title: [Challenges in renal transplantation].
abstract: OBJECTIVE
  To describe kidney transplantation surgical techniques and to propose strategies in high-risk recipients.
  
  
  METHODS
  Relevant publications were identified through Medline (http://www.ncbi.nlm.nih.gov/) and Embase (http://www.embase.com/) database using the following keywords, alone or in association, "renal transplantation; peripheral arterial disease; obesity; third and fourth transplantation; robotic-assisted kidney transplant; anticoagulant therapy; dual kidney transplant". Articles were selected according to methods, language of publication and relevance. The reference lists were used to identify additional historical studies of interest. Both prospective and retrospective series, in French and English, as well as review articles and case-reports were selected. A total of 1949 articles were analyzed for arterial disease and anticoagulant therapy, 1083 for obesity, 663 for dual kidney transplants, 458 for third and subsequent procedures and 84 for robotic-assisted kidney transplantation. After careful selection, 304 publications were eligible for our review.
  
  
  RESULTS
  Surgical assessment of future recipients is a pivotal step to anticipate technical difficulties, to interrupt clopidogrel or direct oral anticoagulants and to propose a revascularization procedure when necessary. Lack of data regarding obese recipients does not allow us to conclude about best surgical care or optimal timing but suggest that an early global management of obesity in chronic kidney disease patients is mandatory to improve access to a successful transplantation. In neurologic bladder and congenital anomalies, urodynamics and bladder function must be assessed prior to the onset of oliguria to intend an early treatment. Urinary diversion may be performed prior to or after transplantation with similar survival outcome and comparable rates of infections. Because of a rigorous selection of donors, the French dual kidney transplant program provides satisfactory outcomes, but fails in convincing surgical teams nationwide. Third and subsequent transplant procedures remain a surgical and immunological challenge, with an increased morbidity and a moderate decline in transplant survival only when donors are extended criteria' with extensive duration of waiting time between procedures. Robotic-assisted kidney transplantation is a recent technique requiring methodical evaluation.
  
  
  CONCLUSIONS
  Kidney transplantation in challenging recipients implies a global understanding of patients' prognosis and benefits versus dialysis, in the context of the attribution of a valuable resource awaited by other patients on waiting list.
authors.affiliation: Service d'urologie et transplantation rénale, CHU de Montpellier, 34000 Montpellier, France; Université de Montpellier, 34040 Montpellier, France. Electronic address: rodolphe.thuret@gmail.com.
authors.forename: R
authors.initials: R
authors.lastname: Thuret
authors.affiliation: Service d'urologie et transplantation rénale, CHRU de Besançon, 25000 Besançon, France; Université de Franche-Comté, 25000 Besançon, France; Inserm UMR 1098, 25000 Besançon, France.
authors.forename: F
authors.initials: F
authors.lastname: Kleinclauss
authors.affiliation: Service d'urologie et de transplantation rénale, CHU Grenoble Alpes, 38700 Grenoble, France.
authors.forename: N
authors.initials: N
authors.lastname: Terrier
authors.affiliation: Service d'urologie et transplantation rénale, CHU de Nantes, 44000 Nantes, France; Université de Nantes, 44000 Nantes, France.
authors.forename: G
authors.initials: G
authors.lastname: Karam
authors.affiliation: Service d'urologie, hôpital européen Georges-Pompidou, AP-HP, 75015 Paris, France; Université Paris Descartes, 75006 Paris, France.
authors.forename: M O
authors.initials: MO
authors.lastname: Timsit
mesh_terms: D000465:Algorithms; D000714:Anastomosis, Surgical; D000925:Anticoagulants / Q000627:therapeutic use; D002318:Cardiovascular Diseases / Q000150:complications; D006801:Humans; D016030:Kidney Transplantation / Q000379:methods*; D009392:Nephrectomy; D009765:Obesity / Q000150:complications; D011182:Postoperative Care / Q000379:methods; D011183:Postoperative Complications / Q000209:etiology; D011300:Preoperative Care / Q000379:methods; D012307:Risk Factors; D065287:Robotic Surgical Procedures; D016896:Treatment Outcome; D014656:Vascular Surgical Procedures
chemical_list: D000925:Anticoagulants
keywords: Anticoagulant therapy; Bi-transplantation rénale; Chirurgie assistée par robot; Dual kidney transplantation; Iterative transplants; Maladie artérielle; Obesity; Obésité; Peripheral arterial disease; Robotic-assisted surgery; Traitements anticoagulants; Transplantation; Transplantations itératives; Troisièmes transplantations