RESUMO
Renal artery stenosis is the most common vascular complication following renal transplantation. Percutaneous endovascular transluminal angioplasty with stenting is the treatment of choice for clinically significant renal artery stenosis. The authors present a case describing a novel combined transrenal parenchyma and transfemoral approach to repairing a disrupted transplant renal artery stent. The patient's allograft renal artery stenosis was initially managed via the standard percutaneous approach, but during follow-up the stent became disrupted and crushed, causing partial occlusion of the renal artery. This was manifested by persistently elevated serum creatinine values, lower extremity edema, and four-medication hypertension. After a failed traditional percutaneous transfemoral attempt, the authors were able to successfully access the renal arterial system via a combined transrenal and transfemoral approach, using an upper-pole artery through the renal parenchyma. This transrenal approach used a 3 Fr system, allowing the authors to get a wire across the stent, which they were previously unable to do. With wire access, they performed a balloon angioplastic reconstruction to restore the stent's patency, resulting in a reduction in serum creatinine, lower extremity edema, and blood pressure. This technique avoided a potentially difficult reoperative repair without immediate complication and provides a method for vascular access to the renal arterial system in select patients.
Assuntos
Angioplastia/métodos , Transplante de Rim/efeitos adversos , Rim/irrigação sanguínea , Obstrução da Artéria Renal/terapia , Artéria Renal/cirurgia , Terapia de Salvação , Stents , Humanos , Masculino , Pessoa de Meia-Idade , Obstrução da Artéria Renal/etiologiaRESUMO
Incompatible living donor kidney transplantation (ILDKT) has been established as an effective option for end-stage renal disease patients with willing but HLA-incompatible living donors, reducing mortality and improving quality of life. Depending on antibody titer, ILDKT can require highly resource-intensive procedures, including intravenous immunoglobulin, plasma exchange, and/or cell-depleting antibody treatment, as well as protocol biopsies and donor-specific antibody testing. This study sought to compare the cost and Medicare reimbursement, exclusive of organ acquisition payment, for ILDKT (n = 926) with varying antibody titers to matched compatible transplants (n = 2762) performed between 2002 and 2011. Data were assembled from a national cohort study of ILDKT and a unique data set linking hospital cost accounting data and Medicare claims. ILDKT was more expensive than matched compatible transplantation, ranging from 20% higher adjusted costs for positive on Luminex assay but negative flow cytometric crossmatch, 26% higher for positive flow cytometric crossmatch but negative cytotoxic crossmatch, and 39% higher for positive cytotoxic crossmatch (p < 0.0001 for all). ILDKT was associated with longer median length of stay (12.9 vs. 7.8 days), higher Medicare payments ($91 330 vs. $63 782 p < 0.0001), and greater outlier payments. In conclusion, ILDKT increases the cost of and payments for kidney transplantation.
Assuntos
Incompatibilidade de Grupos Sanguíneos/economia , Rejeição de Enxerto/economia , Teste de Histocompatibilidade/economia , Falência Renal Crônica/cirurgia , Transplante de Rim/economia , Doadores Vivos , Complicações Pós-Operatórias/economia , Estudos de Casos e Controles , Feminino , Seguimentos , Taxa de Filtração Glomerular , Rejeição de Enxerto/epidemiologia , Sobrevivência de Enxerto , Humanos , Testes de Função Renal , Masculino , Pessoa de Meia-Idade , Prognóstico , Qualidade de Vida , Estudos Retrospectivos , Fatores de RiscoRESUMO
Compatible living donor/recipient pair participation (CPP) in kidney exchange (KE) transplantation may substantially increase transplant volumes and significantly mitigate the O blood group donor shortage in KE. Initial ethical analysis did not support CPP for two primary reasons: (1) KE would be "unbalanced," and (2) the possibility of undue influence experienced by the compatible pair living donor. Recent developments with CPP (modeling studies and small clinical experiences), have demonstrated substantial potential for increasing KE volumes. This encouraged us to reconsider initial ethical concerns, with a focus on the potential for a design of a prospective CPP clinical trial. This ethical reconsideration led us to conclude that the concept of unbalanced kidney exchanges (manifested primarily by differential benefit between compatible and incompatible pairs) is no longer as clear cut as originally conceived. In addition, application of two concepts substantially diminishes ethical concerns including: (1) "quasi-compatible" pairs, and (2) a priori definition of mitigating factors. We conclude that genuine uncertainty exists regarding whether kidney exchange is best performed with or without compatible pair participation and that a clinical trial is therefore warranted.
Assuntos
Ensaios Clínicos como Assunto/ética , Ética Médica , Transplante de Rim/ética , Doadores Vivos , Projetos de Pesquisa , Equipolência Terapêutica , Fatores Etários , Incompatibilidade de Grupos Sanguíneos , Histocompatibilidade , Humanos , Educação de Pacientes como Assunto , Participação do Paciente , Obtenção de Tecidos e Órgãos/éticaRESUMO
In 2006, a survey from the American Society of Transplant Surgeons disclosed significant and sometimes fatal hemorrhagic events in live donor nephrectomies (LDN) related to failure of clips, leading to the contraindication of the Weck® Hem-o-lok® clip for control of the renal artery during LDN. A survey regarding vascular control techniques, their perceived safety ratings and their failures was sent to 645 European Society for Organ Transplantation members who profiled their profession as "surgeon" and selected "kidney" as organ type. Two hundred forty-three (41%) members responded, of whom 171 (63.3%) independently perform LDN. Their responses were analyzed. For arterial and venous vascular control, the GIA™ and TA™stapler are used most frequently, and were rated the safest. Of the 121 reported hemorrhagic events, slippage and dislodgement of clips occurred at least 58 times, while stapler malfunction occurred at least 40 times. One donor death from hemorrhage related to clip dysfunction was reported. Hemorrhagic complications of LDN with fatal and non-fatal outcomes still occur. Strikingly, many surgeons do not use the vascular closing technique that they consider most safe. Failure of non-transfixion techniques is associated with greater risks for the donor. Control of major vessels in LDN must employ transfixion techniques for optimal donor safety.
Assuntos
Perda Sanguínea Cirúrgica/prevenção & controle , Transplante de Rim , Rim/cirurgia , Doadores Vivos , Nefrectomia/métodos , Cirurgiões/estatística & dados numéricos , Inquéritos e Questionários , Adulto , Feminino , Humanos , Rim/irrigação sanguínea , Masculino , Pessoa de Meia-Idade , Sistemas On-Line , Segurança do Paciente , Fatores de Risco , Instrumentos Cirúrgicos/efeitos adversos , Grampeadores Cirúrgicos/efeitos adversos , Suturas/efeitos adversosRESUMO
Hypothermic machine preservation (HMP) remains investigational in clinical liver transplantation. It is widely used to preserve kidneys for transplantation with improved results over static cold storage (SCS). At our center, we have used HMP in 31 adults receiving extended criteria donor (ECD) livers declined by the originating United Network for Organ Sharing region ("orphan livers"). These cases were compared to ECD SCS cases in a matched cohort study design. Livers were matched for donor age, recipient age, cold ischemic time, donor risk index and Model for End-Stage Liver Disease (MELD) score. HMP was performed for 3-7 h at 4-8 °C using our previously published protocol. Early allograft dysfunction rates were 19% in the HMP group versus 30% in the control group (p = 0.384). One-year patient survival was 84% in the HMP group versus 80% in the SCS group (p = NS). Post hoc analysis revealed significantly less biliary complications in the HMP group versus the SCS group (4 vs. 13, p = 0.016). Mean hospital stay was significantly shorter in the HMP group (13.64 ± 10.9 vs. 20.14 ± 11.12 days in the SCS group, p = 0.001). HMP provided safe and reliable preservation in orphan livers transplanted at our center.
Assuntos
Criopreservação/métodos , Hipotermia/fisiopatologia , Tempo de Internação/estatística & dados numéricos , Hepatopatias/cirurgia , Transplante de Fígado , Preservação de Órgãos/métodos , Adolescente , Adulto , Idoso , Estudos de Coortes , Isquemia Fria , Feminino , Seguimentos , Humanos , Testes de Função Hepática , Masculino , Pessoa de Meia-Idade , Perfusão , Cuidados Pós-Operatórios , Prognóstico , Projetos de Pesquisa , Adulto JovemRESUMO
Half of the recovered expanded criteria donor (ECD) kidneys are discarded in the United States. A new kidney allocation system offers kidneys at higher risk of discard, Kidney Donor Profile Index (KDPI)>85%, to a wider geographic area to promote broader sharing and expedite utilization. Dual kidney transplantation (DKT) based on the KDPI is a potential option to streamline allocation of kidneys which otherwise would have been discarded. To assess the clinical utility of the KDPI in kidneys at higher risk of discard, we analyzed the OPTN/UNOS Registry that included the deceased donor kidneys recovered between 2002 and 2012. The primary outcomes were allograft survival, patient survival and discard rate based on different KDPI categories (<80%, 80-90% and >90%). Kidneys with KDPI>90% were associated with increased odds of discard (OR=1.99, 95% CI 1.74-2.29) compared to ones with KDPI<80%. DKTs of KDPI>90% were associated with lower overall allograft failure (HR=0.74, 95% CI 0.62-0.89) and better patient survival (HR=0.79, 95% CI 0.64-0.98) compared to single ECD kidneys with KDPI>90%. Kidneys at higher risk of discard may be offered in the up-front allocation system as a DKT. Further modeling and simulation studies are required to determine a reasonable KDPI cutoff percentile.
Assuntos
Seleção do Doador , Rejeição de Enxerto/etiologia , Falência Renal Crônica/cirurgia , Transplante de Rim/estatística & dados numéricos , Obtenção de Tecidos e Órgãos/estatística & dados numéricos , Idoso , Feminino , Seguimentos , Rejeição de Enxerto/diagnóstico , Rejeição de Enxerto/mortalidade , Sobrevivência de Enxerto , Humanos , Falência Renal Crônica/mortalidade , Transplante de Rim/efeitos adversos , Masculino , Pessoa de Meia-Idade , Prognóstico , Sistema de Registros , Estudos Retrospectivos , Fatores de Risco , Doadores de TecidosRESUMO
Incompatible live donor kidney transplantation (ILDKT) offers a survival advantage over dialysis to patients with anti-HLA donor-specific antibody (DSA). Program-specific reports (PSRs) fail to account for ILDKT, placing this practice at regulatory risk. We collected DSA data, categorized as positive Luminex, negative flow crossmatch (PLNF) (n = 185), positive flow, negative cytotoxic crossmatch (PFNC) (n = 536) or positive cytotoxic crossmatch (PCC) (n = 304), from 22 centers. We tested associations between DSA, graft loss and mortality after adjusting for PSR model factors, using 9669 compatible patients as a comparison. PLNF patients had similar graft loss; however, PFNC (adjusted hazard ratio [aHR] = 1.64, 95% confidence interval [CI]: 1.15-2.23, p = 0.007) and PCC (aHR = 5.01, 95% CI: 3.71-6.77, p < 0.001) were associated with increased graft loss in the first year. PLNF patients had similar mortality; however, PFNC (aHR = 2.04; 95% CI: 1.28-3.26; p = 0.003) and PCC (aHR = 4.59; 95% CI: 2.98-7.07; p < 0.001) were associated with increased mortality. We simulated Centers for Medicare & Medicaid Services flagging to examine ILDKT's effect on the risk of being flagged. Compared to equal-quality centers performing no ILDKT, centers performing 5%, 10% or 20% PFNC had a 1.19-, 1.33- and 1.73-fold higher odds of being flagged. Centers performing 5%, 10% or 20% PCC had a 2.22-, 4.09- and 10.72-fold higher odds. Failure to account for ILDKT's increased risk places centers providing this life-saving treatment in jeopardy of regulatory intervention.
Assuntos
Anticorpos/imunologia , Incompatibilidade de Grupos Sanguíneos/epidemiologia , Rejeição de Enxerto/etiologia , Antígenos HLA/imunologia , Transplante de Rim/legislação & jurisprudência , Transplante de Rim/estatística & dados numéricos , Doadores Vivos/provisão & distribuição , Adulto , Incompatibilidade de Grupos Sanguíneos/diagnóstico , Incompatibilidade de Grupos Sanguíneos/imunologia , Feminino , Seguimentos , Sobrevivência de Enxerto , Humanos , Incidência , Falência Renal Crônica/mortalidade , Falência Renal Crônica/cirurgia , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/mortalidade , Padrões de Prática Médica/estatística & dados numéricos , Prognóstico , Fatores de Risco , Taxa de SobrevidaRESUMO
BACKGROUND: Clostridium difficile infection (CDI) is a common cause of nosocomial antibiotic-associated diarrhea with an increased incidence reported in solid organ transplant recipients. We sought to determine if kidney and/or pancreas transplant recipients possess unique risk factors for CDI. METHODS: Between January 2009 and February 2011, 942 kidney and 56 pancreas transplants were performed at the 2 centers. Of these, 28 recipients (kidney, n = 24; pancreas, n = 4) developed CDI. Cases were matched to controls (n = 56) in a 1:2 ratio. RESULTS: Those with CDI were mostly male patients (82% vs. 48%, P = 0.003), deceased-donor organ recipients (86% vs. 64%, P = 0.045), more likely to have leukopenia (18% vs. 4%, P = 0.038), and had undergone a gastrointestinal procedure within 3 months preceding CDI diagnosis (18% vs. 4%, P = 0.038). Cases had higher cumulative and restricted antimicrobial exposure in days (37 ± 79 vs. 8 ± 12, P = 0.009 and 27 ± 69 vs. 7 ± 10, P = 0.032). Cephalosporin use was more common among cases (43% vs. 16%, P = 0.008). CONCLUSION: Careful antimicrobial selection and assurance of optimal treatment duration in the kidney and pancreas transplant population is prudent. Clinicians should have a heightened awareness of CDI risk particularly during periods of leukopenia and in the setting of gastrointestinal procedures.
Assuntos
Antibacterianos/efeitos adversos , Clostridioides difficile/isolamento & purificação , Infecções por Clostridium/epidemiologia , Diarreia/etiologia , Transplante de Rim/efeitos adversos , Transplante de Pâncreas/efeitos adversos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Aloenxertos , Estudos de Casos e Controles , Infecções por Clostridium/complicações , Infecções por Clostridium/tratamento farmacológico , Infecção Hospitalar/complicações , Infecção Hospitalar/tratamento farmacológico , Infecção Hospitalar/epidemiologia , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Adulto JovemRESUMO
Hemorrhagic deaths of living kidney donors from failure of vascular clips used on the renal artery, first documented in 2006, have continued due to postoperative Hem-o-lok clip failure with sudden, massive bleeding. While the FDA issued a Class II recall of the Hem-o-lok clip for laparoscopic donor nephrectomies in 2006, two live kidney donors in the United States and one in India have since died. Compliance in timely reporting of deaths by the manufacturer and donor hospitals has not been enforced. Oversight agencies did not inform practitioners that donors died due to clip failures. A February 2011 survey disclosed that Hem-o-lok or other clips are still used by some surgeons as a sole means of arterial control in laparoscopic donor nephrectomy; thus, a practice with documented fatal outcomes persists. We conclude that systems failures by oversight-regulatory agencies in communication to active clinicians led, at least in part, to preventable deaths. Information which was disseminated was neither complete nor timely. A corrective plan, funded by oversight agencies and the Hem-o-lok manufacturer, is proposed. All surgeons operating on a living organ donor must select vascular control techniques that entail tissue transfixion and assure a safe operative recovery. The Hem-o-lok and other surgical clips must not be used to control the donor renal artery.
Assuntos
Nefropatias/mortalidade , Nefropatias/cirurgia , Doadores Vivos , Nefrectomia/instrumentação , Nefrectomia/legislação & jurisprudência , Nefrectomia/mortalidade , Complicações Pós-Operatórias , Humanos , Laparoscopia , Tempo de Internação , Artéria Renal , Veias Renais/cirurgia , Taxa de Sobrevida , Estados UnidosRESUMO
The number of kidneys obtained from deceased diabetic donors available for transplantation has increased >eightfold increase in the past 15 years. We assessed allograft outcomes associated with deceased diabetic donors and compared them with that of standard and extended criteria donors (ECD) in the UNOS data registry. We identified 1982 recipients of diabetic standard criteria donors over a 10-year period from 1995 through 2004. Both overall and death-censored survival of organs from diabetic standard criteria donors was significantly better than that of organs obtained from nondiabetic ECD while inferior to that from nondiabetic standard criteria donors. Compared with ECD donors, diabetic donors had lower serum creatinine, less cold ischemia and these kidneys were less likely to be pump-perfused. Recipients of diabetic kidneys were younger and less likely to experience delayed graft function compared with recipient of ECD kidneys. More recently, many diabetic donor kidneys have been given to diabetic recipients with early graft survival being similar to that among nondiabetic recipients. These findings demonstrate the potential to expand and to improve utilization of this resource without compromising outcomes for recipients. Improved, evidence-based evaluation and allocation of deceased diabetic donor kidneys is needed to optimize their use.
Assuntos
Diabetes Mellitus/fisiopatologia , Transplante de Rim , Sistema de Registros , Obtenção de Tecidos e Órgãos , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Resultado do Tratamento , Estados UnidosRESUMO
Donor safety is of paramount importance in living donor transplantation. Yet, living donor deaths occur. We believe that problems exist in our system of live donor transplantation that can be summarized in a series of simple statements: (1) Donor mortality can never be completely eliminated; (2) Live donor risk has not been mitigated so that it is as low as possible; (3) After a donor death, systematic reviews are not routinely performed to identify correctable causes; (4) The lessons learned from any donor death are not adequately communicated to other programs and (5) The administrative mechanisms and resources are not universally available at all transplant centers to implement lessons learned. To rectify these problems, we propose the following: (1) A national living donor death task force be established with the purpose of performing systematic reviews of any donor death. (2) Findings of these reviews be disseminated to all institutions performing live donor transplants on a secure, password-protected website. (3) A no-fault donor death indemnity fund be established to provide a financial imperative for institutions to cooperate with this external peer-review. These measures will serve the best interests of the involved institutions, the transplant community, and most importantly, the patients and their families.
Assuntos
Doadores Vivos , Nefrectomia/mortalidade , Revisão dos Cuidados de Saúde por Pares , Feminino , Hepatectomia/mortalidade , Humanos , Transplante de Rim , Masculino , Obtenção de Tecidos e ÓrgãosRESUMO
Acute arterial thrombosis is an uncommon but potentially devastating consequence of kidney transplantation. Early recognition followed by thrombectomy may salvage the graft. We present a case of acute renal artery thrombosis after a living-related kidney transplant with successful treatment with operative thrombectomy and intraarterial infusion of recombinant tissue-type plasminogen activator.
Assuntos
Transplante de Rim/efeitos adversos , Artéria Renal , Trombose/tratamento farmacológico , Ativador de Plasminogênio Tecidual/uso terapêutico , Adolescente , Feminino , Humanos , Rim/cirurgia , Transplante de Rim/métodos , Proteínas Recombinantes/uso terapêutico , Artéria Renal/cirurgia , Trombectomia/métodos , Trombose/cirurgiaRESUMO
Despite the Organ Donation Breakthrough Collaborative's work to engage the transplant community and the suggested positive impact from these efforts, availability of transplanted organs over the past 5 years has declined. Living kidney, liver and lung donations declined from 2004 to 2008. Living liver donors in 2008 dropped to less than 50% of the peak (524) in 2001. There were more living donors that were older and who were unrelated to the recipient. Percentages of living donors from racial minorities remained unchanged over the past 5 years, but percentages of Hispanic/Latino and Asian donors increased, and African American donors decreased. The OPTN/UNOS Living Donor Transplant Committee restructured to enfranchise organ donors and recipients, and to seek their perspectives on living donor transplantation. In 2008, for the first time in OPTN history, deceased donor organs decreased compared to the prior year. Except for lung donors, deceased organ donation fell from 2007 to 2008. Donation after cardiac death (DCD) has accounted for a nearly 10-fold increase in kidney donors from 1999 to 2008. Use of livers from DCD donors declined in 2008 to 2005 levels. Understanding health risks associated with the transplantation of organs from 'high-risk' donors has received increased scrutiny.
Assuntos
Doadores de Tecidos/provisão & distribuição , Doadores de Tecidos/estatística & dados numéricos , Obtenção de Tecidos e Órgãos/estatística & dados numéricos , Obtenção de Tecidos e Órgãos/tendências , Negro ou Afro-Americano/estatística & dados numéricos , Hispânico ou Latino/estatística & dados numéricos , Humanos , Rim , Fígado , Doadores Vivos/estatística & dados numéricos , Pulmão , Grupos Minoritários/estatística & dados numéricos , Grupos Raciais , Estados Unidos/epidemiologiaRESUMO
Hypothermic machine perfusion (HMP) is widely used to preserve kidneys for transplantation with improved results over cold storage (CS). To date, successful transplantation of livers preserved with HMP has been reported only in animal models. In this, the first prospective liver HMP study, 20 adults received HMP-preserved livers and were compared to a matched group transplanted with CS livers. HMP was performed for 3-7 h using centrifugal perfusion with Vasosol solution at 4-6 degrees C. There were no cases of primary nonfunction in either group. Early allograft dysfunction rates were 5% in the HMP group versus 25% in controls (p = 0.08). At 12 months, there were two deaths in each group, all unrelated to preservation or graft function. There were no vascular complications in HMP livers. Two biliary complications were observed in HMP livers compared with four in the CS group. Serum injury markers were significantly lower in the HMP group. Mean hospital stay was shorter in the HMP group (10.9 +/- 4.7 days vs. 15.3 +/- 4.9 days in the CS group, p = 0.006). HMP of donor livers provided safe and reliable preservation in this pilot case-controlled series. Further multicenter HMP trials are now warranted.
Assuntos
Transplante de Fígado , Adulto , Criopreservação , Humanos , Hipotermia/fisiopatologia , Fígado/fisiopatologia , Testes de Função Hepática , Perfusão/métodosRESUMO
It is critical to balance waitlist mortality against posttransplant mortality. Our objective was to devise a scoring system that predicts recipient survival at 3 months following liver transplantation to complement MELD-predicted waitlist mortality. Univariate and multivariate analysis on 21,673 liver transplant recipients identified independent recipient and donor risk factors for posttransplant mortality. A retrospective analysis conducted on 30,321 waitlisted candidates reevaluated the predictive ability of the Model for End-Stage Liver Disease (MELD) score. We identified 13 recipient factors, 4 donor factors and 2 operative factors (warm and cold ischemia) as significant predictors of recipient mortality following liver transplantation at 3 months. The Survival Outcomes Following Liver Transplant (SOFT) Score utilized 18 risk factors (excluding warm ischemia) to successfully predict 3-month recipient survival following liver transplantation. This analysis represents a study of waitlisted candidates and transplant recipients of liver allografts after the MELD score was implemented. Unlike MELD, the SOFT score can accurately predict 3-month survival following liver transplantation. The most significant risk factors were previous transplantation and life support pretransplant. The SOFT score can help clinicians determine in real time which candidates should be transplanted with which allografts. Combined with MELD, SOFT can better quantify survival benefit for individual transplant procedures.
Assuntos
Técnicas de Apoio para a Decisão , Determinação de Ponto Final/métodos , Transplante de Fígado/mortalidade , Modelos Teóricos , Avaliação de Resultados em Cuidados de Saúde/métodos , Adulto , Feminino , Humanos , Estimativa de Kaplan-Meier , Hepatopatias/diagnóstico , Hepatopatias/mortalidade , Hepatopatias/cirurgia , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Prognóstico , Estudos Retrospectivos , Análise de Sobrevida , Resultado do Tratamento , Listas de Espera , Isquemia QuenteRESUMO
To assess the significance of antibodies detected by complement-dependent cytotoxicity (CDC), solid phase (SPA) and flow cytometry (FC) assays we compared their predictive value in 354 consecutive cases of deceased-donor kidney transplantation. Pre-transplantation screening of anti-HLA class I and class II antibodies was performed by CDC and SPA. The direct crossmatch between recipients' sera and donors' T and B cells was performed by CDC followed by FC and SPA ("virtual cross-match"). The past history of antibodies displayed by the recipient was not considered a contraindication for transplantation even when it showed DSA. A side-by-side comparison of the correlation between graft loss, history of DSA and cross-match results indicated that sensitivity was 5%, 16% and 17% while specificity was 99%, 93% and 86% in CDC, SPA, FC crossmatches respectively. There was no significant difference between the 3 year survival of primary and secondary kidney allografts. We conclude that screening and cross-matching the sera by CDC provides reliable results and optimizes the patient's chances to receive a transplant. SPA and FC, however, are of great importance for identifying patients which require close monitoring by biopsy and serology for early diagnosis and treatment of acute antibody mediated rejection (AAMR).
Assuntos
Rejeição de Enxerto/imunologia , Antígenos de Histocompatibilidade Classe II/imunologia , Antígenos de Histocompatibilidade Classe I/imunologia , Teste de Histocompatibilidade/métodos , Isoanticorpos/sangue , Transplante de Rim/imunologia , Corticosteroides/administração & dosagem , Corticosteroides/uso terapêutico , Adulto , Idoso , Cadáver , Testes Imunológicos de Citotoxicidade , Feminino , Citometria de Fluxo , Rejeição de Enxerto/tratamento farmacológico , Rejeição de Enxerto/mortalidade , Sobrevivência de Enxerto/imunologia , Humanos , Terapia de Imunossupressão , Transplante de Rim/mortalidade , Masculino , Pessoa de Meia-Idade , Ácido Micofenólico/administração & dosagem , Ácido Micofenólico/análogos & derivados , Ácido Micofenólico/uso terapêutico , Valor Preditivo dos Testes , Sensibilidade e Especificidade , Tacrolimo/administração & dosagem , Tacrolimo/uso terapêuticoRESUMO
INTRODUCTION: Our center has recently observed foreign carbohydrate-appearing particles (FP) on transplant postreperfusion biopsy specimens: (PRBx). METHODS: To further characterize FPs, we reviewed all renal transplant RBx (30-45 minutes) performed between September 1, 2004 and December 3, 2005. Donor, preservation, and outcome variables were collected among patients with FP. RESULTS: A total of 135 PRBx were performed (45 deceased donors [DD] and 90 live donors [LD]). Fifteen PRBx demonstrated FP. All 15 cases were DD kidneys that underwent machine perfusion (MP) on the Waters RM3 (Waters Medical Systems, Rochester, Minn, United States) with Belzer MP solution (Trans Med, Elk River, Minn, United States). Donor age was 39.8 +/- 15.7 years. Terminal creatinine level was 1.45 +/- 0.8 mg/dL. Two of 15 were flushed in situ with HTK solution (no starch). Cold ischemia time was 28.8 +/- 9.1 hours with 14.3 +/- 5.1 hours of MP. In 13 of 15 patients, perfusion parameters were excellent (flow > 100 mL; resistance < .35). CHARACTERISTICS OF FP: Particles were 10-30 mu and globular in shape. FP were not visible on hematoxylin and eosin stain, but stained strongly periodic acid-Schiff-(PAS) positive and were refractile under polarized light. FP were seen segmentally within glomerular capillaries in all cases and in peritubular capillaries in 3. In 11 of the 15 cases with FP, focal glomerular fibrin thrombi or intracapillary neutrophil margination was seen. Ten of 15 patients with FP had a biopsy within the first week with no identifiable FP. OUTCOMES: Recipient age was 45.3 +/- 11.6 years. Eight patients (53.3%) had delayed graft function. Biopsy-proven rejection occurred in 3 patients (20%). Three-month creatinine level was 1.59 +/- 0.35 mg/dL. One graft was lost to early thrombosis in a patient with a hypercoagulable state and 1 patient died of sepsis at 2 months. All remaining 13 patients are alive with excellent graft function at a median follow-up of 6.7 months (range, 3-17 months). CONCLUSIONS: Microscopic intrarenal particles may be seen on DD kidney PRBx after MP. These FPs likely originate from surgical gloves. FPs are too small to be captured by standard filters but clear spontaneously and do not have deleterious effects on renal function or outcomes.
Assuntos
Transplante de Rim/patologia , Preservação de Órgãos/métodos , Adulto , Biópsia , Cadáver , Carboidratos/análise , Creatinina/sangue , Seguimentos , Corpos Estranhos/patologia , Humanos , Glomérulos Renais/citologia , Glomérulos Renais/ultraestrutura , Transplante de Rim/fisiologia , Doadores Vivos , Pessoa de Meia-Idade , Fatores de Tempo , Doadores de Tecidos , Resultado do TratamentoRESUMO
Renal transplantation after repair of aortoiliac aneurysms with traditional prosthetic vascular grafts has been shown to be effective. Vascular surgery continues to rapidly evolve, most notably with the advancement of endovascular repair of abdominal aortic aneurysms. Controlled trials continue to support the trend toward the use of endovascular bifurcated aortic stent grafts. For this we describe the first renal transplant in a patient with an endovascular bifurcated aortoiliac stent graft. No intraoperative difficulties were encountered. At 1-year follow-up, the transplanted kidney is functioning well with a normal serum creatinine level of 1.3 mg/dl, and the patient has no worsening of peripheral vascular disease. We recommend that the presence of an endovascular aortic graft not be a contraindication to renal transplantation.