Paired Analysis of Outcomes After Kidney Transplantation in Peritoneal and Hemodialysis Patients.

BACKGROUND: The impact of dialysis modality before kidney transplantation (hemodialysis or peritoneal dialysis) on outcomes is not clear. In this study we retrospectively analyzed the impact of dialysis modality on posttransplant follow-up. METHODS: To minimize donor bias, a paired kidney analysis was applied. One hundred thirty-three pairs of peritoneal dialysis (PD) and hemodialysis (HD) patients were transplanted at our center between 1994 and 2016. Those who received kidneys from the same donor were included in the study. HD patients were significantly older (44 vs 48 years), but the Charlson Comorbidity Index was similar (3.12 vs 3.46) in both groups. The groups did not differ significantly with respect to immunosuppressive protocols and number of mismatches (2.96 vs 2.95). RESULTS: One-year patient (98% vs 96%) and graft (90% vs 93%) survival was similar in the PD and HD patient groups. The Kaplan-Meier curves of the patients and graft survival did not differ significantly. Delayed graft function (DGF) and acute rejection (AR) occurred significantly more often in the HD recipients. Graft vessel thrombosis resulting in graft loss occurred in 9 PD (6.7%) and 4 HD (3%) patients (P > .05). Serum creatinine concentration and estimated glomerular filtration rate (using the Modification of Diet in Renal Disease guidelines) showed no difference at 1 month, 1 year, and at final visit. On multivariate analysis, factors significantly associated with graft loss were graft vessel thrombosis, DGF, and graft function 1 month after transplantation. On univariate analysis, age, coronary heart disease, and graft loss were associated with death. Among these factors, only coronary heart disease (model 1) and graft loss were significant predictors of death on multivariate analysis. CONCLUSION: The long-term outcome for renal transplantation is similar in patients with PD and HD. These groups differ in some aspects, however, such as susceptibility to vascular thrombosis in PD patients, and to DGF and AR in HD patients.

Psychological Well-Being in Patients After Preemptive Kidney Transplantation.

BACKGROUND: Preemptive kidney transplantation (PKT) is associated with improved patient and graft survival as compared with transplantation in previously dialyzed patients. Complications related to dialysis are avoided in preemptively transplanted patients. Psychological functioning of those patients is still under investigation. The aim of the study was to evaluate the acceptance of illness, satisfaction of life, and anxiety in patients preemptively transplanted (PET) and transplanted after dialysis (PTD). METHODS: The present study compares 23 pairs of PET and PTD patients after kidney transplantation from the same donor. Each patient completed a set of psychological questionnaires: Acceptance of Illness Scale, Satisfaction With Life Scale, and State-Trait Anxiety Inventory. Pairs were examined in the same moment, from 7 days to 5 years after transplantation. The PET and PTD groups did not differ significantly in respect to sex, underlying renal diseases, incidence of acute rejection, surgical complications, and graft function. More PTD patients had delayed graft function (P < .05). RESULTS: The statistical analysis revealed a significant lower acceptance of illness as well as satisfaction with life in PET recipients (P < .05). The groups differed significantly in the trait of anxiety but not in the state of anxiety. CONCLUSIONS: Although the medical benefits of PKT are widely known, numerous psychological problems may occur in patients who do not have difficulties of dialysis and who after transplantation are faced with unexpected discomfort, which influences psychological well-being. Further effort should focus on providing psychological support during qualification to the transplantation and in follow-up after surgery.

Treatment of the Lymphocele After Kidney Transplantation: A Single-center Experience.

BACKGROUND: Lymphocele is one of the most common complications after kidney transplantation. It is usually asymptomatic, but can cause pressure on the kidney transplant, ureter, bladder, and adjacent vessels with deterioration of graft function, ipsilateral leg edema, and external iliac vein thrombosis. Peritoneal fenestration is a well-established method for treatment. In this report, we present the incidence of symptomatic lymphocele requiring treatment (LRT), demographic and surgical factors that influenced lymphocele formation, its clinical presentation, and 2 types of treatment: open and laparoscopic intraperitoneal drainage in the experience of our center. MATERIAL AND METHODS: We retrospectively analyzed all kidney transplantations performed between January 2007 and December 2014 in Gdansk Transplantation Center (n = 740) and selected patients with LRT. LRT occurred in 59 cases (8%). All other patients transplanted during the same time (n = 681) were treated as a control group in the univariate and multivariate analysis of risk factors of the lymphocele formation. RESULTS: Surgical intraperitoneal drainage was performed in an open method in 53 cases and laparoscopically in 6 patients. We observed recurrence of lymphocele in 11 cases (18.6%). Acute rejection episodes (ARE) and delayed graft function (DGF) were more frequent in patients with LRT. ARE and age were independent risk factors for LRT in multivariate analysis. The mean estimated glomerular filtration rate by the Modification of Diet in Renal Disease method at 1 month after the fenestration was higher than before the operation (51.7 and 43.6 mL/min, respectively). CONCLUSIONS: Fenestration is a safe and effective method of treatment of symptomatic lymphocele. ARE, DGF, and older age were associated with a greater risk of LRT.

Candida arteritis in kidney transplant recipients: case report and review of the literature.

Multi-organ procurement is a risk factor for contamination of preservation fluid with intestinal flora including fungi (e.g., Candida). Transmission of fungal species to the graft vessel can cause mycotic arteritis. This is a very rare but life-threatening complication of renal transplantation. We present 2 cases of renal transplant recipients from the same multi-organ donor. Both recipients suffered from severe hemorrhages from renal graft anastomosis and renal artery pseudoaneurysm due to Candida albicans arteritis (CAA). The culture of the preservation fluid revealed growth of Escherichia coli, but neither preservation fluid nor multiple routine blood cultures performed before hemorrhagic complications revealed fungal growth (media non-selective for fungal growth were applied). The first recipient suffered from sudden severe hemorrhage in the area of graft anastomosis on day 10 post surgery (without any preceding clinical or radiological symptoms). This led to urgent surgery and graftectomy, which was complicated by cardio-respiratory arrest with resuscitation in the operating room; despite resuscitation, irreversible brain damage, and subsequent death occurred in the intensive care unit (ICU) 2 weeks later (on day 24 after transplantation). The second patient underwent urgent vascular surgery on day 22 (after transplantation), because of hemorrhage from a pseudoaneurysm of the graft artery. She required repeated vascular operations, extended antimicrobial and antifungal therapy, and ICU monitoring and, despite these interventions, she died on day 80 after transplantation as a result of Pseudomonas aeruginosa sepsis. Arteritis of the renal artery in both patients was caused by C. albicans. This was confirmed by histopathology: infiltration of renal artery with budding yeast forming pseudohyphae (Case 1), and the presence of C. albicans in the culture of the renal artery and surrounding tissue (Case 2). We conclude that organ preservation solution should be cultured with use of media selective for fungal growth. As soon as the positive culture is detected, appropriate measures protecting patients against CAA should be undertaken.

The use of Tenckhoff catheters for draining of symptomatic lymphoceles: a review of literature and our experience.

BACKGROUND: Lymphoceles are one of the common complications of kidney transplantations. While small, asymptomatic lypmhoceles do not require intervention, however, larger, high-pressure cases can lead to graft dysfunction and are thus an indication for decompression. The aim of this study is to present the drainage using a Tenckhoff catheter as effective treatment for recurrence of symptomatic lymphoceles based on both a single center's experience as well as existing literature. MATERIALS AND METHODS: In our database, two patients were operated with a Tenckhoff catheter for the recurrence of symptomatic lymphocele. A review of MEDLINE in search of cases with lymphoceles treated with Tenckhoff catheterization yielded only five articles published between 1990 and 2014. The reports covered 15 cases in which 11 patients were treated for a primary lymphocele whereas 4 were treated for a recurring lymphocele. RESULTS: There was no evidence of lymphocele recurrence or infections after Tenckhoff catheterization in either the material review or our database. CONCLUSIONS: Intraperitoneal drainage with a Tenckhoff catheter seems to be an effective and safe method for treating recurrent, symptomatic lymphoceles after renal transplantation.

Preemptive kidney transplantation: analysis of kidney grafts from the same donor.

BACKGROUND: From November 2003 to December 2012, in the Gdansk Center, 64 patients received preemptive transplantation (PET). PET comprised 8% of 794 kidney transplantations performed during this time. The benefits for individual patients and for the health care system are discussed. METHODS: This study compares the outcomes of these PET patients who had their kidney pairs transplanted after a variable duration of dialysis (PTD), a total of 51 pairs. RESULTS: The mean Charlson comorbidity index was 2.57 vs 3.04 (P > .05) for the PET and PTD groups, respectively. Both groups did not differ significantly with respect to 1-year patient and graft survivals, and incidences of acute rejection. Five (9.8%) PET patients and 20 (39%) PTD patients experienced delayed graft function (P < .05). The graft function (serum creatinine/4p MDRD) 1 year after transplantation was similar in both groups (1.42/53.7 vs 1.43/57.4; mg/dL/mL/min/1.73 m(2)). More PET patients continued normal professional activities or education before and after transplantation (P < .05). CONCLUSIONS: Our single-center results confirmed that for both medical and socioeconomic reasons, PET is an optimal mode of renal replacement therapy.

Acute graft pyelonephritis during the first year after renal transplantation.

INTRODUCTION: Urinary tract infections are the most common infections in renal transplant recipients. Acute graft pyelonephritis (AGPN) is considered a potential risk factor for poorer graft outcomes; however, its clinical impact still remains controversial. METHODS: This study analyzed urine cultures performed within the first 12 months after renal transplantation with reference to clinical data of patients who received a renal transplant at Gdansk Transplantation Centre between January 2007 and December 2009. Renal function assessed by creatinine concentration and estimated glomerular filtration rate was recorded 24 months after renal transplantation. RESULTS: This study examined urine cultures and clinical data from 209 renal transplant recipients, including 59.3% men, with a mean age of 46 ± 14 years. We observed 70 AGPN episodes defined as the presence of significant bacteriuria, fever >38°, and/or graft pain and/or acute graft function impairment, including 13 cases of bacteremia, in 46 patients. This accounted for 22% of all diagnosed urinary tract infections. Over 80% of all AGPN episodes were diagnosed beginning from the second month posttransplantation, and the most frequently isolated uropathogen was Escherichia coli (65.7%, n = 46). Female sex, vesicoureteral reflux, or strictures at the ureterovesical junction and a history of cytomegalovirus infection emerged as independent predictors of AGPN. The evolution of renal graft function measured by serum creatinine concentration and MDRG eGFR rate did not differ significantly between patients with and without AGPN. CONCLUSIONS: AGPN may be a marker of an underlying impairment of urine flow, eg, due to vesicoureteral reflux or strictures at the ureterovesical junction, whereas it does not affect graft function in renal transplant recipients.

11-year single-center experience in living-donor kidney transplantation in Poland.

Living-donor kidney transplantation (LDKT) is a viable option that is characterized by better short- and long-term results than cadaver-donor kidney transplantation (CKT). In Poland number of LDKT is low (2%-3%). We collected data on all 29 LDKTs performed in our center between 1999 and 2010; 82.7% were obtained from living related donors. The mean recipient age was 34.4±12.8 years (range, 15-58) and mean donor age was 48.5±7 years. Most donors were women (n=17; 62%). In 3 cases the LDKT was a second transplantation. The mean numbers of HLA class I and II mismatches were 2.18±0.98 and 0.93±0.6 respectively. The mean total ischemia time was 3.22±1.74 hours. Induction therapy included antithymocyte globulin daclizumab 4; (13.7%) (n=7; 24.1%); 27.6% of recipients were placed on cyclosporine based immunosuppression and the remaining 72.4% on tacrolimus with 69% also receiving mycophenolate mofetil. All recipients were prescribed steroids. Delayed graft function was observed in 3 cases and an acute rejection episode in 4 subjects. One-year patient and graft survivals were both 100% (98% and 83% for CKT). Five-year patient and graft survival were 100% and 89.6%, respectively, compared with 83% and 69% in CKT. The mean serum creatinine levels at 1, 6, 12, and 60 months were 1.59±0.4, 1.51±0.3, 1.51±0.4 and 1.49±0.3 mg/dL respectively. Our results, albeit concerning a small group of patients, confirmed excellent outcomes of LDKT, which should be actively promoted in our country.

Renal transplantation in dialysis patients with the history of coronary artery bypass grafting and cardiac valve replacement.

Death with a functioning kidney is the most frequent cause of graft failure. Cardiovascular disease is the most frequent cause of death after renal transplantation. Therefore, prior to grafting, it is mandatory to diagnose and treat coronary artery disease and heart valve impairment. Transplantation is the best option for renal replacement therapy as far as the quality of life and life expectancy are concerned, although patients with such comorbidities may experience a higher short-term mortality risk. The objective for this study was to analyze both short- and long-term results of patients after coronary artery bypass grafting (CABG) or cardiac valve replacement (CVR). The cardiac surgery recipient group (CSR) included 16 patients (15 men, 1 woman) aged from 44 to 73 (mean 54.9 +/- 7.8) years. CABG was performed in 13/16 patients, and CVR in 3/16. The rest of our patients were treated as a comparative noncardiac surgery recipient (non-CSR) group. It consisted of 422 patients (264 men, 158 women) aged from 14 to 68 years (mean 43.2 +/- 12.9). The comparison revealed that graft function estimated at 1 year after transplantation was not different: serum creatinine concentrations of 1.7 +/- 0.2 and 1.6 +/- 0.5 mg/dL in CSR and non-CSR, respectively. One-year patient survival in the CVR group of 93.8% was slightly worse than that in the non-CSR group (97.9%), but death-censored 1-year graft survivals were comparable in both groups (93.8% vs 92%). Urinary tract and cytomegalovirus infections were the most common complications in the CSR group. One patient lost his graft in month 3(rd) due to many serious infectious complications. One patient died at the end of 12 months as a result of a cardiovascular event (1/16). Our single-center results confirm that transplantation in patients after CABG or CVR is a safe procedure; therefore, such patients should be referred into the waiting list.

A single center experience in preemptive kidney transplantation.

Transplantation is recognized as preemptive if it takes place before the initiation of chronic dialysis. This maneuver has the potential to avoid the morbidity and burden of chronic dialysis. From November 2003 to April 2005, 15 (7 male, 8 female) end-stage renal failure patients of mean age 40 +/- 14.8 years received preemptive grafts from 2 living-related and 13 cadaveric donors, constituting 11.5% of all kidney transplantations performed in our center at that time. The period on the waiting list for preemptive recipients, namely, 2 weeks to 6 months (mean, 2.4 months), was significantly shorter than that of other patients (mean, 13.8 months). The mean creatinine clearance calculated from the Cockroft Gault formula and the mean plasma creatinine level in preemptive recipients before transplantation were 12.7 +/- 3.1 mL/min and 6.6 +/- 0.8 mg/dL, respectively. The donors for preemptive and non-preemptive groups of recipients did not differ significantly in respect to age, gender, and renal function. The mean number of mismatches of 3.73 and 3.25 and the mean total ischemic times of 9.53 +/- 5 and 11.2 +/- 5 hours, in preemptive and non-preemptive groups of recipients, respectively. The incidence of delayed graft function (dialysis in the first week after transplantation) was significantly lower among preemptive recipients (20% versus 42%, respectively). The groups did not differ either in respect to the occurrence of acute rejection episodes or graft and patient survivals. In preemptive patients the mean plasma creatinine levels at 3 and 12 months were 1.37 +/- 0.3 and 1.09 +/- 0.3 mg/dL, and in non-preemptive patients 1.7 +/- 0.5 and 1.4 +/- 0.4 mg/dL. In conclusion, these results are promising, confirming the notion that preemptive kidney transplantation is the optimal treatment for end-stage renal disease patients.

Hemolytic anemia after renal transplantation: analysis of case reports.

Hemolysis after renal transplantation in some cases is clearly related to hemolytic-uremic syndrome (HUS) and usually attributed to cyclosporine (CsA) treatment. Acute hemolysis in other recipients is related to anti-erythrocyte autoantibodies. In most cases these patients have received ABO-compatible, although ABO-nonidentical, organs, mostly from O blood group donors. We report three cases of autoimmune hemolytic anemia after renal transplantation. Two patients (patients: 1 and 2; ABO-compatible, but nonidentical kidneys) suffered acute hemolysis in the third week after transplantation. One patient (patient 3: ABO-identical kidney) suffered a chronic, subclinical course of disease beginning 5 months after transplantation. The clinical picture of this disease was completely different from HUS. The existence of severe anemia (patients 1 and 2), hyperbilirubinemia (particularly high in patient 3), increased serum lactic dehydrogenase levels, and decreased serum haptoglobin in the presence of good graft function suggested an hemolytic anemia. In all patients the direct antiglobulin test was positive. The acute or chronic symptoms of hemolysis disappeared, at 2 and 5 weeks, respectively, after conversion from CsA to tacrolimus. Hemolysis in these patients probably relates to alloantibodies derived from passenger B lymphocytes transplanted with the organs. Because hemolysis has been most frequently related to CsA therapy, it is suggested that B lymphocytes proliferated and produced antibodies because CsA effects to inhibit T-cell function generally spares B-cell activity. It is proposed that a subtype of B cells, which are resistant to CsA, produces anti-A and/or anti-B antibodies. Treatment with tacrolimus appears to be successful, probably due to its alternate, and likely more effective, manner of B-cell suppression.

Small intestine perforation because of capacitive coupling as a cause of abdominal wall gas gangrene and clostridial sepsis after laparoscopic cholecystectomy.

The authors present a case report regarding abdominal wall gas gangrene and clostridial sepsis after laparoscopic cholecystectomy. Capacitive coupling was considered to be the most probable cause of small intestine perforation and further complications. Despite intensive treatment, the 69-year-old patient died.

Two-millimeter minisite mini-laparoscopy for rescue of dysfunctional continuous ambulatory peritoneal dialysis catheters.

In addition to peritonitis, mechanical outflow obstruction is the most common complication of continuous ambulatory peritoneal dialysis. If conservative methods are unsuccessful, the insufficient catheter must be placed in the right position or freed surgically. Currently, laparoscopy appears to be the method of choice in these cases. "Standard" laparoscopy using 10- and 5-mm ports can lead to dialysate wound leakage. Two-mm mini-laparoscopy was employed in three cases with good results. In two patients, catheters are still patent (after 19 and 23 months), and in one patient, the catheter had to be replaced after 5 weeks. No postoperative complications occurred. In some cases of catheter dislodgement or wrapping, mini-laparoscopy using a 2-mm MiniSite device can replace open surgery and even "standard" laparoscopy.

[Left-side portal hypertension as a clinical problem]. / Lewostronne nadcisnienie wrotne jako problem kliniczny.

Left-sided portal hypertension (LSPH) is caused by isolated obstruction (in most cases--thrombosis) of splenic vein. In about 50% of patients it generates a haemorrhage from gastric or oesophageal varices, rarer from other sources in abdominal cavity. The most common origin of the splenic vein thrombosis is a pancreatic disease--acute or chronic pancreatitis or neoplasm. The procedure of choice in the management of the haemorrhage in these cases is splenectomy. The advantages of prophylactic splenectomy in LSPH have not been verified yet.

[Prospective evaluation of treatment results while using surgical esophageal devascularization and transection for esophageal varices]. / Prospektywna ocena wyników leczenia zylaków przelyku przy zastosowaniu operacji dewaskularyzacyjnych i transekcji przelyku.

During the years 1979-1996 over 300 patients aged 2-71, with esophageal varices had been treated in our Clinic. In 104 cases extended gastroesophageal devascularization and esophageal transection combined with splenectomy was performed. According to Child-Pugh's classification 60 patients (58%) were qualified to group A and B, 44 (42%)-to group C. In 61 cases (59%) the operations were carried out electively, in 30 (29%)-as an emergency and in the remaining 13 (12%)-prophylacticly. In all cases the operation was successful in controlling preoperative variceal bleeding. Postoperative mortality amounted in 20 cases (19%): in Child's group A and B-10% and in group C-32%. The highest mortality rate was noted in group C patients operated emergently (38%). The main cause of death was developing hepatic failure (18 cases) and esophageal fistula in the remaining 2. Recurrence of esophageal varices was observed in 4 patients (4%) and the recurrence of variceal bleeding in 3 of them (3%). In other 3 cases recurrent bleeding was caused by acute mucosal lesions in the stomach. No cases of postoperative encephalopathy have been observed. Follow-up period ranged from 2 months to 15 years (mean 6.5 years) and actuarial survival-67 patients (64%). In our opinion esophageal transection with extended gastroesophageal devascularization is an effective method of controlling variceal hemorrhage, with very low recurrence rate and allows to avoid postoperative encephalopathy.

[Evaluation of esophageal motility after its resection and extensive devascularization]. / Ocena motoryki przelyku po jego transekcji polaczonej z rozlegla dewaskularyzacja.

UNLABELLED: Almost complete lack of information concerning esophageal motility after non-shunt operations due to bleeding esophageal varices was the main stimulus of this study. Thirty seven patients from 112 treated for bleeding esophageal varices in our Clinic in the years 1993-1997, were studied. To evaluate esophageal parameters the Autronic GmbH D-7500 pH-meter, and from 1995, the Microdigitrapper 2 MB (Synectics) System were used. The latter enables 24-hour, simultaneous pH and pressure measurements. In patients before operation, and those who did not undergo surgery (24 measurements), reflux occurred in 14 (58%). In 10, the varices were qualified to gr. III and IV according to Paquet's classification. Five cases of mixed (supine/upright) reflux was observed. Among 9 patients subjected to previous sclerotherapy, 4 had reflux. Ph parameters in 14 patients examined before and after operation did not differ significantly. 24-hour pressure monitoring was performed in 24 patients. Eight were examined before and after operation. All pre and postoperative results were compared. No statistic differences were found. CONCLUSION: 1. Gastroesophageal reflux is frequent in cirrhotic patients with varices, and concerns over 50% of them. 2. No significant differences between pre and postoperative results, suggest that extensive devascularisation and esophageal transection do not affect esophageal motility significantly. 3. 24-hour combined pH and manometry is an extremely helpful method of obtaining objective motility data.