Ethylene-vinyl alcohol copolymer endobiliary obliteration of hepatic segments in a patient with isolated bile leaks.

A 54-year-old woman with a symptomatic giant hepatic hemangioma underwent an extended left hepatic trisegmentectomy complicated by 250-350 mL/d postoperative bilious drainage. After 5 months of therapy, drainage was unabated, and the patient was no longer a surgical candidate. Sinography revealed three distinct isolated bile duct leaks involving segments 6, 7, and 8. Endobiliary segmentectomy was achieved by obliterating the isolated systems with ethylene-vinyl alcohol copolymer (Onyx; ev3, Plymouth, Minnesota) during three fluoroscopic procedures. Bilious leaks were successfully eliminated, and compensatory hypertrophy of noninvolved liver occurred. At 2 years from the last embolization procedure, the patient remained asymptomatic with no bilious leak.

Modification of the HeRO graft allowing earlier cannulation and reduction in catheter dependent days in patients with end stage renal disease: a single center retrospective review.

After creation of an arteriovenous fistula or placement of an arteriovenous graft, several weeks are required for maturation prior to first cannulation. Patients need an alternative way to receive hemodialysis during this time, frequently a catheter. After multiple failed access attempts, patients can run out of options and become catheter dependent. At our institution, we place HeRO grafts in eligible patients who have otherwise been told they would be catheter dependent for life. By combining the HeRO graft system with a Flixene graft, patients are able to remove catheters sooner or avoid placement as they can undergo cannulation for hemodialysis the next day. Utilizing this novel technique, twenty-one patients over a two-year period with various forms of central venous stenosis, catheter dependence, or failing existing arteriovenous access have been successfully converted to stable long term noncatheter based upper extremity access.

Hemodialysis Arteriovenous Access Cosmesis Scale (AVACS): A new measure for vascular access.

RATIONALE AND OBJECTIVE: This study aimed to develop a cosmesis scale to evaluate the cosmetic appearance of hemodialysis (HD) arteriovenous (AV) accesses from the perspective of the patient and clinician, which could be incorporated into clinical trials. STUDY DESIGN: Using a modified Delphi process, two AV access cosmesis scale (AVACS) components were developed in a four-round Delphi panel consisting of two surveys and two consensus meetings with two rounds of patient consultation. SETTING AND PARTICIPANTS: The Delphi panel consisted of 15 voting members including five interventional or general nephrologists, five vascular surgeons, three interventional radiologists, and two vascular access nurse coordinators. Four patients experienced with vascular access were involved in patient question development. ANALYTICAL APPROACH: For a component to be included in the AVACS, it had to meet the prespecified panel consensus agreement of ⩾70%. RESULTS: The clinician component of the AVACS includes nine questions on the following AV access features: scarring, skin discoloration, aneurysm/pseudoaneurysms and megafistula appearance. The patient component includes six questions about future vascular access decisions, interference with work or leisure activities, clothing choices, self-consciousness or attractiveness, emotional impact, and overall appearance. LIMITATIONS: Delphi panel methods are subjective by design, but with expert clinical opinion are used to develop classification systems and outcome measures. The developed scale requires further validation testing but is available for clinical trial use. CONCLUSIONS: While safety and efficacy are the primary concerns when evaluating AV access for HD, cosmesis is an important component of the ESKD patient experience. The AVACS has been designed to assess this important domain; it can be used to facilitate patient care and education about vascular access choice and maintenance. AVACS can also be used to inform future research on developing new techniques for AV access creation and maintenance, particularly as relates to AV access cosmesis.

Post transplant renal vein thrombosis, with successful thrombectomy and review of the literature.

INTRODUCTION: Renal vein thrombosis post kidney transplant is a rare but graft threatening event. RVT is reported in 0.3-4.2% of kidney transplants. When occurring early post transplant, prior to development of collateral venous outflow, may be catastrophic with loss of the allograft or even death. Anatomic abnormalities or technical problems during surgery are common causes. Early diagnosis and urgent treatment are necessary but often unsuccessful. PRESENTATION OF CASE: We report a patient with residual function in a failing allograft who developed RVT in a living donor preemptive kidney transplant. DISCUSSION: We review the literature regarding renal vein thrombosis following kidney transplant. CONCLUSION: Prompt diagnosis and immediate surgicathrombectomy after ex-planting allograft with subsequent re-implanting the allograft was successful.

Living donor kidney transplantation at the University of Michigan.

Since renal transplantation is the definitive therapy for most patients with end stage renal disease, we have the challenge of meeting the needs of this rapidly growing population. Currently greater than 1000 patients are waiting for kidney transplantation at the University of Michigan. To meet this demand we have aggressively expanded the donor pool from both deceased and living donors. The focus of this update has been the evolving living donor program at the University of Michigan. In light of the rising rates of obesity in America, we have developed a specialized evaluation to assess potential obese donors. Individuals with a history of hypertension and no other risk factors for kidney failure are screened according to a protocol seeking to identify patients with a low risk of developing chronic kidney disease. We have developed unique approaches to patients with anatomic anomalies as well as nephrolithiasis. Despite all of these progressive approaches, our living donor outcomes at the University of Michigan have remained excellent and we have continued to provide a high standard of care for our recipients suffering from end stage renal disease.

Role for CD4(+)CD25(+) T cells in inhibition of graft rejection by extracorporeal photopheresis.

BACKGROUND: Extracorporeal photopheresis (ECP) is used to treat recurrent severe rejection in clinical heart and lung recipients. The mechanisms of the salutary effects of ECP are poorly understood, but appear to involve regulation of T-cell-mediated alloreactive responses, possibly by induction of regulatory T cells. We created a mouse model of ECP to determine the effects of ECP on T-cell responses in vivo and the contribution of CD4(+)CD25(+) T cells. METHODS: In this study, 1 x 10(7) splenocytes were treated with 8-methoxypsoralen (8-MOP, 200 ng/ml), followed by ultraviolet A (UVA) irradiation (2 J/cm(2), 350 nm), and then injected intravenously into syngeneic mice. Thirty minutes later, the treated animals received heterotopic cardiac allografts with no immunosuppression. Treated graft recipients were analyzed to determine the effect of ECP on graft survival, deletion of allospecific T cells, and the frequency and in vivo suppressive activity of CD4(+)CD25(+) T cells. RESULTS: ECP extends cardiac allograft survival in at least two different strain combinations. For CBA/Ca recipients of C57BL/6 allografts, median survival time (MST) in ECP-treated animals was 16 days vs 10 days in graft recipients treated with cells exposed only to 8-MOP (p = 0.04). The frequency of splenic CD4(+)CD25(+) cells expressing FoxP3(+) increased 2-fold in ECP-treated CBA/Ca mice (82.6 +/- 5.2%, n = 4) relative to untreated mice (44.9 +/- 4.5%, n = 4, p < 0.001). Adoptive transfer of 3 x 10(5) sorted CD4(+)CD25(+) splenocytes from ECP-treated graft recipients to untreated cardiac allograft recipients 30 minutes after transplantation resulted in extended graft survival compared with animals that received the same number of CD4(+)CD25(+) splenocytes from cardiac allograft recipients not treated with ECP (MST: 24 days vs 13 days, respectively, p = 0.001). Analyses of 5,6-carboxy-fluorescein-succinimidyl-ester (CFSE)-labeled H-2K(b)-specific T cells in the spleen and lymph node showed no evidence of peripheral deletion after ECP treatment. CONCLUSIONS: ECP extends graft survival even in fully histoincompatible strain combinations with no immunosuppression. It increases the frequency of FoxP3(+)CD4(+)CD25(+) splenic T cells, and its effects can be transferred to untreated recipients using minimal numbers of CD4(+)CD25(+) T cells, indicating that CD4(+)CD25(+) T cells may play a key role in the immunomodulatory effects of ECP.