OPO Strategies to Prevent Unintended Use of Kidneys Exported for High PRA (>98% cPRA) Recipients.

Since the advent of the Kidney Allocation System (KAS), matched candidates with high (>98%) panel reactive antibody (hPRA) are given priority over local candidates with lower PRA. This often leads to exporting of kidneys. Data for these kidneys are not detailed on routine reports. Twenty-two organ procurement organizations prospectively submitted data from August 2015 to July 2016, describing allocation practices of kidneys to hPRA patients and outcomes of these kidneys. Five hundred twenty out of 6924 procured kidneys were exported for hPRA recipients. Of these, 402 (77.3%) were transplanted into the intended recipient (IR); 100 (19.2%) were transplanted into unintended recipients (UR), and 18 (3.5%) were discarded. The most common reason for use in an UR was a positive crossmatch (XM) (63%). The most common reasons for discard were donor quality (44%) and ischemic time (39%). Prior to kidney export, when tissue crossmatching was done, 96.2% of the kidneys went to the IR, versus 80.7% following virtual CM, versus 56.7% when no crossmatching was performed (p < 0.0001). A significant number of kidneys exported for hPRA patients are not being used in the IR or are being discarded. The most common reason for this is positive tissue XM. We report that unintended use of the kidney was minimized when tissue was shipped and XM results were known prior to exporting the kidney.

A randomized trial of the effects of nebulized albuterol on pulmonary edema in brain-dead organ donors.

Donor lung utilization rates are persistently low primarily due to donor lung dysfunction. We hypothesized that a treatment that enhances the resolution of pulmonary edema by stimulating the rate of alveolar fluid clearance would improve donor oxygenation and increase donor lung utilization. We conducted a randomized, blinded, placebo-controlled trial of aerosolized albuterol (5mg q4h) versus saline placebo during active donor management in 506 organ donors.The primary outcome was change in oxygenation arterial partial pressure of oxygen/fraction of inspired oxygen [PaO2/FiO2] from enrollment to organ procurement.The albuterol (n»260) and placebo (n»246)groups were well matched for age, gender, ethnicity,smoking, and cause of brain death. The change in PaO2/FiO2 from enrollment to organ procurement did not differ between treatment groups (p»0.54) nor did donor lung utilization (albuterol 29% vs. placebo 32%,p»0.44). Donors in the albuterol versus placebo groups were more likely to have the study drug dose reduced (13% vs. 1%, p<0.001) or stopped (8% vs. 0%,p<0.001) for tachycardia. In summary, treatment with high dose inhaled albuterol during the donor management period did not improve donor oxygenation or increase donor lung utilization but did cause tachycardia.High dose aerosolized albuterol should not be used in donors to enhance the resolution of pulmonary edema.

Just a number? Donor age and (lack of) associated reasons for heart offer refusal.

Use of 50+ year-old donors for heart transplant (HT) is rare in the US. We assessed reasons for this-and whether it reflects concern about age itself or associated risk factors-using a survey of US HT centers. The Donor Heart Study enrolled US adult potential heart donors from 2015-2020. 6,814 surveys across 2,197 donors cited, on average, 2.4 reasons (per donor) for offer refusal. Age was cited often (by ≥ 50% of centers surveyed) for 715 donors (33%). In this subgroup, accompanying donor-related reasons for refusal were infrequent, with no cardiac abnormality cited in most cases. Donor age showed associations with (1) age as a reason for refusal and (2) discard. Both abruptly increased at age 50: 55% of 50-51-year-old donors were refused often due to age (vs. 38% of 48-49-year-olds) and 72% were discarded (vs. 55% of 48-49-year-olds), despite no evidence of a threshold effect of age on outcomes.

Incidence of and risk factors for posttransplant diabetes mellitus after pancreas transplantation.

Posttransplant diabetes mellitus (PTDM) after pancreas transplantation (PTX) has not been extensively examined. This single center, retrospective analysis of 674 recipients from 1994 to 2005 examines the incidence of and risk factors for PTDM after PTX. PTDM was defined by fasting plasma glucose level > or =126 mg/dL, confirmed on a subsequent measurement or treatment with insulin or oral hypoglycemic agent for > or =30 days. The incidence of PTDM was 14%, 17% and 25% at 3, 5 and 10 years after PTX, respectively and was higher (p = 0.01) in solitary pancreas (PAN) versus simultaneous kidney pancreas (SPK) recipients (mean follow-up 6.5 years). In multivariate analysis, factors associated with PTDM were: older donor age (hazard ratio [HR] 1.04, 95% confidence interval [CI] 1.03-1.06, p < 0.001), higher recipient body mass index (HR 1.07,CI 1.01-1.13, p = 0.01), donor positive/recipient negative CMV status (HR 1.65,CI 1.03-2.6, p = 0.04), posttransplant weight gain (HR 4.7,CI 1.95-11.1, p < 0.001), pancreas rejection (HR 1.94.CI 1.3-2.9, p < 0.001) and 6 month fasting glucose (HR 1.01,CI 1.01-1.02, p < 0.001), hemoglobin A(1)c, (HR 1.12,CI 1.05-1.22, p = 0.002) and triglyceride to high-density lipoprotein (TG/HDL) ratio (HR 0.94,CI 0.91-0.96, p < 0.001). This study delineates the incidence and identifies risk factors for PTDM after PTX.

Meckel's diverticulum causing cecal volvulus.

Meckel's diverticulum is present in 2 per cent of the population with bowel obstruction as its most common complication. This case report describes an extremely rare complication of a Meckel's diverticulum, a cecal volvulus. The diagnosis of cecal volvulus was made preoperatively on abdominal X-rays; the diagnosis of a Meckel's diverticulum was made intraoperatively. The cecum was found to be twisted around a vitelline band on a broad-based Meckel's diverticulum extending to the umbilicus. The diverticulum was resected. The patient did well postoperatively and was discharged without any difficulty.

Is there any role for antithymocyte induction in renal transplantation?

The use of an antibody induction agent in kidney transplantation lowers the risk of an acute rejection episode and may improve graft outcomes. Antithymocyte globulin (ATG) is the most commonly used antibody induction agent for kidney transplantation in the United States, despite its significant side effect profile and cost compared to the interleukin-2 receptor antagonists (IL2-RA). Our review suggests the IL2-RA are safe and well tolerated, and provide equal clinical benefit to ATG at a lower cost. We propose that there is insufficient evidence to justify the use of ATG induction in kidney transplantation.