[Dual kidney transplantation - a single-center experience]. / Duální transplantace ledvin - zkusenosti jednoho centra.

INTRODUCTION: Dual kidney transplantation is one of the options to utilize the so-called marginal grafts, kidneys that would be insufficient for normal single transplantation. This time-consuming surgical procedure is also burdensome for the patient. METHODS: The authors present their experience from the Pilsen Transplant Center. Between 2008 and 2016, 13 dual kidney transplantations were performed. Median donor age was 66 years (34-77) and median recipient age 46 years (40-78). Mean operating time was 4 hours and 40 minutes (3-6 h). Mean surgery ward stay was 5 days (4-6). Bilateral surgical technique was used in all cases. Mean follow-up time was 63 months (18-101). RESULTS: From our group of DKTs (N=13), 4 patients (31%) experienced delayed graft function and we observed no primary graft non-function. Surgical complications occurred in 4 patients (31%). Currently, all 13 patients are living with good graft function, none of them being dependent on dialysis. CONCLUSION: Dual kidney transplantation is currently a viable option. The success and benefits of this surgical procedure are directly related to careful donor and recipient selection.Key words: dual kidney transplantation - marginal donor - chronic renal failure - expanded criteria donor.

[Kidney donors after circulatory death (DCD) - single centre experience]. / Dárci ledvin po nezvratné zástave obehu (DCD) - zkusenosti jednoho centra.

INTRODUCTION: Kidney procurement from donors after circulatory death (DCD) is an important part of worldwide transplantation programmes. The first kidney transplantation from DCD was successfully performed in the Czech Republic in 2002. METHOD: Forty four kidneys from DCD were procured in the Transplant Centre of Pilsen between 2002 and 2015. We used the technique of "in situ" procurement with the double balloon triple lumen catheter and 510 minutes of the no-touch interval. The method of pulsatile hypothermic perfusion was used to test the viability of the kidneys. Twenty eight recipients with mean age 51.1 (2673) years were transplanted. Sixteen (57.1%) kidneys were from the 2nd, 8 (28.6%) from the 3rd and 4 (14.3%) from the 4th category according to the Maastricht criteria. RESULTS: 30-day mortality and morbidity rates were 0 and 10.7% i. e.14.3% respectively (N=4). Primary non-function was presented in 2 (7.1%), and delayed graft function in 5 (17.9%) cases. One, five and ten years of recipient and graft survival rates were 100%, 86.4% and 76.7%; and 92.9%, 69.6% and 61.9%, respectively. The long-term results are fully comparable with kidneys transplanted from donors after brain death. CONCLUSION: DCD are an important source for kidney transplantation. Kidney transplantation from DCD is a logistically, economically and personally demanding method with very good long-term results. KEY WORDS: donors after circulatory death - kidney transplantation - results.

Valganciclovir versus valacyclovir prophylaxis for prevention of cytomegalovirus: an economic perspective.

INTRODUCTION: Valganciclovir (vGCV) and valacyclovir (vACV) are used in cytomegalovirus (CMV) prophylaxis in renal transplant recipients. The aim of this study was to compare the economic impact of both regimens during 1-year follow-up. METHODS: A total of 117 renal transplant recipients at risk for CMV were randomized to 3-month prophylaxis either with vGCV (900 mg/day, n = 60) or vACV (8 g/day, n = 57) and their data used in a pharmacoeconomic analysis. The pharmacoeconomic evaluation involved all direct CMV-related expenses in the first year after transplantation. Sensitivity analysis was employed to examine the effects of various prices of antiviral drugs and diagnostic procedures on overall CMV-related costs. Simulation of the more expensive US healthcare perspective was performed, and a scenario involving costs of acute rejection (AR) was examined. RESULTS: Overall CMV-related costs were significantly lower in the vACV arm; median United States dollars (USD) 3473 (3108-3745) vs. USD 5810 (4409-6757; P < 0.001) per patient, respectively. Our data showed that the critical determinant of the major disparity between the prophylactic regimens was the prophylaxis price. Median cost of prophylaxis in the vACV group was USD 1729 (1527-2173) compared to USD 3968 (2683-4857) in the vGCV group (P < 0.001). In sensitivity analysis of the overall CMV-related costs, the least and the most expensive pharmacotherapy and diagnostic scenarios were used; nevertheless, the vACV arm remained markedly less expensive. Simulation considering the higher physician/nurse and hospitalization fees of the US healthcare system and the scenario including expenditure associated with AR episodes also favored vACV. CONCLUSION: VACV prophylaxis for CMV is associated with a significant 44% lower cost than vGCV at the first year after renal transplantation.

[An overview of the results of renal transplantation in the Czech Republic]. / Piehled výsledku transplantací ledvin v Ceské republice.

Renal (kidney) transplantation is now a routine and the most successful form of renal replacement therapy. There is a long tradition of renal transplantation in the Czech Republic, The first was performed as early as 1961 in Hradec Kralove, and the programme as such was launched in 1966 with the first successful transplantation at the Institute of Experimental Surgery (later Institute for Clinical and Experimental Medicine, Prague). At present, transplantations are being performed at 7 transplantation centres (IKEM Prague, Centre for Cardiovascular and Transplantation Surgery Brno, Faculty Hospitals Hradec Kralove, Plzen, Olomouc and Ostrava and Faculty Hospital Motol for children). From the programme launch until the end of 2010, 8,761 renal transplantations were performed, 364 in 2010 alone. One-year patient and cadaver renal allograft survival, transplanted in the CR between 2000 and 2009, is around 95% and 92%, respectively, and 5-year survival is 87% and 81%, respectively. As of 31st December 2009, a total of 3,771 patients lived with functional renal allograft in the Czech Republic and the proportion of patients with irreversible renal failure treated with transplantation has recently been around 40%.

Ischemia-reperfusion injury in kidney transplantation from non-heart-beating donor--do antioxidants or antiinflammatory drugs play any role?

BACKGROUND: Ischemia reperfusion injury (IRI) is a serious problem of transplanted kidneys from a non-heart-beating donor (NHBD). IRI is probably the main cause of primary disfunction or delayed graft function. The aim of this study was to demonstrate the reduction of IRI by intravenous application of antioxidants or immunosuppressives to the recipient before the kidney transplantation in an experimental model. METHOD: Piglets weighing between 20-25 kg were used (n=45) for the experiment. Intravenous application of multivitamins (GI) and a combination of immunosuppressives (GII) was tested one hour before the kidney transplantation from the NHBD. In control group (GIII) simple NHBD modelling was used. Plasma levels of malondiadehyde (MDA) and reduced glutathione (GSH) were assessed at intervals of 0, 20, 60 and 120 minutes after the kidney transplantation. Concentrations of both MDA and GSH were also assessed in the transplanted kidney before and 120 minutes after transplantation. RESULTS: A permanent increase in MDA plasma concentrations occurred in GIII. In GI and GII, after a transient increase in MDA plasma levels within the first 20 minutes after reperfusion, it decreased permanently (p<0.05, p<0.01). MDA plasma levels were not significantly different between GI and GII groups, but both groups differed from GIII (p<0.001). GSH plasma levels and tissue concentrations of MDA and GSH were not statistically significant in any group in the course of the experiment. CONCLUSION: Intravenous application of multivitamins or immunosuppressives before kidney transplantation could have a significant influence on the immediate function of transplanted kidneys from a NHBD (Tab. 3, Fig. 1, Ref. 13). Full Text (Free, PDF) www.bmj.sk.

[Ischemia-reperfusion injury in kidney transplantation from non-heart beating donor--do antioxidants or antiinflammatory drugs play any role?]. / Ischemicko-reperfuzní poskození ledvin transplantovaných z nebijícího dárce (NHBD)--mají antioxidanty nebo protizánetlivé léky význam v jeho prevenci?

BACKGROUND: Ischemia reperfusion injury (IRI) represents a serious problem of transplanted kidneys from a non-heart-beating donor (NHBD). It is probably the main cause of primary a function or delayed graft function. The aim of the experimental study was to demonstrate on an experimental model the possibilities of reduction of IRI by intravenous application of antioxidants or immunosuppressives to the recipient before the kidney transplantation. METHOD: Piglets weighing between 20-25 kg were used (N = 45) for the experiment. Intravenous application of multivitamins (GI) and a combination of immunosuppressives (GII) was tested one hour before the kidney transplantation from the NHBD. As a control a group (GIII) with simple NHBD modelling was used. At intervals of 0, 20, 60 and 120 minutes after the kidney transplantation, plasma levels of malondiadehyde (MDA) and reduced glutathione (GSH) were assessed. Before and 120 minutes after transplantation tissue concentrations of both factors were assessed in the transplanted kidney. RESULTS: A permanent increase in MDA plasma concentrations occurred in GIII. In GI and GII, after a temporary increase of MDA plasma levels in the first 20 minutes after reperfusion, there was their permanent decrease then. (p < 0.05, resp. p < 0.01). The differences in the MDA plasma levels of GI and GII groups did not reach statistical significance. The both groups differed from GIII (p < 0.001). GSH plasma levels and also tissue concentrations of MDA and GSH were not statistically significant in any group in the course of the experiment. CONCLUSION: Intravenous application of multivitamins or immunosuppressives before kidney transplantation could have a significant influence on the immediate function of transplanted kidneys from a NHBD.

Tumours in end-stage kidney.

OBJECTIVE: Patients with end-stage kidney disease (ESKD) show a greater risk for renal cell carcinoma (RCC), which tends to be multifocal and bilateral. The malignant potential is unclear. The question is whether to remove both kidneys in patients with a tumor on one side only diagnosed by computed tomography (CT). MATERIALS AND METHODS: Kidney tumors were found in 14 patients with ESKD from January 2002 to December 2006. One was unfit for surgery. Thirteen patients underwent nephrectomy and 6 a bilateral procedure of whom only 2 had bilateral tumors on CT, 3 multiple tumors on the contralateral side, and 1 uncontrollable hypertension with tumors as an incidental finding. Tumors were found in all 19 specimens. RESULTS: In 13 kidneys (68.4%), the tumors were multiple; in 6 (31.6%), solitary. The types of tumor were: 13 (68.4%) papillary RCCs (PRCC), 9 (47.4%) clear RCCs (CRCC), a combination of PRCC and CRCC in 4 (21.0%), and myxoid liposarcoma (with solitary PRCC contralaterally). The mean follow-up was short (19 +/- 15 months; maximum, 54 months). Only 1 patient died due to a tumor at 16 months after operation. CONCLUSIONS: There is a high risk for bilateral involvement. Patients who undergo unilateral nephrectomy must be regularly followed and contralateral nephrectomy carefully considered, mainly in transplanted patients on immunosuppression. Further studies are needed to give a definitive answer about the indications for surgery and the indications for contralateral nephrectomy as well. To date, prophylactic contralateral nephrectomy should not be a therapeutic standard.

Valacyclovir prophylaxis versus preemptive valganciclovir therapy to prevent cytomegalovirus disease after renal transplantation.

Both preemptive therapy and universal prophylaxis are used to prevent cytomegalovirus (CMV) disease after transplantation. Randomized trials comparing both strategies are sparse. Renal transplant recipients at risk for CMV (D+/R-, D+/R+, D-/R+) were randomized to 3-month prophylaxis with valacyclovir (2 g q.i.d., n = 34) or preemptive therapy with valganciclovir (900 mg b.i.d. for a minimum of 14 days, n = 36) for significant CMV DNAemia (>/=2000 copies/mL by quantitative PCR in whole blood) assessed weekly for 16 weeks and at 5, 6, 9 and 12 months. The 12-month incidence of CMV DNAemia was higher in the preemptive group (92% vs. 59%, p < 0.001) while the incidence of CMV disease was not different (6% vs. 9%, p = 0.567). The onset of CMV DNAemia was delayed in the valacyclovir group (37 +/- 22 vs. 187 +/- 110 days, p < 0.001). Significantly higher rate of biopsy-proven acute rejection during 12 months was observed in the preemptive group (36% vs. 15%, p = 0.034). The average CMV-associated costs per patient were $5525 and $2629 in preemptive therapy and valacyclovir, respectively (p < 0.001). However, assuming the cost of $60 per PCR test, there was no difference in overall costs. In conclusion, preemptive valganciclovir therapy and valacyclovir prophylaxis are equally effective in the prevention of CMV disease after renal transplantation.

Urological complications of congenital nephrogenic diabetes insipidus--long-term follow-up of one patient.

A male with a severe form of congenital nephrogenic diabetes insipidus (diuresis 10 l per day) had megaureters, megavesica, large residuum and a history of three traumatic ruptures of the megavesica and a recurrent urinary tract infection (RUTI). Hemodialysis was introduced at 41 years of age. At age of 42, he underwent a bilateral retroperitoneoscopic nephrectomy to prevent further RUTI and 8 months later transplantation of a cadaver kidney. Intermittent catheterization is necessary due to residual urine in the urinary bladder.

[The results of kidney transplantation from very young paediatric cadaveric donors to adult recipients in Czech Republic in the years 1994-2001 (retrospective study of the Czech transplant centres)]. / Výsledky transplantací ledvin od malých detských kadaverózních dárcu dospelým príjemcum v Ceské republice v letech 1994-2001 (Retrospektivní studie ceských transplantacních center).

The results of kidney transplantation from very young paediatric cadaveric donors up to five years, which were transplanted to adult recipients, are evaluated in the first retrospective study of all Czech transplantcentres. In general, 42 of these transplantations were carried out during 1994-2001. In 28 cases single kidney was transplanted, in 14 cases en bloc graft of both children kidneys was transplanted. The reasons of kidney failure by recipients are usual (in 42.9% glomerulonephritis). An average age of the donors was 34.7 months (median 39 months). An average age of the recipients during transplantation was 42.6 years (median 43.5 years). All the kidneys were placed into retroperitoneum. As long as only single kidney was transplanted, the rules, already propagated by Salvatiera in 1970, were respected. At the transplantation of en bloc graft, Kinne's method with possible vessels elongation of the graft and with uretero-uretero anastomoses (in so called Ostrava modification) was used. The higher occurrence of the primary graft non-function (as 50% losses of all grafts) was confirmed in the study. Its reason was an acute thrombosis of vessels or rotation of graft stem. One-, three- and five-years patients and grafts survival were 97.6-90.5-90.5% and 76.2-73.8-73.8% actually. Patients survival are very good while grafts survival are average, momentarily a bit worse than national data published by the Czech Transplant Society, which determines one-, three- and five-years grafts survival with 90.3-82.9-75.5% and 79.1-71.1-65% actually. The kidney transplantation from paediatric cadaveric donors to adult recipients is acceptable under present allocated criteria, in case that some principles are kept. The study confirms the international experiences about rather higher incidence of surgical complications and primary graft non-function. In conclusion, some general references for reduction of complications, as well as for improvement of these transplantation results are introduced.

[Initial experience with transplantation of a kidney from a non-beating heart donor (NHBD)]. / Nase první zkusenosti s transplantací ledvin odebraných z nebijícího dárce (NHBD).

The authors present their initial experience with transplantations of the kidneys from a donor with a non-beating heart (NHBD). This programme was developed because of the permanently declining number of cadaverous kidney donors with a beating heart. Since January 2002 the authors collected a total of three kidneys from NHBD 3 kidneys of which were used for transplantation. The first two started to function immediately, the third one restored its function three weeks after transplantation. The viability and suitability of use of kidneys from NHBD is evaluated with regard to vascular resistance and flow of the perfusion fluid through the kidneys when using a perfusion pump and by means of totalglutathione-S-transferase (tGST) assessed at intervals in the perfusion fluid. The values of the above parameters are limiting between the 6th and 8th hour after the onset of instrumental perfusion of the collected kidneys when the perfusion values should be within the range of 30-50 ml/min/100 g and the vascular resistance should be < 0.7 mmHg and tGST < 100 U/l. For immunosuppression the authors use during the fist days after transplantation basiliximab, rapamycin and corticoids, later in case of satisfactory function of the graft they add cyclosporin A. The initial results of renal transplantation from NHBD are promising and the programme will be developed further.