も第9波が確認されている。この第9波時期に腎機能悪化を認めた生体腎移植後の症例を我々は経験した。【症例】40歳代、男性。間質性腎炎を原疾患とする末期腎不全に対して、実母をドナーとする血液型一致（抗ドナー抗体なし）の生体腎移植を4年前に施行し、Cr 2.1mg/dL前後で経過していた。定期受診の際、Cr 2.78mg/dLと腎機能悪化を認めたが発熱はなく、体調変化の訴えもなかった。エコーで移植腎の血流も以前と著変なかったが、即時腎生検は希望されず、14日後にCr 8.15mg/dLと急激な腎機能悪化認めた。緊急生検目的に当日入院、全身スクリーニングCTにて肺野にすりガラス影を認め、SARS-CoV-2核酸検査で陽性が判明した。抗ウイルス薬としてモルヌピラビルを開始、MMFは中止した。その後Cr 9.4mg/dLまで上昇しHDを行った。生検では拒絶反応やBKvなどのウイルス腎症は否定的で、尿細管の脱落や空胞変化・増殖に見える部位が見られるが細胞浸潤がなく、間質の炎症も有意なものはなく、尿細管壊死の回復の途中を見ている可能性が推察された。COVID-19感染症が改善するとともにHD離脱、Cr 3.5mg/dLまで低下、12日目に退院となった。

DOI： 10.11386/jst.59.supplement_s363_3

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Language：Japanese   Publisher：一般社団法人 日本移植学会  

【目的】腎移植における術前栄養状態と骨格筋評価がレシピエントの腎予後に関与するかについて検討した。【対象と方法】2009年5月~2022年12月に当院で腎移植を行った144症例。術前栄養状態としてcontrolling nutritional status: CONUT score（血清アルブミン、総コレステロール、末梢リンパ球数による栄養評価指標、cut off値3）、骨格筋評価として腹部CTを用いたpsoas muscle mass index: PMI(腰椎第3レベル、cut off値:男性6.36cm2/m2、女性3.92cm2/m2)をそれぞれ算出し、全腎生着率を比較検討した。【結果】年齢中央値や性別、透析歴、免疫学的リスク、術前脱感作歴に差はなかった。術前低栄養群で糖尿病罹患率が高く(11.7% vs 30.0%, p=0.011)、低骨格筋群でBMI低値であった(22.2kg/m2 vs 20.9kg/m2, p=0.032)。周術期合併症や急性拒絶有無に関して各群間で差を認めなかったが、低栄養群で術後1年以内に入院を要した感染症発生率が高かった (23.4% vs 46.0%, p=0.008)。術前低栄養かつ低骨格筋群は術前低栄養もしくは低骨格筋群、術前栄養・骨格筋正常群と比較し、5年移植腎生着率の低下を認めた(77.0% vs 89.4% vs 92.7%, P=0.013)。移植腎廃絶のリスク因子として、術前低栄養かつ低骨格筋量 (HR; 4.88, 95% CI 1.48-16.1, P=0.009)が認められた。【結語】術前低栄養かつ低骨格筋量を認める腎移植レシピエントは、腎生着悪化のリスクを有することが示唆された。

DOI： 10.11386/jst.59.supplement_s323_2

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Publisher：株式会社医学書院  

DOI： 10.11477/mf.1429204238

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Publisher：株式会社医学書院  

DOI： 10.11477/mf.1429204240

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Language：Japanese   Publisher：一般社団法人 日本移植学会  

【緒言】2020年、我々は、生体腎移植における低用量リツキシマブを用いた脱感作療法は移植後のサイトメガロウイルス(CMV)感染症を増加させることなく、移植後2年にわたり良好な生着率を実現することを報告した。今回、さらに長期の成績を検討した。【対象と方法】対象は2009年5月から2021年9月までに当院で生体腎移植を受けた131名のレシピエント。術前リツキシマブ（200mg/body）の適応は1. ABO血液型不適合、2.ABO血液型不一致、3.ドナー特異的抗体（DSA）陽性、4.巣状分節性糸球体硬化症（FSGS）であった。【結果】リツキシマブ群83例、非リツキシマブ群34例。年齢(中央値:51歳vs41歳, p=0.03）はリツキシマブ群がやや高齢であった。38℃以上の発熱（11％ vs 9％, p=1.00）、消化器症状（8％ vs 15％, p=0.32）、好中球＜1000の好中球減少症(43％ vs 29％, p=0.21)などのCMV感染症における臨床症状（14％ vs 21％, p=0.41）に有意差はなく、移植後5年までの腎機能 (Cr, eGFR)は同等で、5年間のグラフト生着率（96％ vs 93％, p=0.54）も両群で差を認めなかった。【結論】前回の研究と同様、低用量リツキシマブを用いた脱感作療法は免疫学ハイリスクなレシピエントに対して、予防投与法を用いずともCMV感染を増加させることなく良好なグラフト予後を得られることが示された。

DOI： 10.11386/jst.58.supplement_s307_1

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Language：Japanese   Publisher：一般社団法人 日本移植学会  

【緒言】当院における腎移植後の悪性腫瘍発症例を検討した。【対象と方法】2009年から2022年に腎移植を施行した153症例について、患者背景、悪性腫瘍の発生率や、転帰について検討した。【結果】悪性腫瘍は7例(5%)、9腫瘍(重複あり)に発生し、その内訳は自己腎癌1例、筋層非浸潤性膀胱癌2例、子宮体癌1例、肺癌1例、肝内胆管癌1例、PTLD3例であった。年齢中央値は58歳で女性2例、悪性腫瘍既往1例、血液型不適合移植3例（うち2例DSA陽性）、術前脱感作としてリツキサン投与3例、急性細胞性拒絶反応1例であった。発症時期の中央値は腎移植後70ヶ月(3-97ヶ月)、無症状(偶発的もしくは移植後スクリーニング)で5/9腫瘍(56%)が判明した一方、症状を有した肺癌とPTLDの2症例で癌死となった。悪性腫瘍発生群と非発生群の比較検討では、有意なリスク因子は認めず、5年移植腎生着率も有意差はなかった (97 vs 86%, P=0.24)が5年生存率は悪例腫瘍発生群が不良であった（97 vs 71%, P=0.001）。【結語】腎移植後の悪性腫瘍発生のリスクは今回の検討では不明であるも、生存率を低下させるためスクリーニングが重要である。

DOI： 10.11386/jst.58.supplement_s262_2

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Language：Japanese   Publisher：一般社団法人 日本移植学会  

【症例】40歳代、女性。X-11年、他院で59歳の父親をレシピエントとしたドナー右腎採取術を施行。術後3年以降、lost follow upとなった。X年１月に人間ドックで左腎腫瘤を指摘され、前医にてCTで45mm大の左腎癌が疑われ、当科紹介。cT1bN0M0,stage1（RENAL score 11、PADUA score 10）の診断にて、腎部分切除の適応と判断。安定した腎冷却が可能な開放腎部分切除を選択した。X年4月、自家腎移植へも備えつつ、経腰的に冷阻血下左腎部分切除術を施行。腫瘍底部の切離の際、開放した静脈内に腫瘍浸潤を認めたが、肉眼的に断端陰性にて腎部分切除を完遂した（手術時間503分、冷阻血時間107分、出血量700ml；冷水込み）。術後はCr 5.7 mg/dlまで上昇するも透析を行うことなく、high gradeの合併症も認めず、術後22日目に退院となった。病理組織は、Clear cell RCC、G2、v1、広がり：腎洞脂肪組織［腎静脈・区域静脈］、切除断端：陰性、pT3aにて、病期はup gradeとなり転移再発リスクは高く、現在、厳重経過観察中である。【考察】若年ドナーは年齢的に医療機関を受診する機会が少なく、フォロー中断になる危険性が増すと予想される。加えて、単腎となることで進行した腎癌を認めた場合に腎機能温存と癌制御の両立が困難になり得る。また、10年以上の長期でみると腎不全に至るリスクも報告されており、ガイドライン上は若年でもドナーとなり得るが、その選定は慎重に行うべきである。

DOI： 10.11386/jst.58.supplement_s265_3

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Language：Japanese   Publisher：東京 : 科学評論社  

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Other Link： https://ndlsearch.ndl.go.jp/books/R000000004-I032529687

Language：Japanese   Publisher：一般社団法人 日本移植学会  

＜緒言＞

COVID-19感染症は腎移植患者のグラフトだけでなく生命予後にも寄与し、慎重な治療介入を必要とする。今回、当科で腎移植後にCOVID-19と診断された9症例を報告する。

＜症例＞

2009年5月～2022年5月までに腎移植を受けたレシピエント149人のうち、9人がCOVID-19と診断された。8人は生体腎移植後、1人は献腎移植後で、献腎移植の患者は移植前にもCOVID-19に罹患していた。ワクチン未接種が3人、2回または3回接種が5人。年齢の中央値は42歳(IQR:33-51歳)、移植後からCOVID-19と診断されるまでの期間は46ヶ月(IQR:28-72ヶ月)であった。原疾患はIgA腎症3例、糖尿病性腎症2例など様々で、移植前の免疫抑制学的リスクが低い (ABO血液型一致かつDSA陰性のため、リツキシマブ非投与)のは2例であった。COVID-19感染症の治療では、MMFの減量または休薬のみで対応した低リスク群は4例、抗ウイルス薬投与や酸素吸入まで行った中リスク群が3例、肺炎の診断でステロイドパルスやNHFまで行った高リスク群は2例であった。高リスク群のうち1症例はワクチン未接種で、30日間の入院加療のすえ自宅退院となり、退院時は在宅酸素を必要とするも数日で不要となった。いずれの症例も腎機能はベースラインまで改善し、大きな後遺症なくフォロー終了となり、感染前と同様の生活を過ごしている。

＜結語＞

COVID-19は免疫抑制状態にある腎移植後レシピエントにとって切っても切り離せない病態である。ワクチン接種や早期診断に加え、リスク分類に則った適切な治療介入を行うことが重要と考えられる。

DOI： 10.11386/jst.57.supplement_s262_3

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Language：Japanese   Publisher：一般社団法人 日本移植学会  

【緒言】増加傾向にあるABO血液型不適合や抗ドナー抗体陽性の生体腎移植において、リツキシマブとアフェレーシス併用を中心とした術前脱感作療法が主流となっている。リツキシマブの抗体産生抑制による周術期感染症の増加が懸念され、今回、後方視的検討を行った。

【対象と方法】当科で2009年5月から2022年3月までに行った生体腎移植139例中、「泌尿器科領域における周術期感染予防ガイドライン」で推奨された、単回もしくは72時間以内の予防抗菌薬投与の111例を対象とし、術後1か月以内に抗菌薬投与を必要とした細菌感染症のリスク因子を単変量および多変量解析を用いて検討した。

【結果】全ての細菌感染症が尿路感染症（Urinary tract infection；UTI）、21例であった。UTIのリスク因子についての単変量・多変量解析では、糖尿病やASA、維持透析、予防抗菌薬投与期間等は有意差なく、リツキシマブとアフェレーシス併用の脱感作療法は単変量で有意差を認め（p=0.048）、多変量では強い関係を示した（p=0.054）。サブ解析では、リツキシマブとアフェレーシス併用例においても予防抗菌薬投与期間はリスク因子ではなかった。

【結語】リツキシマブとアフェレーシス併用の脱感作療法を施行する免疫学的ハイリスク腎移植ではUTIが増加する可能性がある。

DOI： 10.11386/jst.57.supplement_s284_1

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Language：Japanese   Publisher：一般社団法人 日本移植学会  

【緒言】生体腎移植ドナーの長期的予後は、一般人口と同様でQOLも損なわないことが示されている。しかし、高血圧や年齢などの医学的問題を抱えたマージナルドナー(MD)のQOLに関する報告は少ない。今回、当院におけるMDの腎提供後5年間のQOL変化をスタンダードドナー(SD)と比較した。【対象・方法】2009年2月~2021年4月の間に当院で腎提供を経験した症例のうち、SF-36v2を使用したQOL評価を腎提供後1年以上継続して行えた81例(SD40例、MD41例)を対象とし、国民標準値50点と比較した。また、術後の腎機能推移、CVD併発、新規悪性腫瘍発生についても比較検討した。【結果】両群間で術後の腎機能推移、CKD 3b以上の症例数に有意差なく(各群10例ずつ)、CVDや悪性腫瘍発生についても有意差を認めなかった。術前において3つのQOLサマリースコアは国民標準値と比較し高く、両群間で有意差を認めなかった。術後の身体的QOLサマリースコア(PCS)において、術後2か月(53.3 vs 50.1, P=0.03)、術後1年(55.3 vs 52.5, P=0.03)、術後4年(53.8 vs 51.8, P=0.01)、術後5年(53.9 vs 49.5, P=0.03)でMD群はSD群と比較し有意に低下していた。術後の精神的QOLサマリースコア(MCS)、社会的QOLサマリースコア(RCS)においては国民標準値と比較し高く、両群間で有意差を認めなかった。【結語】マージナル生体腎移植ドナーの術前QOLは国民標準値と比べ良好であるが、術後PCSにおいてSD群、さらには一般人口と比較し長期的に低下する可能性があり、今後更なる調査が必要である。

DOI： 10.11386/jst.57.supplement_s286_2

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Language：Japanese   Publisher：一般社団法人 日本移植学会  

【目的】腎移植後患者において、尿細胞診で6ヶ月以上のDecoy細胞陽性所見の持続はBKウイルス腎症 (BKVN)発症予測に有効である事を以前報告した。今回、尿沈渣におけるウィルス感染細胞で代替できるか、比較検討した。【方法】2012年05月から2021年09月までに当院で腎移植を行った141例で後方視的に検討した。尿細胞診は、腎移植後6ヶ月間は1ヶ月毎、その後の6ヶ月は1から2ヶ月毎、以降は1から3ヶ月毎に行なっており、同日の尿沈渣でのウィルス感染細胞の有無を解析に含めた。尿細胞診でのDecoy細胞、尿沈渣でのウィルス感染細胞それぞれの陽性持続期間を算出し、最大陽性持続期間が6ヶ月以上か否かで患者を2群に分け、Fisherの正確検定やROC曲線による解析で、BKVN発症率や予測精度を比較検討した。【結果】尿検体数は計3,530検体。尿細胞診で、Decoy細胞陽性が6ヶ月以上持続した（Decoy≧6M）群は55例、6ヶ月未満の（Decoy＜6M）群は86例であった。尿沈渣では、ウィルス感染細胞が6ヶ月以上持続した（Sediment≧6M） 群は6例、6ヶ月未満の（Sediment <6M）群は135例であった。AUCを用いた比較では、尿細胞診（Decoy≧6M）の方が尿沈渣（Sediment≧6M）よりも予測精度が有意に高かった（Decoy≧6M：AUC=0.826, Sediment≧6M：AUC=0.655, p=0.047）。それぞれの2群間の比較では、尿細胞診では尿沈渣に比べBKVNの発症率は高かった（尿細胞診：9 vs 0, p＜0.001、尿沈渣：3 vs 6, p=0.003）。尿細胞診によるBKVN発症予測の感度、特異度、陽性的中率、陰性的中率はそれぞれ100%, 66%, 17%, 100%であり、尿沈渣はそれぞれ33%, 98%, 50%, 95.6%であった。【結語】6ヶ月以上のDecoy細胞陽性持続の所見はBKVN発症予測に有用であり、尿沈渣では代替できない。

DOI： 10.11386/jst.57.supplement_s363_2

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Language：Japanese   Publisher：[吹田] : [腎移植・血管外科研究会]  

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Other Link： https://ndlsearch.ndl.go.jp/books/R000000004-I032529025

Language：Japanese   Publisher：一般社団法人 日本移植学会  

【緒言】ABO血液型不適合腎移植では脱感作療法が不十分な場合や、移植後導入期の感染症がaccommodationの誘導・成立を妨げる大きな因子といわれている。

【対象と方法】2009年から2021年3月までに当科で施行された生体腎移植122例のうち、ABO血液型不適合移植46例について、細菌感染症が急性抗体関連型拒絶反応AMRの発生に与える影響を後方視的に検討した。発熱を伴いGram陰性菌を分離し、治療を要した場合を細菌感染症と定義し、脱感作療法は全例でリツキシマブ200mg、DFPP2回、PEX1回が実施された。

【結果】細菌感染症は10例（甲群）で、拒絶反応は1例もなかった。術直前抗A抗B抗体価IgG、IgM（中央値）はそれぞれ、1倍（1倍以下-64倍）、2倍（1倍以下-8倍）、感染後は、1倍（1倍以下-32倍）、2倍（1倍-2倍）であった。

残りの36例（乙群）のうち、2例は術後1週間でAMR、2例は2ヶ月以降にACRを発症していた。甲・乙群で脱感作療法前の抗体価IgMが64倍vs16倍（p=0.049）と有意差を認めたが、その他の背景や、脱感作療法以降の抗体価、術後腎機能に有意差は認めなかった。

【考察】移植後に発熱を伴う細菌感染を疑った場合は即座に培養、empiricな抗菌薬投与を行うことで、移植後1～2週間のcritical periodにGram陰性菌への暴露により発症するとされるⅡ型のAMRを抑制している可能性が示唆される。

【結語】ABO血液型不適合生体腎移植後の細菌感染症への迅速な対応によりAMRは認めなかった。

DOI： 10.11386/jst.56.supplement_s112

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Language：Japanese   Publisher：一般社団法人 日本移植学会  

【緒言】本研究の目的は、マージナルドナー(MD)から生体腎移植を受けたレシピエントの転帰を評価することであった。【方法】日本のガイドラインに基づき、(a)年齢≥70歳、(b)血圧≤130/80mmHg、(c)25<BMI≤32、(d)70≤24時間CCr<80、(e)6.2<HbA1c≤6.5あるいは経口糖尿病薬内服下でHbA1c≤6.5をMDと定義した。標準ドナー(SD)から腎提供を受けたレシピエントは61名(54％)、MDからは53名(46％)で、MDのうち糖尿病を有する者(MD+DM)は12名(11%)であった。60カ月間の血清クレアチニン、推定糸球体濾過率(eGFR)、腎移植後のeGFR残存率、尿蛋白/アルブミン・クレアチニン比などの腎機能、およびグラフト生着率を比較した。【結果】SDとMDではすべての腎機能に有意な差はなかった。移植後5年時点のGraft survivalは95 vs 84 %(p=0.09)、Death censored graft survivalは 98 vs 88 %(p=0.18)であった。SDとMD+DMを比較したところ、MD+DMでeGFRが最初の6ヶ月間はわずかに低値だが、12ヶ月以降はその差はなくなった。移植後5年時点のGraft survivalは95vs 100 %(p=0.61)、Death censored graft survivalが98 vs 100 %(p=0.66)であった。【結論】MDおよびMD+DMからの腎提供を受けたレシピエントの移植後成績は、SDからのそれと比較して差はなかった。MDを慎重に選択することにより、たとえDMを有する場合でもドナープールを拡大し得ることが示唆された。

DOI： 10.11386/jst.56.supplement_s474

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Language：Japanese   Publisher：日本泌尿器内視鏡・ロボティクス学会  

上部尿路結石による閉塞性腎盂腎炎に対して尿路ドレナージを含む治療後に施行された経尿道的尿路結石砕石術 (TUL) 68症例の検討を後向きに行った. 術前の尿培養ではE. coliが最も多く検出され, 周術期抗菌剤投与日数中央値は3日であった. 65例でstone freeが得られ, 周術期合併症を6例に認めたが全例で保存的に改善した. ADL重度障害例では, ESBL産生菌検出率が高い傾向で, 入院日数, TUL施行から退院までの日数, 周術期抗菌剤投与日数, 合併症率が有意に長期間かつ高率であった. 閉塞性腎盂腎炎を生じた上部尿路結石症例では, 感染コントロール後に尿培養結果に沿った周術期抗菌剤投与を行うことで安全にTULを行うことが可能ではあるが, ADL障害例は薬剤耐性菌保菌率が高く, 周術期に注意が必要と考えられた.

DOI： 10.11302/jsejje.34.268

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Language：Japanese   Publisher：福岡 : 西日本泌尿器科学会  

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CiNii Books

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Other Link： https://ndlsearch.ndl.go.jp/books/R000000004-I028724747