Living Donor Kidney Transplantation for a Recipient after 41 Years of Hemodialysis

Round 1

Reviewer 1 Report

Tanaka and colleagues reported a successful case of living-related kidney transplantation with over 41 years hemodialysis. Although atrophic bladder along with vesicoureteral reflux is the common and difficult problem to manage, this case demonstrated no complication following transplantation.

However, some comments should be addressed.

1. The authors should provide some information about the barrier(s) to perform kidney transplantation during 41-year dialysis.
2. Patient characteristics of body weight, height, and body mass index (BMI) are necessary in this case and should be addressed since the BMI may be associated to surgical outcome.
3. Figure 2, the data of 24-h urine volume during admission should be added for better information. And, wording “PSL” and “MMF” should be spelled out in the figure information.
4. Is it true that the recipient was prescribed tacrolimus (TAC) and tested for TAC level on day-5 before engraftment? It yes, please do explain the season. Likewise, perhaps the TAC level of 5 ng/mL seems to be too low level for the early phase of postoperative kidney transplantation. Please confirm the detail in the Figure 2.
5. What was the allograft function determined by Cr and creatinine clearance at 12 and 24 months? (Good allograft function is frequently defined as Cr <1.5 mg/dL at 12-month post transplantation). Sometimes, chronic vesicoureteral reflux may present with proteinuria even no evidence of reflux demonstrated by ultrasonography. Thus, the authors should 
   clarify as well.
6. There is no doubt that this patient was at risk of urinary leakage. Accordingly, was there any incidence of urinary leakage at anastomosis site? How frequent of postoperative allograft ultrasonography was performed because DJ-stent and Foley catheter were seems removed quite early and, normally, 24-hour urine output in the first few weeks is usually over 3-4 L. This information should be addressed in the clinical course and follow-up.
7. Regarding to the case, what is the important key messages or hintsto a successful outcome? What should do/ shouldn’t do in the management of recipients with atrophic bladder from long-term hemodialysis? Could the authors do conclusion or suggestion for the readers in the next case?

Author Response

Please see the attachment.

Author Response File: Author Response.pdf

Reviewer 2 Report

1. Well written and measurements of improvement and increase in bladder capacity are the strong point
2. Novelty is lacking
3. As a reader I would like to know if the addition of the anti-reflux procedure in the OR in this case helped prevent UTIs in the recipient
4. A short additional review of the literature of this procedure in preventing UTI and reflux in patients with small bladders would bolster this manuscript

Author Response

Please see the attachment.

Author Response File: Author Response.pdf