Kidney transplant outcomes following the introduction of hand-assisted laparoscopic living donor nephrectomy: a comparison of recipient groups.

BACKGROUND: Laparoscopic donor nephrectomy has become the procedure of choice for living donor kidney transplantation in many centres. We report on our experience with hand-assisted laparoscopic donor nephrectomy (HALDN). We concentrated on graft function and postoperative surgical complications in the recipient population, and compared outcomes to a similar recipient group who had received kidneys procured by open living-donor nephrectomy (OLDN). METHOD: Following the receipt of institutional approval, the files of all patients who received a kidney transplant between September 2008 and June 2011 were reviewed. One hundred patients with end-stage renal disease received kidney transplantations from living donors. OLDN was performed in 65 donors, and 35 underwent HALDN. Delayed graft function (DGF) and postoperative complications were recorded. RESULTS: Six adverse events were reported, during which five patients presented with DGF. One DGF was reported in the HALDN group, and four in the OLDN group. The morbidity in the HALDN group (1/35, 3%) was a graft rupture secondary to acute rejection which required exploration and transplant nephrectomy. Reoperation was required in five patients in the OLDN group (5/65, 8%). This amounted to overall morbidity of 6%, with no recipient mortalities. CONCLUSION: As previously documented, HALDN is safe for the donor, and not inferior to OLDN. In this study, it was associated with neither an increased incidence of DGF, nor a higher complication rate in the transplant recipient, when compared to the cohort that received a kidney harvested using the OLDN technique.

Hand-assisted laparoscopic live donor nephrectomy - initial experience.

INTRODUCTION: The advantages of minimally invasive live donor nephrectomy have been well documented, with no adverse effect on graft function. Minimal access nephrectomy has now become the standard of care in many units. We have adopted the hand-assisted laparoscopic live donor (HALLDN) technique, and present our initial experience with the first 24 cases. MATERIAL AND METHODS: HALLDNs were performed trans-peritoneally. Primary outcomes included total operative time, warm ischaemic time, time to discharge, and post-operative complications. Warm ischaemic time was measured from the time of clamping the renal artery to the time of perfusing the kidney on the back table. RESULTS: Mean total operative time was 143 minutes and mean warm ischaemic time was 188 seconds. A downward trend was displayed for operative times. Mean time to discharge was 60 hours. A right nephrectomy was performed in 2 cases. No surgical morbidity is reported. We describe 1 donor mortality. DISCUSSION: Our results compare favourably with those documented in the literature. Aberrant renal vascular anatomy had no adverse effect on operative or warm ischaemic times. HALLDN proved beneficial in patients with a high BMI. CONCLUSION: Surgical experience is vital when performing HALLDN. Overcoming the learning curve with an animal model is beneficial.

Parathyroid hypertension. A reversible disorder.

A retrospective study of 75 patients who were surgically cured of primary hyperparathyroidism from 1976 to 1984 was performed to evaluate the blood pressure and metabolic responses to parathyroid surgery. Published data on the population prevalence of hypertension (HT) in South Africa were used for comparison. The overall prevalence of HT before surgery was 47%, compared with 23% in the general population. Hypertension was most frequent in patients older than 60 years (62% vs 39% expected). Renal insufficiency was found in 13 of 35 hypertensive patients and in two of 40 normotensive patients. However, the prevalence of HT in patients with normal creatinine levels (37%) exceeded that expected. The frequency of urolithiasis and mean levels of serum and urine calcium and phosphate were similar in normotensive and hypertensive patients. Parathyroidectomy resulted in a substantial fall in both mean systolic and mean diastolic blood pressures in 54% of the hypertensive subjects, unrelated to improvement in renal function.

Primary hyperaldosteronism due to a functional black (pigmented) adenoma of the adrenal cortex.

The clinical and pathologic findings are reported in a case of primary hyperaldosteronism due to a functional black (pigmented) adenoma of the adrenal cortex. Cortical atrophy of the involved gland was present, the mechanism of which was obscure.

Parathyroid function after successful renal transplantation.

PURPOSE: The aim of this retrospective study was to assess parathyroid function after renal transplantation in patients with good renal function (creatinine < 133 mumol/l). METHODS AND MATERIALS: Of 1,628 patients on whom we performed renal transplantation, 210 have stable good renal function as defined above. Total calcium (Ca), creatinine, albumin and parathyroid hormone (PTH) values were obtained from patient records at varying intervals after transplantation, and in 91/210 patients pre-transplant values were available. Patients who had undergone parathyroidectomy before the transplant were excluded from the study. Follow-up ranged from 6 months to 24 years. RESULTS: These 210 patients were divided into 4 groups according to PTH and Ca levels. Group 1 consisted of 118 patients (56%) with normal Ca and PTH levels and group 2 of 69 patients (33%) with normal Ca but persistently high PTH levels, of whom 25 persistently have Ca levels in the high normal range. The reason for the inappropriate PTH levels is not obvious. In group 3 there were 18 patients (8%) with high Ca and PTH levels. They have disease requiring parathyroidectomy. Group 4 comprised 5 patients (3%) with low Ca and high PTH levels. In the 91 patients for whom pre-transplant PTH values were available, 16/46 patients with tertiary hyperparathyroidism (3 degrees HPT) have normalised after transplant, 12/46 patients have ongoing 3 degrees HPT post transplant, while 4/45 patients with less severe disease (secondary HPT) have developed 3 degrees HPT (P < 0.059). CONCLUSIONS: In 56% of patients with good renal function after transplant parathyroid function is normal. Thirty-three per cent have high PTH levels with normal Ca, but 36% of these are in the high normal range. Eight per cent have persistent 3 degrees HPT. Post-transplant parathyroid dysfunction correlates with the severity of pre-transplant disease.

Hypercalcaemia in sarcoidosis co-existing with primary hyperparathyroidism. A case report.

Patients presenting with hypercalcaemia caused by the co-existence of sarcoidosis and primary hyperparathyroidism may present a diagnostic problem. Tests for sarcoid activity, together with the cortisone suppression test and an estimation of the immunoreactive parathyroid hormone level are all necessary to differentiate between those conditions.

Escherichia coli O157:H7 haemorrhagic colitis. Report of the first South African case.

Escherichia coli O157:H7, although recognised 15 years ago, has only become a significant pathogen since 1982 when two outbreaks of haemorrhagic colitis due to this organism were described in the USA. Since then, numerous such outbreaks have been reported. Recent experience with a patient presenting with E. coli O157:H7-induced haemorrhagic colitis is described. The main features, pathological findings and investigations are described and the principles of management outlined.

Time-dependent changes in serum gastrin measurements after parathyroidectomy.

A prospective study involving 7 patients with primary hyperparathyroidism and hypergastrinaemia was conducted to assess the time-dependent change in serum gastrin value before and after parathyroidectomy and to determine at which postoperative stage persistent hypergastrinaemia may be indicative of an associated gastrinoma (Zollinger-Ellison syndrome). Five of the 7 patients had hypergastrinaemia in the early postoperative period. One patient had a strikingly high serum gastrin level pre-operatively (1,500 pg/ml). The mean serum gastrin value declined to within the normal range 6 weeks after parathyroidectomy, except in 1 patient who had a gastrinoma. It is concluded that hypergastrinaemia in patients with primary hyperparathyroidism should only be considered significant if pre-operative gastrin levels are strikingly supranormal and/or levels fail to normalise by the 6th postoperative week.

Successes and failures of endoscopic injection haemostasis for bleeding peptic ulcers. A prospective clinical study.

Fifty-two consecutive patients with upper gastrointestinal haemorrhage, shock (systolic blood pressure less than 100 mmHg) and a peptic ulcer showing endoscopic stigma of recent haemorrhage underwent attempts at endoscopic haemostasis. The ulcers were injected with a dilute solution of adrenaline followed by 5% ethanolamine oleate. Active bleeding was present in 22 patients (42%) at initial endoscopy. Bleeding was controlled in 40 patients (77%) in hospital. Failure occurred more frequently in duodenal ulcers than gastric ulcers (46% v. 7%; P < 0.004), and in giant (more than 2 cm diameter) duodenal ulcers (6/7) than smaller duodenal ulcers (3/15). We recommend early surgery for large posterior duodenal ulcers in preference to endoscopic injection methods.