DCD donor hemodynamics as predictor of outcome after kidney transplantation.

Insufficient hemodynamics during agonal phase-ie, the period between withdrawal of life-sustaining treatment and circulatory arrest-in Maastricht category III circulatory-death donors (DCD) potentially exacerbate ischemia/reperfusion injury. We included 409 Dutch adult recipients of DCD donor kidneys transplanted between 2006 and 2014. Peripheral oxygen saturation (SpO2-with pulse oximetry at the fingertip) and systolic blood pressure (SBP-with arterial catheter) were measured during agonal phase, and were dichotomized into minutes of SpO2 > 60% or SpO2 < 60%, and minutes of SBP > 80 mmHg or SBP < 80 mmHg. Outcome measures were and primary non-function (PNF), delayed graft function (DGF), and three-year graft survival. Primary non-function (PNF) rate was 6.6%, delayed graft function (DGF) rate was 67%, and graft survival at three years was 76%. Longer periods of agonal phase (median 16 min [IQR 11-23]) contributed significantly to an increased risk of DGF (P = .012), but not to PNF (P = .071) and graft failure (P = .528). Multiple logistic regression analysis showed that an increase from 7 to 20 minutes in period of SBP < 80 mmHg was associated with 2.19 times the odds (95% CI 1.08-4.46, P = .030) for DGF. In conclusion, duration of agonal phase is associated with early transplant outcome. SBP < 80 mmHg during agonal phase shows a better discrimination for transplant outcome than SpO2 < 60% does.

Early Conversion to Prednisolone/Everolimus as an Alternative Weaning Regimen Associates With Beneficial Renal Transplant Histology and Function: The Randomized-Controlled MECANO Trial.

In renal transplantation, use of calcineurin inhibitors (CNIs) is associated with nephrotoxicity and immunosuppression with malignancies and infections. This trial aimed to minimize CNI exposure and total immunosuppression while maintaining efficacy. We performed a randomized controlled, open-label multicenter trial with early cyclosporine A (CsA) elimination. Patients started with basiliximab, prednisolone (P), mycophenolate sodium (MPS), and CsA. At 6 months, immunosuppression was tapered to P/CsA, P/MPS, or P/everolimus (EVL). Primary outcomes were renal fibrosis and inflammation. Secondary outcomes were estimated glomerular filtration rate (eGFR) and incidence of rejection at 24 months. The P/MPS arm was prematurely halted. The trial continued with P/CsA (N = 89) and P/EVL (N = 96). Interstitial fibrosis and inflammation were significantly decreased and the eGFR was significantly higher in the P/EVL arm. Cumulative rejection rates were 13% (P/EVL) and 19% (P/CsA), (p = 0.08). A post hoc analysis of HLA and donor-specific antibodies at 1 year after transplantation revealed no differences. An individualized immunosuppressive strategy of early CNI elimination to dual therapy with everolimus was associated with decreased allograft fibrosis, preserved allograft function, and good efficacy, but also with more serious adverse events and discontinuation. This can be a valuable alternative regimen in patients suffering from CNI toxicity.

Incidence, risk factors, and the impact of allograft pyelonephritis on renal allograft function.

BACKGROUND: The impact of allograft pyelonephritis (AGPN) on renal allograft function is controversial. In this study, we evaluated the incidence, risk factors, and the impact of AGPN on renal allograft function. METHODS: Retrospective cohort study in adult renal allograft recipients with 1-year follow-up after transplantation (Tx). Renal allograft function was evaluated by estimated glomerular filtration rate (eGFR) (by Modification of Diet in Renal Disease formula) and 24-h urine protein excretion. RESULTS: A total of 431 renal allograft recipients were analyzed; 57 (13.2%) developed AGPN within 1 year after Tx. Median time between Tx and AGPN was 50 days. Risk factors for AGPN were the presence of a urological catheter (odds ratio [OR] = 18.93, 95% confidence interval [CI] = 8.00-44.81, P < 0.001) and preceding asymptomatic bacteriuria (ASB) (OR = 2.16, 95% CI = 1.20-3.90, P = 0.009). In 72.7%, the causative microorganism of ASB was identical to that of the succeeding AGPN episode. Multivariable linear regression analysis showed that experiencing AGPN did not decrease the eGFR (P = 0.61) nor did increased proteinuria (P = 0.29) 1 year after Tx. For the eGFR, an interaction was found between AGPN/bacteriuria (BU) and acute rejection (AR): the group experiencing BU preceding AR had significantly (P < 0.001) lower eGFR compared with the group that experienced only AR (21 mL/min/1.73 m2 vs. 48 mL/min/1.73 m2 ), as a result of increased prevalence of combined rejections within the BU group. CONCLUSION: Indwelling urological catheters and preceding ASB are associated with developing AGPN. An incident of AGPN itself does not impair renal allograft function 1 year after Tx. However, a relevant interaction occurs between BU and AR, in which the sequence of occurrence of these 2 events synergistically impairs the eGFR.

Duplicated ureters and renal transplantation: a case-control study and review of the literature.

INTRODUCTION: Complications of the transplant ureter are the most important cause of surgical morbidity after renal transplantation. The presence of ureteral duplication in the renal graft might result in an increased complication rate. We analyzed our data of double-ureter renal transplantations using a case-control study design. Additionally, we performed a review of the literature. METHODS: From January 1995 to April 2012, 12 patients received a donor kidney with a double ureter (0.8%). We created a control group of 24 patients matched in age, sex, donor type, and ureteral stenting. Patient charts and surgical reports were reviewed retrospectively. RESULTS: In 7 patients both ureters were separately anastomosed to the bladder. In 4 patients a common ostium was created. In 1 patient 1 of the 2 ureters was ligated. No postoperative urologic complications occured. In the single-ureter group, the urologic complication rate was 17% (P = .71). Mean creatinine levels after transplantation were comparable between both groups. DISCUSSION: A double-ureter donor kidney is not associated with an increased complication rate after renal transplantation and yields equal outcomes as compared to single-ureter donor kidneys. We conclude that transplantation of a kidney with a duplicated ureter is safe.

Chylous ascites after laparoscopic hand-assisted donor nephrectomy: Is it specific for the left-side?

We describe a case-report of a chylous ascites after laparoscopic donor nephrectomy, summarize the current literature, and hypothesize on the etiology of this complication.

First clinical experience with polysol solution: pilot study in living kidney transplantation.

In this study, we assessed the safety of the new organ preservation solution polysol solution in the clinical setting of living kidney transplantation. We conducted a prospective pilot study in nine adult donor-recipient couples using polysol solution for washout and cold storage of kidney grafts. Adverse reactions possibly related to the use of polysol solution as well as renal function at 1, 6, and 12 months after transplantation were monitored. All living kidney transplantation performed in adults in our center within 2002 to 2008 using the University of Winconsin solution served as controls (n = 190). The use of polysol solution was associated with a higher acute rejection rate compared to University of Wisconsin solution at all time points. Also, antibody-mediated rejection occurred more frequently in the polysol group. Renal function at all time points was also comparable between the groups. This pilot study in living kidney transplantation is the first clinical study on the use of polysol solution. Although the study was not powered on the endpoint rejection, we observed a high number of acute rejection and antibody-mediated rejection episodes in recipients of polysol solution preserved grafts as compared to University of Wisconsin solution controls. As a consequence the study was terminated prematurely.

Abdominal wall phlebitis due to Prevotella bivia following renal transplantation in a patient with an occluded inferior vena cava.

Pre-existing occlusion of the inferior vena cava may complicate renal transplantation. Suppurative abdominal wall phlebitis following renal transplantation was diagnosed in a patient with pre-existing thrombosis of the inferior vena cava of unknown cause. The phlebitis developed in the subcutaneous collateral veins of the abdominal wall contra-laterally to the renal transplant. Cultures from abdominal wall micro-abscesses yielded Prevotella bivia as the causative agent. This complication has not been described before in the context of renal transplantation. The pathogenesis and management of this serious complication are discussed in this paper.

Posterior circumflex humeral artery injury with distal embolisation in professional volleyball players: a discussion of three cases.

Presented are three cases of volleyball players with ischaemia of the hand due to arterial emboli originating from an injured posterior circumflex humeral artery (PCHA). An operative treatment with ligation of the PCHA was performed in all patients because of the proximity of the occlusion to the axillary artery. After a rehabilitation programme, all patients could return to their previous level of competition. During overhead motion, the PCHA is prone to injury in its position overlying the humeral head and its course through the quadrilateral space. Recognition of the vascular origin of these symptoms in athletes is important to prevent serious ischaemic complications. Signs of ischaemia might be subtle and may be misdiagnosed as musculoskeletal injuries. Therefore, the examining physician must have a high index of suspicion and awareness about these injuries is important.

Ureteral reconstruction after renal transplantation: clinical outcome and risk factors.

INTRODUCTION: The incidence of urological complications after renal transplantation ranges from 2.5 to 30%. Often surgical revision is necessary. The risk factors for surgical revision and which surgical techniques to apply are not elucidated. This study investigates the outcome and risk factors for surgical revision of the ureterocystostomy. MATERIALS AND METHODS: Between January 1995 and March 2009, 1,157 consecutive kidney transplantations were performed. All patient charts and surgical reports were reviewed. RESULTS: Urological complications occurred in 142 (12.3%) patients. In 60 patients (5.2%) surgical revision was necessary. Of these 60 patients, 43 (71.7%) received neoureterocystostomy, 10 (16.7%) ureteropyelostomy reconstruction and 7 (11.7%) other techniques. Independent risk factors for surgical revision were donor ureteral reconstruction (odds ratio (OR) 48.66, 95% confidence interval (CI) 5.01-472.97), recipient age <18 years (OR 4.85, 95% CI 1.50-15.72) and delayed graft function (OR 2.70, 95% CI 1.36-5.36). Ureteral stenting was a protective factor for surgical revision (OR 0.30, 95% CI 0.12-0.81). The urological complication rates after neoureterocystostomy, ureteropyelostomy reconstruction and other techniques were 16, 0 and 0%, respectively. The overall surgical success rate was 92%. CONCLUSIONS: Ureteral stenting, recipient age, delayed graft function and perioperative ureteral reconstruction are significant factors associated with surgical revision of the ureterocystostomy. Surgical revision of the ureterocystostomy is a successful therapy with a low recurrence rate.

Comparison of preserved vascular allografts using glycerol and University of Wisconsin solution in a goat carotid artery transplantation model.

BACKGROUND: Prosthetic grafts have poor patency rates in peripheral arterial reconstructions. Glycerol (GL)-preserved grafts are an alternative. The aim of this study was to examine patency, graft morphology and function of GL-preserved allografts in a goat carotid artery animal model. METHODS: The first group (n = 7) underwent bilateral replacement of the carotid artery by a carotid allograft that was preserved in GL for 1 week. In the second group (n = 5), a carotid artery allograft that was preserved in University of Wisconsin solution (UW) for 48 h was used. In the third group (n = 5), the jugular vein (autologous vein, AU) was used. The follow-up was 3 months. RESULTS: One UW graft and 1 GL graft occluded in the first 24 h postoperatively. Three-month primary patency rates for GL, UW and AU grafts were 93, 100 and 80%, respectively (p = 0.39). Graft diameter was increased in UW allografts (p < 0.005), whereas GL allografts remained unchanged. After explantation, GL allografts demonstrated contraction and relaxation capacity and lower intimal thickness (p < 0.001). CONCLUSION: GL preservation has proven to be a feasible method for arterial allograft transplantation in a large animal model with decreased intimal hyperplasia and renewed functional capability.

Risk factors for delayed graft function after hand-assisted laparoscopic donor nephrectomy.

BACKGROUND: Delayed graft function (DGF) has a negative effect on the results of living-donor kidney transplantation. OBJECTIVE: To investigate potential risk factors for DGF. METHODS: This prospective study included 200 consecutive living donors and their recipients between January 2002 and July 2007. Delayed graft function was defined as need for dialysis within the first postoperative week. RESULTS: Delayed graft function was diagnosed in 12 patients (6%). Intraoperative complications occurred in 10 donors (5%), and postoperative complications in 24 donors (13.5%). One-year kidney graft survival with vs without DGF was 52% and 98%, respectively (P < .002). In donors, 2 univariate risk factors for DGF identified were lower counts per second at peak activity during scintigraphy, and multiple renal veins. In recipients, only 2 or more kidney transplantations and occurrence of an acute rejection episode were important factors. At multivariate analysis, increased risk of DGF was associated with the presence of multiple renal veins (odds ratio, 151.57; 95% confidence interval, 2.53-9093.86) and an acute rejection episode (odds ratio, 78.87; 95% confidence interval, 3.17-1959.62). CONCLUSION: Hand-assisted laparoscopic donor nephrectomy is a safe procedure. The presence of multiple renal veins and occurrence of an acute rejection episode are independent risk factors for DGF.

Laparoscopic donor nephrectomy.

Living donor nephrectomy has been developed and promoted as a method to address the shortfall in kidneys available for transplantation. The classical method to procure a kidney from a living donor is the open donor nephrectomy performed through a flank lumbotomy incision. However, this classical method has negative short- and long-term side effects for the donor. These disincentives are a drawback for possible donors to donate a kidney. Therefore, transplant surgeons were stimulated to develop new and less invasive techniques. In this review several new open and laparoscopic techniques are described. Compared with open donor nephrectomy, laparoscopic donor nephrectomy has shown superior results in terms of postoperative pain, cosmetics, convalescence, and return to normal daily activities. No significant differences exist between the two approaches in terms of complication rates, cost-effectiveness and graft function. Nowadays, laparoscopic donor nephrectomy has become the preferred method for procuring kidney grafts of living donors in many centres.

Outcome of total parathyroidectomy and autotransplantation as treatment of secondary and tertiary hyperparathyroidism in children and adults.

BACKGROUND: Treatment safety and effectiveness of total parathyroidectomy and autotransplantation for secondary and tertiary hyperparathyroidism have been extensively proven in adults; the evidence for children, however, is scarce. Children and adolescents cannot simply be seen as young adults in the case of chronic kidney disease and hyperparathyroidism. The aim of this retrospective study was therefore, to evaluate whether parathyroidectomy with forearm autograft is as effective and safe in children and adolescents as in adults. METHODS: A group of 64 adults and 8 children and adolescents treated for secondary or tertiary hyperparathyroidism were retrieved from our database. The outcomes were compared on patient demographics, operation results, and blood parameters consisting of parathyroid hormone (PTH) and calcium levels. Our results were compared with all currently available articles on parathyroidectomy in children with secondary or tertiary hyperparathyroidism (n = 11). RESULTS: For adults, preoperative mean serum calcium was 2.67 +/- 0.29 mmol/l and mean parathyroid hormone (PTH) level was 120 +/- 86 pmol/l. For children, preoperative mean serum calcium was 2.62 +/- 0.20 mmol/l and mean parathyroid hormone (PTH) level was 80 +/- 38 pmol/l. Postoperative calcium and parathyroid hormone levels for adults dropped to 2.39 +/- 0.23 mmol/l and 30 +/- 53 pmol/l, respectively. Postoperative calcium and parathyroid hormone levels for children dropped to 2.41 +/- 0.16 mmol/l and 26 +/- 33 pmol/l, respectively. The effectiveness of parathyroidectomy with autotransplantation was 75% in children and 72% in adults. Thus, effectiveness did not differ significantly between children and adults. CONCLUSIONS: Combining the results of our own study with a literature review on pediatric parathyroidectomy, we conclude that parathyroidectomy and forearm autograft is as effective a treatment for secondary and tertiary hyperparathyroidism in children and adolescents as it is in adults.

Pulsatile perfusion preservation of warm ischaemia-damaged experimental kidney grafts.

BACKGROUND: Cold storage using histidine-tryptophan-ketoglutarate (HTK) solution is used widely in clinical practice for the preservation of warm ischaemia-damaged kidney grafts. This study assessed the efficacy of pulsatile machine perfusion in combination with Polysol for the preservation of warm ischaemia-damaged kidney grafts. METHODS: After induction of warm ischaemia by clamping of the left renal pedicle for 30 min, pigs were subjected to left nephrectomy. Thereafter, grafts were preserved for 20 h by cold storage with HTK (CS-HTK) or Polysol (CS-PS), or machine preservation with Polysol (MP-PS). Subsequently, contralateral kidneys were removed and preserved kidneys were transplanted. Control pigs underwent unilateral nephrectomy. Renal function was assessed daily for 1 week. Kidney biopsies were analysed for morphology and proliferative response. RESULTS: Renal function of warm ischaemia-damaged grafts preserved using MP-PS was comparable to that of non-ischaemic controls. MP-PS and CS-PS groups showed improved renal function compared with the CS-HTK group, with more favourable results for MP-PS than for CS-PS. The proliferative response of tubular cells in the CS-HTK group was higher than in all other groups. CONCLUSION: This study demonstrated that the function of warm ischaemia-damaged kidney grafts after pulsatile perfusion preservation was comparable to that of non-ischaemic controls.

Improved renal function of warm ischemically damaged kidneys using Polysol.

OBJECTIVE: We sought to assess the efficacy of POLYSOL, a low-viscosity, colloid-based organ preservation solution, for the preservation of warm ischemically damaged kidney grafts compared with histidine-tryptophane-ketoglutarate (HTK) solution. METHODS: Pigs (25-30 kg) underwent a left nephrectomy after clamping the renal vessels for 30 minutes. Kidney grafts washed out with Polysol (n = 6) or HTK (n = 6) were cold stored (CS) for 20 hours at 4 degrees C. After the preservation period, the contralateral kidney was removed and the preserved kidney implanted heterotopically. Renal function was assessed daily for 7 days. Thereafter, animals were killed and the kidney grafts removed for histologic analysis. RESULTS: All animals survived for 7 days. All Polysol CS-preserved grafts showed immediate function, as demonstrated by urine production within 24 hours after reperfusion as compared with 3/6 grafts in the HTK CS group. Overall, the Polysol CS group showed improved renal function compared with HTK CS. Also, peak serum creatinine and blood urea values were lower in the Polysol CS group compared with HTK-preserved grafts. Histologic evaluation of warm ischemically damaged grafts showed less glomerular shrinking, less tubular damage, less edema, less inflammatory infiltration, and less necrosis in Polysol compared with HTK-preserved grafts. CONCLUSION: Application of Polysol solution for washout and CS preservation of warm ischemically damaged kidney grafts resulted in improved renal function and structural integrity when compared with HTK.

Glycerol-preserved arterial allografts evaluated in the infrarenal rat aorta.

BACKGROUND: Vascular transplantation has become an alternative for prosthetic grafts. Suitable storage methods for vascular allografts are therefore necessary. For small caliber arterial allografts, cryopreservation and cold storage showed discouraging results. Since glycerol preservation proved effective for the storage of skin allografts, this preservation method was investigated for vascular allografts using a rat aortic transplantation model. METHODS: Glycerol-preserved allografts (GA) were transplanted to the infrarenal aorta (n = 18) in Wistar rats. A control group (n = 18) underwent immediate autotransplantation (AU) of an equal length of aorta. RESULTS: Cumulative graft patency at 90 days' follow-up was 93% for AU and 78% for GA (ns). No aneurysm formation was detected in both groups. Intraluminal endothelial cell coverage, integrity of the media and smooth muscle cell repopulation were comparable in both groups. Intimal thickness was less in GA than in AU and inflammatory reaction in the adventitia was diminished in GA. CONCLUSION: GA were successfully grafted with acceptable patency rates compared to autografts, while intima hyperplasia and adventitial inflammatory reaction were less.

Multiple bacteria contribute to intraplaque T-cell activation in atherosclerosis.

BACKGROUND: Infection with microorganisms is considered a pathogenic factor in atherogenesis. Several studies have shown the presence of a broad spectrum of bacterial species in atherosclerotic plaques, which could trigger local inflammation. Because T cells contribute to atherosclerotic plaque inflammation, we studied the responsiveness of human plaque derived T-cell cultures to bacteria of different species. MATERIALS AND METHODS: Primary polyclonal T-cell cultures were generated from both carotid endarterectomy tissue and peripheral blood of nine patients, and the peripheral blood of eight matched controls. The in vitro proliferative responses of the T-cell cultures against H. pylori, N. meningitidis, N. lactamica, S. aureus, S. pneumoniae, S. epidermidis and E. coli were analysed. T-cell proliferation was measured by (3)H-thymidine incorporation and expressed as a stimulation index. Selective outgrowth of intraplaque microbial specific T cells was studied by calculating the ratio of plaque T-cell SI and peripheral blood T-cell SI in each patient. RESULTS: All patients showed T-cell responsiveness to multiple bacteria in their plaque tissue. Stimulation indices were in the range of 0.3-30, and this degree of reactivity with the different species was heterogeneous among patients. Selective outgrowth (plaque/peripheral blood ratio) of T cells against multiple bacteria was observed in six out of nine patients. CONCLUSIONS: T cells in atherosclerotic plaques have the capacity to selectively respond to antigens of a wide variety of microbial antigens. This supports the view that such mechanisms could contribute to the atherosclerotic inflammatory response.

Catastrophic antiphospholipid syndrome mimicking a malignant pancreatic tumour--a case report.

The catastrophic antiphospholipid syndrome is characterised by rapid onset thromboses, often resistant to conventional anticoagulant treatment, and resulting in life threatening multiple organ dysfunction. The diagnosis of catastrophic antiphospholipid syndrome may be difficult, predominantly due to its frequently atypical presentation. We report a case of a 35-year-old female who presented with a pancreatic tumour and extensive thromboses. Following a storm of ischemic events due to thrombotic occlusions in spite of therapeutic heparin dose, the suspicion of catastrophic antiphospholipid syndrome emerged. The patient was successfully treated with anticoagulants, immunoglobulins, plasmapheresis and rituximab. The present report shows that the use of the diluted Russell's viper venom time can be helpful in providing additional information on the lupus anticoagulants antibody status, allowing careful monitoring of lupus anticoagulants conversion and hence response to therapy.

[The first 100 hand-assisted laparoscopic donor nephrectomies at the Academic Medical Center in Amsterdam]. / De eerste 100 met de hand begeleide laparoscopische donornefrectomieën in het Academisch Medisch Centrum te Amsterdam.

OBJECTIVE: To evaluate the results of the first 100 hand-assisted donor nephrectomies in our hospital. DESIGN: Prospective, descriptive. METHOD: In the period January 2000-July 2004, 100 consecutive donors underwent laparoscopic nephrectomy as part of a living-related kidney transplantation at the Academic Medical Center in Amsterdam, the Netherlands. The operation was performed laparoscopically using a hand port (hand-assisted nephrectomy). The incision made for the hand port was also used for the removal of the kidney. RESULTS: Mean operating time was 168 min (range: 88-285). Median warm ischaemia time was 3 min (1.0-4.5) and median blood loss was 50 ml (20-1500). None of the operations required conversion to an open procedure and there were no deaths among donors or recipients. Postoperatively, 12 complications occurred in 10 donors. Median hospital stay for the donors was 5 days. In 3 recipients, the transplanted kidney had to be removed within 14 days. 1n 3 other recipients, surgical re-intervention was necessary due to urological complications. One-year graft survival was 94%. CONCLUSION: Hand-assisted laparoscopic donor nephrectomy was a safe and minimally invasive procedure for renal transplantation in this patient series.

Meta-analysis of the clinical effectiveness of venous arterialization for salvage of critically ischaemic limbs.

OBJECTIVE: The aim of this study is to assess the clinical effectiveness of venous arterialization in patients with critical limb ischaemia not reconstructable by conventional bypass. DESIGN: Meta-analysis of observational studies. MATERIALS: Eligible studies concerning treatment by venous arterialization for chronic critical leg ischaemia were identified from electronic database, cross-reference search and pertinent articles. There was no language restriction. METHODS: All relevant studies were systematically reviewed and data extracted by two independent reviewers. Study endpoints were foot preservation, secondary graft patency, postoperative clinical improvement and complications. RESULTS: A total of 56 studies were selected for comprehensive review. No RCTs were identified. Seven patient series, comprising 228 patients, matched the selection criteria. Overall 1-year foot preservation was 71% (95% CI: 64-77%) and 1-year secondary patency was 46% (95% CI: 39-53%). The large majority of patients in whom major amputation was avoided experienced successful wound healing, disappearance of rest pain and absence of serious complications. CONCLUSION: On the basis of limited evidence, venous arterialization may be considered as a viable alternative before major amputation is undertaken in patients with 'inoperable' chronic critical leg ischaemia.