Transplanting a left or right donor kidney into the left or right iliac fossa: importance of laterality and site of venous anastomosis.

Data on the impact of donor-to-recipient laterality on kidney transplantation are lacking. This study evaluated the impact of donor-to-iliac fossa laterality and the site of venous anastomosis on operating time and surgical outcome. This retrospective single-center study analyzed 1262 deceased donor adult kidney transplants into pristine iliac fossa. Multivariable linear and logistic regression analyses were used to identify variables with an impact on operating time and surgical complications. Operating time was shorter by 11 min in median for transplantations into the right iliac fossa compared to the left iliac fossa (p < 0.001). Operating time in left-to-right donor-to-recipient combination was shorter by 17 min in median if venous anastomoses were performed on the caval vein or common iliac vein as compared to anastomoses to the external iliac vein (p < 0.001). Overall, the shortest operating times (median 112.5 min) were achieved in left-to-right donor-to-recipient combinations with venous anastomosis to the caval or common iliac vein, without an increase in surgical complications. Kidney transplantation into the right iliac fossa with anastomosis to the caval vein or the common iliac vein saves operating time and reduces thrombotic complications. Acceptance of a left donor kidney is likely to further reduce operating time.

RAS-challenge as a first-look test for detection of primary aldosteronism in patients with treatment-resistant hypertension.

PURPOSE: Primary aldosteronism (PA), characterised by low-renin hypertension, confers a high cardiovascular risk and is the most common cause of secondary hypertension, with an increased prevalence in patients with treatment-resistant hypertension. However, it is estimated that only a small percentage of affected patients are identified in routine clinical practice. Inhibitors of the renin-angiotensin system cause an increase in renin levels in patients with intact aldosterone regulation, and inadequate low renin with concurrent RAS inhibition (RASi) may therefore indicate PA, which could serve as a first look screening test for selection for formal work-up. METHODS: We analysed patients between 2016-2018 with treatment-resistant hypertension who had inadequate low renin in the presence of RASi (i. e. at risk for PA) and who were offered systematic work-up with adrenal vein sampling (AVS). RESULTS: A total of 26 pts were included in the study (age 54.8 ± 11, male 65%). Mean office blood pressure (BP) was 154/95 mmHg on 4.5 antihypertensive drug classes. AVS had a high technical success rate (96%) and demonstrated unilateral disease in the majority of patients (57%), most of which (77%) were undetected by cross-sectional imaging. CONCLUSION: In patients with resistant hypertension, low renin in the presence of RASi is a strong indicator for autonomous aldosterone secretion. It may serve as an on-medication screening test for PA to select for formal PA work up.

What is the context? Primary aldosteronism (PA) is associated with an uncontrolled secretion of the hormone aldosterone and often causes severe forms of high blood pressure. PA is considered the most common cause of high blood pressure which is caused by another medical condition. Medical societies have issued precise recommendations for the screening of this disease, which includes the determination of aldosterone and its main regulator renin. However, it is estimated that only a small percentage of affected patients are identified in routine clinical practice.What is the problem? In clinical studies, the determination of renin, aldosterone and its ratio (ARR) proved to be a valid screening tool. Nevertheless, in everyday life assessing and interpreting these results can be challenging for the clinician. The ARR is influenced by all first-line antihypertensives and in case of doubt, an extensive change in medication is recommended. Especially patients with resistant hypertension may require intensive medical care when medication is changed.What is important? In this study, we analysed patients at risk for PA who had inadequate low renin in presence of RASi (ACE inhibitors, Angiotensin receptor blockers). This study suggests that in patients with severe hypertension, the determination of renin in presence of RASi can provide further information on the presence of autonomic aldosterone secretion at a glance. However, this approach cannot and should not replace the algorithm proposed by current guidelines. In contrast, this approach should be an easy-to-implement concept that should prime the initiation of further appropriate diagnostics.

Recurrent Hurthle cell thyroid carcinoma does not preclude long-term survival: a case report and review of the literature.

BACKGROUND: Follicular thyroid carcinoma is the second most common malignancy of the thyroid gland. In 2016, the so-called Hurthle cell thyroid carcinoma, formerly known as the oxyphilic variant of the follicular thyroid carcinoma, was reclassified by the World Health Organization as a separate pathological entity, which accounts for approximately 3% of all thyroid cancers. Although Hurthle cell thyroid carcinomas are known for their more aggressive tumor biology, metastases are observed in a minority of cases, and long-term survival can be expected. However, disseminated disease is often associated with poor outcome. CASE PRESENTATION: In the presented case, a 63-year-old Caucasian female was incidentally diagnosed with Hurthle cell thyroid carcinoma after undergoing hemithyroidectomy for a nodular goiter. Following completion thyroidectomy, two courses of radioactive iodine therapy were administered. After 4 years of uneventful follow-up, the patient gradually developed metastases in five different organs, with the majority representing unusual sites, such as heart, kidney, and pancreas over a course of 14 years. The lesions were either treated with radioactive iodine therapy or removed surgically, depending on iodine avidity. CONCLUSION: Follicular and Hurthle cell thyroid carcinoma are known to potentially spread hematogenously to typical sites, such as lung or bones, however; unusual metastatic sites as presented in our case can also be observed. A search of the literature revealed only scattered reports on patients with multiple metastases in unusual locations. Furthermore, the observed long-term survival of our patient is contradictory to the existing data. As demonstrated, recurrent disease may appear years after the initial diagnosis, emphasizing the importance of consistent aftercare. Radioactive iodine therapy, extracorporeal radiation therapy, and surgical metastasectomy are central therapeutic components. In summary, our case exemplifies that thorough aftercare and aggressive treatment enables long-term survival even in recurrent Hurthle cell thyroid carcinoma displaying unusual multisite metastases.

Risk-factors for nodular hyperplasia of parathyroid glands in sHPT patients.

INTRODUCTION: Nodular hyperplasia of parathyroid glands (PG) is the most probable cause of medical treatment failure in secondary hyperparathyroidism (sHPT). This prospective cohort study is located at the interface of medical and surgical consideration of sHPT treatment options and identifies risk-factors for nodular hyperplasia of PG. MATERIAL AND METHODS: One-hundred-eight resected PG of 27 patients with a broad spectrum of sHPT severity were classified according to the degree of hyperplasia by histopathology. Twenty routinely gathered parameters from medical history, ultrasound findings of PG and laboratory results were analyzed for their influence on nodular hyperplasia of PG by risk-adjusted multivariable binary regression. A prognostic model for non-invasive assessment of PG was developed and used to weight the individual impact of identified risk-factors on the probability of nodular hyperplasia of single PG. RESULTS: Independent risk-factors for nodular hyperplasia of single PG were duration of dialysis in years, PG volume in mm3 determined by ultrasound and serum level of parathyroid hormone in pg/mL. Multivariable analyses computed a model with an Area Under the Receiver Operative Curve of 0.857 (95%-CI:0.773-0.941) when predicting nodular hyperplasia of PG. Theoretical assessment of risk-factor interaction revealed that the duration of dialysis had the strongest influence on the probability of nodular hyperplasia of single PG. CONCLUSIONS: The three identified risk-factors (duration of dialysis, PG volume determined by ultrasound and serum level of parathyroid hormone) can be easily gathered in daily routine and could be used to non-invasively assess the probability of nodular hyperplasia of PG. This assessment would benefit from periodically collected data sets of PG changes during the course of sHPT, so that the choice of medical or surgical sHPT treatment could be adjusted more to the naturally changing type of histological PG lesion on an individually adopted basis in the future.

Risk Balancing of Cold Ischemic Time against Night Shift Surgery Possibly Reduces Rates of Reoperation and Perioperative Graft Loss.

Background. This retrospective cohort study evaluates the advantages of risk balancing between prolonged cold ischemic time (CIT) and late night surgery. Methods. 1262 deceased donor kidney transplantations were analyzed. Multivariable regression was used to determine odds ratios (ORs) for reoperation, graft loss, delayed graft function (DGF), and discharge on dialysis. CIT was categorized according to a forward stepwise pattern ≤1h/>1h, ≤2h/>2h, ≤3h/>3h,…, ≤nh/>nh. ORs for DGF were plotted against CIT and a nonlinear regression function with best R2 was identified. First and second derivative were then implemented into the curvature formula k(x) = f''(x)/(1 + f'(x)2)3/2 to determine the point of highest CIT-mediated risk acceleration. Results. Surgery between 3 AM and 6 AM is an independent risk factor for reoperation and graft loss, whereas prolonged CIT is only relevant for DGF. CIT-mediated risk for DGF follows an exponential pattern f(x) = A · (1 + k · e(I · x)) with a cut-off for the highest risk increment at 23.5 hours. Conclusions. The risk of surgery at 3 AM-6 AM outweighs prolonged CIT when confined within 23.5 hours as determined by a new mathematical approach to calculate turning points of nonlinear time related risks. CIT is only relevant for the endpoint of DGF but had no impact on discharge on dialysis, reoperation, or graft loss.

Liver Transplantation for Hepatocellular Carcinoma: A Single Center Resume Overlooking Four Decades of Experience.

Background. This is a single center oncological resume overlooking four decades of experience with liver transplantation (LT) for hepatocellular carcinoma (HCC). Methods. All 319 LT for HCC that were performed between 1975 and 2011 were included. Predictors for HCC recurrence (HCCR) and survival were identified by Cox regression, Kaplan-Meier analysis, Log Rank, and χ (2)-tests where appropriate. Results. HCCR was the single strongest hazard for survival (exp⁡(B) = 10.156). Hazards for HCCR were tumor staging beyond the histologic MILAN (exp⁡(B) = 3.645), bilateral tumor spreading (exp⁡(B) = 14.505), tumor grading beyond G2 (exp⁡(B) = 8.668), and vascular infiltration of small or large vessels (exp⁡(B) = 11.612, exp⁡(B) = 18.324, resp.). Grading beyond G2 (exp⁡(B) = 10.498) as well as small and large vascular infiltrations (exp⁡(B) = 13.337, exp⁡(B) = 16.737, resp.) was associated with higher hazard ratios for long-term survival as compared to liver transplantation beyond histological MILAN (exp⁡(B) = 4.533). Tumor dedifferentiation significantly correlated with vascular infiltration (χ (2) p = 0.006) and intrahepatic tumor spreading (χ (2) p = 0.016). Conclusion. LT enables survival from HCC. HCC dedifferentiation is associated with vascular infiltration and intrahepatic tumor spreading and is a strong hazard for HCCR and survival. Pretransplant tumor staging should include grading by biopsy, because grading is a reliable and easily accessible predictor of HCCR and survival. Detection of dedifferentiation should speed up the allocation process.

Value of oral effervescent powder administration for multidetector CT evaluation of esophageal cancer.

PURPOSE: To assess the value of oral effervescent powder (EP) for evaluation of esophageal distension, and for detection and staging of esophageal cancer with contrast-enhanced CT. MATERIALS AND METHODS: 84 patients without esophageal pathology and 52 patients with histological confirmed diagnosis of esophageal cancer were included in this prospective IRB-approved study. Half of the patients in both groups received EP prior to CT. Esophageal distension was assessed by planimetry of the inner (IA) and outer area (OA). Two blinded readers evaluated the datasets separately with regard to diagnosis of esophageal cancer (yes/no) and staging (T0-T4), if applicable. Distension results were compared (t-Test). In patients with cancer sensitivity, specificity, NPV and PPV were calculated. CT staging results were compared to histopathology (Cohen-k). RESULTS: IA and IA/OA were significantly larger after EP as compared to the group without EP (p<0.05). Sensitivity, specificity, NPV and PPV for cancer detection cancer were as follows: 78%/78%, 98%/98%, 95%/95%, 87%/87% with EP; 60%/68%, 98%/98%, 94%/94%, 80%/83% without EP. Staging with EP was good (k=0.84/0.67) and moderate without EP (k=0.58/0.59). CONCLUSIONS: Administration of EP prior to CT results in good distension of the esophagus, and improves detection and staging of esophageal cancer, as compared to control studies without EP.

Evaluation of living liver donors using contrast enhanced multidetector CT - The radiologists impact on donor selection.

BACKGROUND: Living donor liver transplantation (LDLT) is a valuable and legitimate treatment for patients with end-stage liver disease. Computed tomography (CT) has proven to be an important tool in the process of donor evaluation. The purpose of this study was to evaluate the significance of CT in the donor selection process. METHODS: Between May 1999 and October 2010 170 candidate donors underwent biphasic CT. We retrospectively reviewed the results of the CT and liver volumetry, and assessed reasons for rejection. RESULTS: 89 candidates underwent partial liver resection (52.4%). Based on the results of liver CT and volumetry 22 candidates were excluded as donors (31% of the cases). Reasons included fatty liver (n = 9), vascular anatomical variants (n = 4), incidental finding of hemangioma and focal nodular hyperplasia (n = 1) and small (n = 5) or large for size (n = 5) graft volume. CONCLUSION: CT based imaging of the liver in combination with dedicated software plays a key role in the process of evaluation of candidates for LDLT. It may account for up to 1/3 of the contraindications for LDLT.

Characterization and staging of central bile duct stenosis--evaluation of the hepatocyte specific contrast agent gadoxetate disodium.

OBJECTIVE: To assess the value of gadoxetate disodium for characterization and staging of central bile duct stenosis (CBDS). MATERIALS AND METHODS: This prospective HIPAA-compliant study was IRB approved. 14 patients (8 male, 6 female; 36-80 years) with clinical suspicion of CBDS underwent preoperative MRI. To estimate the value of hepatocyte phase images (10, 20, 120 min p.i.), only T2w images (T2), only post-contrast images (CM), or both image datasets were assessed in three reading sessions by 3 readers. Agreement of each reading session with the intraoperative findings in terms of CBDS etiology and tumor extension (weighted kappa statistic) was calculated. RESULTS: CBDS was caused by hilar cholangiocarcinoma (n=9), gallbladder carcinoma (n=4) and pancreatic carcinoma (n=1). Characterization of CBDS etiology was correct by use of: T2w images in 57%, 64%, 50%; CM images in 64%, 57%, 50%; both in 71%, 64%, 64%. Agreement comparing reading sessions and intraoperative findings regarding tumor extension was fair up to moderate (κ-range=0.21-0.54) as a result of common underestimation. Interobserver agreement for tumor extension was fair (κ-range=0.31-0.33). CONCLUSIONS: By means of combined evaluation of T2 and CM images a more reliable characterization of CBDS was possible. Even though CBDS tended to be underestimated assessment of exact tumor extension was improved by contrast administration.

Extended right liver grafts obtained by an ex situ split can be used safely for primary and secondary transplantation with acceptable biliary morbidity.

Split liver transplantation (SLT) is clearly beneficial for pediatric recipients. However, the increased risk of biliary complications in adult recipients of SLT in comparison with whole liver transplantation (WLT) remains controversial. The objective of this study was to investigate the incidence and clinical outcome of biliary complications in an SLT group using split extended right grafts (ERGs) after ex situ splitting in comparison with WLT in adults. The retrospectively collected data for 80 consecutive liver transplants using ERGs after ex situ splitting between 1998 and 2007 were compared with the data for 80 liver transplants using whole liver grafts in a matched-pair analysis paired by the donor age, recipient age, indications, Model for End-Stage Liver Disease score, and high-urgency status. The cold ischemic time was significantly longer in the SLT group (P = 0.006). As expected, bile leakage from the transected surface occurred only in the SLT group (15%) without any mortality or graft loss. The incidence of all other early or late biliary complications (eg, anastomotic leakage and stenosis) was not different between SLT and WLT. The 1- and 5-year patient and graft survival rates showed no statistical difference between SLT and WLT [83.2% and 82.0% versus 88.5% and 79.8% (P = 0.92) and 70.8% and 67.5% versus 83.6% and 70.0% (P = 0.16), respectively]. In conclusion, ERGs can be used safely without any increased mortality and with acceptable morbidity, and they should also be considered for retransplantation. The significantly longer cold ischemic time in the SLT group indicates the potential for improved results and should thus be considered in the design of allocation policies.

Pancreas transplantation with histidine-tryptophan-ketoglutarate (HTK) solution and University of Wisconsin (UW) solution: is there a difference?

CONTEXT: In clinical pancreas transplantation the choice of preservation solution may have an impact on graft pancreatitis. Experience with histidine-tryptophan-ketoglutarate (HTK) is still limited whereas University of Wisconsin (UW) solution is currently the preferred perfusate worldwide. OBJECTIVE: The aim of this study was to analyze our experience with HTK in pancreas transplantation. PARTICIPANTS: In a retrospective analysis, data from 95 primary simultaneous pancreas-kidney transplantations were reviewed. The use of HTK (n=48) and UW (n=47) solution was stratified into two groups. MAIN OUTCOME MEASURES: Patient/graft survival and early graft function were compared. RESULTS: No significant differences between 1, 3 and 12 month patient survival (HTK: 97.9%, 97.9%, and 95.7% vs. UW: 95.7%, 89.4%, and 89.4%, respectively), and pancreas graft survival (HTK: 87.5%, 87.5%, and 85.4% vs. UW: 87.0%, 82.6%, and 82.6%, respectively) were detected. Higher values for peak lipase were observed on day 1 in the HTK group (not reaching significance: P=0.131) whereas no differences were noted for amylase and C-reactive protein. CONCLUSIONS: HTK is clinically comparable to UW. Both solutions have been shown to be safe for pancreas preservation. Successful pancreas transplantation depends on many factors such as donor and recipient factors, but skilled organ procurement techniques, organ preservation, and transplant experience in this field is mandatory. The choice of organ preservation solution is only one point in this context.