Goal-Directed Haemodynamic Therapy Improves Patient Outcomes in Kidney Transplantation.

Introduction: Kidney transplant graft function depends on optimised haemodynamics. However, high fluid volumes risk hypervolaemic complications. The Edwards Lifesciences ClearSight™ device permits fluid titration through markers of preload and beat-to-beat blood pressure monitoring. We evaluated the implementation of a novel goal-directed haemodynamic therapy protocol to determine whether patient outcomes had improved. Design: A retrospective evaluation of standard care versus goal-directed haemodynamic therapy in adults undergoing kidney transplantation was performed in a single centre between April 2016 and October 2019. Twenty-eight standard-of-care patients received intraoperative fixed-rate infusion and 28 patients received goal-directed haemodynamic therapy. The primary outcome was volume of fluid administered intraoperatively. Secondary outcomes included blood product and vasoactive drug exposure, graft and recipient outcomes. Results: Intraoperative fluid administered was significantly reduced in the goal-directed haemodynamic therapy cohort (4325 vs 2751 ml, P < .001). Exposure to vasopressor (67.9% vs 42.9%, P = .060) and blood products (17.9% vs 3.6%, P = .101) was unchanged. Immediate graft function (82.1% vs 75.0%, P = .515), dialysis requirement (14.3% vs 21.4%, P = .729) and creatinine changes post-operatively were unchanged. In the goal-directed haemodynamic therapy cohort, 1 patient had pulmonary oedema (3.6%) versus 21.4% in the standard cohort. Patients in the goal-directed haemodynamic therapy group were more likely to mobilise within 48 hours of surgery (number needed to treat = 3.5, P = .012). Conclusions: Protocolised goal-directed haemodynamic therapy in kidney transplantation was safe and may improve patient, graft, and surgical outcomes. Clinical trials assessing goal-directed approaches are needed.

The Value of Perfusion Fluid Culture Analysis in Deceased Donor Renal Transplants: A 10-Year Single-Center Experience.

Microbiological analysis of kidney perfusion/transport solution is not routinely performed in all transplant centers. This paper gives a 10-year descriptive single-center experience of the routine culture of perfusion fluid in deceased donor renal transplant recipients as well as the prophylactic treatment of certain organisms if identified. Data were collected retrospectively on all deceased donor transplants performed between 2009 and 2018. Organisms detected were classified as either pathologic, of uncertain pathogenicity, or contaminants. Treatment was guided by the microbiology team. A total of 661 specimens were analyzed. Organisms were cultured in 168 of 661 (25.4%) of these samples. The most frequent organisms identified were skin and oral flora (n = 95, 42%). The majority of organisms identified (131 of 226, 58%) necessitated prophylactic treatment on the advice of our microbiology department. On 7 (4.2%) occasions, the perfusion fluid cultures grew organisms not covered by the routine antimicrobial prophylaxis, and on 15 occasions Candida albicans was isolated. Candida isolates were treated preemptively with 1 month of antifungal treatment. There were no infective sequelae in this group.

Oxygenated End-Hypothermic Machine Perfusion in Expanded Criteria Donor Kidney Transplant: A Randomized Clinical Trial.

Importance: Continuous hypothermic machine perfusion during organ preservation has a beneficial effect on graft function and survival in kidney transplant when compared with static cold storage (SCS). Objective: To compare the effect of short-term oxygenated hypothermic machine perfusion preservation (end-HMPo2) after SCS vs SCS alone on 1-year graft survival in expanded criteria donor kidneys from donors who are brain dead. Design, Setting, and Participants: In a prospective, randomized, multicenter trial, kidneys from expanded criteria donors were randomized to either SCS alone or SCS followed by end-HMPo2 prior to implantation with a minimum machine perfusion time of 120 minutes. Kidneys were randomized between January 2015 and May 2018, and analysis began May 2019. Analysis was intention to treat. Interventions: On randomization and before implantation, deceased donor kidneys were either kept on SCS or placed on HMPo2. Main Outcome and Measures: Primary end point was 1-year graft survival, with delayed graft function, primary nonfunction, acute rejection, estimated glomerular filtration rate, and patient survival as secondary end points. Results: Centers in 5 European countries randomized 305 kidneys (median [range] donor age, 64 [50-84] years), of which 262 kidneys (127 [48.5%] in the end-HMPo2 group vs 135 [51.5%] in the SCS group) were successfully transplanted. Median (range) cold ischemia time was 13.2 (5.1-28.7) hours in the end-HMPo2 group and 12.9 (4-29.2) hours in the SCS group; median (range) duration in the end-HMPo2 group was 4.7 (0.8-17.1) hours. One-year graft survival was 92.1% (n = 117) in the end-HMPo2 group vs 93.3% (n = 126) in the SCS group (95% CI, -7.5 to 5.1; P = .71). The secondary end point analysis showed no significant between-group differences for delayed graft function, primary nonfunction, estimated glomerular filtration rate, and acute rejection. Conclusions and Relevance: Reconditioning of expanded criteria donor kidneys from donors who are brain dead using end-HMPo2 after SCS does not improve graft survival or function compared with SCS alone. This study is underpowered owing to the high overall graft survival rate, limiting interpretation. Trial Registration: isrctn.org Identifier: ISRCTN63852508.

Mortality Rates in Transplant Recipients and Transplantation Candidates in a High-prevalence COVID-19 Environment.

BACKGROUND: The risk of COVID-19 infection in transplant recipients (TRs) is unknown. Patients on dialysis may be exposed to greater risk of infection due to an inability to isolate. Consideration of these competing risks is important before restarting suspended transplant programs. This study compared outcomes in kidney and kidney/pancreas TRs with those on the waiting list, following admission with COVID-19 in a high-prevalence region. METHODS: Audit data from all 6 London transplant centers were amalgamated. Demographic and laboratory data were collected and outcomes included mortality, intensive care (ITU) admission, and ventilation. Adult patients who had undergone a kidney or kidney/pancreas transplant, and those active on the transplant waiting list at the start of the pandemic were included. RESULTS: One hundred twenty-one TRs and 52 waiting list patients (WL) were admitted to hospital with COVID-19. Thirty-six TR died (30%), while 14 WL patients died (27% P = 0.71). There was no difference in rates of admission to ITU or ventilation. Twenty-four percent of TR required renal replacement therapy, and 12% lost their grafts. Lymphocyte nadir and D-dimer peak showed no difference in those who did and did not die. No other comorbidities or demographic factors were associated with mortality, except for age (odds ratio of 4.3 [95% CI 1.8-10.2] for mortality if aged over 60 y) in TR. CONCLUSIONS: TRs and waiting list patients have similar mortality rates after hospital admission with COVID-19. Mortality was higher in older TRs. These data should inform decisions about transplantation in the COVID era.

Robot-assisted kidney transplantation: update from the European Robotic Urology Section (ERUS) series.

OBJECTIVE: To report the results of the robot-assisted kidney transplantation (RAKT) experience performed in 10 European centres by members of the European Robotic Urology Section (ERUS)-RAKT group. PATIENTS AND METHODS: This is a multicentre prospective observational study of RAKT. Descriptive analysis of recipients and donor characteristics, surgical data, intraoperative outcomes, complications rate and functional results were collected and analysed. RESULTS: Between July 2015 and September 2019, 291 living-donor RAKTs were performed. Recipients were mostly male (189 [65%]), the mean Standard deviation (sd) age was 45.2 (13.35) years, the mean (sd) body mass index was 27.13 (19.28) kg/m2 , and RAKT was pre-emptive in 155 (53.8%) cases. Right and multiple arteries kidneys were used in 15.4%. The mean (sd) total surgical and re-warming time was 244 (70.5) min and 53.16 (15.27) min, respectively. In all, 17 patients presented with postoperative bleeding (5.7%). Five kidneys had delayed graft function; five (2%) were lost due to thrombosis and one due to acute rejection. Two patients had arterial stenosis, three had incisional hernias, six had ureteric stenosis, and nine had lymphoceles. Neither surgical nor re-warming times were correlated with postoperative serum creatinine levels (P > 0.05). Comparison of surgical data between the first 120 cases and the following 171 cases showed a significantly shorter total surgical time in the second group (265 vs 230 min, P = 0.005). CONCLUSIONS: This is the largest European multicentre study of RAKT with good surgical and functional results competitive with open kidney transplant series, with a relatively short learning curve when performed in centres with a wide experience in open kidney transplantation and robotic surgery.

Complex Open Pyeloplasty in a Pelvic Kidney.

A pelvic kidney occurs in between 1 in 2200 and 1 in 3000 people,1 due to failure of ascent during development. It is commonly asymptomatic and usually functions normally. Pelvic ureteral junction obstruction can either be congenital or acquired, and is characterized by intrinsic stenosis or extrinsic compression of the ureter at the junction with the pelvicalyceal renal system. This can cause symptomatic or asymptomatic hydronephrosis. We describe the complex case and management of a patient with a massive pelvic ureteral junction obstruction in a pelvic kidney.

A Rare Presentation of Escherichia coli Necrotizing Fasciitis in Renal Transplantation.

Necrotizing fasciitis is a devastating, rapidly pro-gressive soft tissue infection. We present an unusual case of Escherichia coli necrotizing fasciitis following renal transplant. The patient was a 50-year-old woman previously on long-term hemodialysis who presented with left thigh erythema adjacent to the site of a central venous catheter 5 days after renal transplant. The classical features of necrotizing fasciitis were initially absent, and, despite aggressive resuscitation and debridement, she did not survive. Monomicrobial E. coli necrotizing fasciitis is rare, especially in this cohort of patients. Immunosuppression is a known risk factor for infection, and patients may present atypically. Shock and erythema may be the only clues to infection. Necrotizing fasciitis must be considered in acutely unwell renal transplant recipients so that immediate and life-saving surgical debridement can be delivered.

Perioperative management of adult cadaveric and live donor renal transplantation in the UK: a survey of national practice.

BACKGROUND: There is a limited evidence base and no national consensus regarding the perioperative management of patients undergoing renal transplantation. We developed an electronic survey to capture an overview of renal transplant perioperative practice across UK renal transplant centres and determine the need for future guidelines on patient management. METHODS: A 29-question survey was developed to encompass the entire renal transplant perioperative pathway and input was sought from clinicians with expertise in renal transplant surgery, anaesthesia, nephrology and intensive care. The survey was sent to lead renal anaesthetists at each of the 23 transplant centres across the UK. RESULTS: A 96% response rate was achieved with 22 out of 23 centres returning complete responses. There was limited evidence of guideline-based approaches to preoperative workup. Questions regarding intraoperative fluid management, blood pressure targets, vasopressor administration and central venous pressure (CVP) monitoring identified a broad range of practice. Of note, the routine use of goal-directed fluid therapy based on cardiac output estimation was reported in six (27.3%) centres, while nine centres (40.9%) continue to target a specific CVP intraoperatively. In all, 12 (54.5%) centres perform transversus abdominis plane blocks with fentanyl-based patient-controlled analgesia as the most common mode of postoperative analgesia. A single centre reported a renal transplant-specific Enhanced Recovery after Surgery programme for cadaveric organ recipients. CONCLUSIONS: This questionnaire highlighted a high degree of heterogeneity in current UK practice as regards the perioperative management of renal transplant recipients. Development of evidence-based national consensus guidelines to standardize the perioperative care of these patients is recommended in order to improve patient outcomes and focus areas of future research.

Rapid and Early Diagnosis of Posttransplant Lymphoproliferative Disease Using Cross-Sectional Nuclear Medicine Imaging and Laparoscopic Lymph Node Biopsy: A Report of 2 Cases.

Posttransplant lymphoproliferative disease is a complication of organ transplant with a myriad clinical and anatomic manifestations, thus making diagnosis difficult without histologic confirmation. In cases of lymphadenopathy confined to the abdomen, the diagnosis can be delayed because of late presentation and difficulty obtaining a tissue for histologic analyses. We describe the use of cross-sectional nuclear medicine imaging to locate enlarged abdominal lymph nodes; this facilitated minimally invasive laparoscopic lymph node excision biopsy to rapidly diagnose 2 cases of post-transplant lymphoproliferative disease. Prompt diagnosis has enabled early effective treatment, resulting in good patient outcomes.

Inflammatory myofibroblastic tumour arising in the adrenal gland: a case report.

INTRODUCTION: Inflammatory myofibroblastic tumour arising in the adrenal gland is exceptional. As far as we are aware, there have been only three previous reports in the literature. We report a fourth case. CASE PRESENTATION: A 29-year-old Caucasian man presented with upper quadrant pain due to a 15cm heterogenous adrenal mass that displaced his liver. He underwent an open right adrenalectomy. Histopathological examination showed the mass to be an inflammatory myofibroblastic tumour, a histologically distinctive lesion composed of myofibroblasts, plasma cells, lymphocytes and histiocytes. Ten months later he is well with no sign of recurrence. CONCLUSIONS: The lesion was indistinguishable on imaging from an adrenal cortical tumour. Surgical treatment is the same but inflammatory myofibroblastic tumour carries a favourable prognosis.

An in vitro model of warm hypoxia-reoxygenation injury in human liver endothelial cells.

BACKGROUND: Ischemia-reperfusion or hypoxia-reoxygenation (H-R) injury adversely affects hepatic function following transplantation and major resection; the death of human sinusoidal endothelial cells (SECs) by apoptosis may play a central role in this process. Caspase-3 is an important intracellular protease in the intrinsic and extrinsic pathways of apoptosis. MATERIALS AND METHODS: SECs and EAhy926 cells were exposed to warm hypoxia at 37°C, followed by reoxygenation at 37°C. Activity of caspase-3 was quantified using Western blotting and colorimetric kinase assays. RESULTS: H-R caused a significant increase in caspase-3 activity compared with controls in both cell types. CONCLUSIONS: Warm H-R injury causes apoptotic cell death of SECs and immortalized cells, but with differing patterns of caspase activity.

Techniques in laparoscopic donor nephrectomy.

What's known on the subject? and What does the study add? Innovations in laparoscopic surgery have provided transplant surgeons with a range of techniques as well as a vast array of minimally invasive instruments. Whilst randomized control trials have compared open and laparoscopic donor nephrectomy, there is a paucity of high quality data comparing different laparoscopic approaches. This article summarizes the main techniques of laparoscopic donor nephrectomy currently in use and reviews the evidence available for each. In addition, controversial aspects of donor nephrectomy are examined, including the technological advances applicable to this operation. Increasing numbers of living donor kidney transplants are being performed worldwide, and the majority of donor operations are now laparoscopic. Transperitoneal 'pure' and hand-assisted laparoscopic donor nephrectomy are the two most commonly performed procedures, although retroperitoneal approaches are advocated by some centres. Controversy persists with respect to the technical aspects of donor nephrectomy, including both the approach and the method of ligation of the hilar vessels. More recently, robot-assisted, laparo-endoscopic single site surgery (LESS) and natural orifice transluminal endoscopic surgery (NOTES) -assisted donor nephrectomy have also been performed, further increasing the number of options available, but creating uncertainty as to the ideal approach.

Outcome of surgical complications following simultaneous pancreas-kidney transplantation.

BACKGROUND: Simultaneous pancreas-kidney (SPK) transplantation carries a higher risk of surgical complications than kidney transplantation alone. We aimed to establish the incidence of surgical complications after SPK transplantation and determine the effect on graft and patient survival. METHODS: Outcomes of all SPK transplants performed at our centre were compared between patients who experienced a surgical complication (SC group) and those who did not (NSC group). RESULTS: Our centre performed 193 SPK transplants in a 15-year period; 44 patients (23%) experienced a surgical complication. One-year and 5-year pancreatic graft survival was 89 and 80%, respectively; this was lower in the SC group. There was no significant difference in patient or kidney graft survival between the SC and NSC groups at 5 years (92 and 83%, respectively.) CONCLUSION: Surgical complications following SPK transplantation can cause significant morbidity and adversely affect pancreas graft survival, but do not affect long-term kidney or patient survival.

Endovascular management of arterial conduit pseudoaneurysm after liver transplantation: a report of two cases.

We describe two cases of pseudoaneurysms in liver-transplant iliac artery conduits, which were successfully treated with endovascular stent grafting.

Aspects of residency programs' web sites important to student applicants.

OBJECTIVES: To determine which components of a residency Web site (RWS) are important to residency applicants. METHODS: The authors performed a cross-sectional observational study of residency applicants. All applicants were invited to participate and were provided with a nine-question survey. Applicants were asked questions regarding the importance and impact of RWSs on the residency application process. They were also asked to rate items regarding content and aesthetics, and then rank all items in order of importance. Descriptive statistics are reported. Rank-order displays were determined using the Condorcet choice method. RESULTS: One hundred eighty-eight (82%) of the applicants responded to the survey. Seventy-eight percent of the respondents reported that information provided in an RWS influenced their decision to apply to a particular program (41% decided not to apply to at least one program based on the quality of its RWS). Applicants believed that presentation of the residency curriculum was most important. Information about the hospital and its affiliates, faculty and resident information, and research activities followed in the rank order. Least important to applicants were the aesthetic quality of the site, faculty/resident photographs, and educational resource materials. The authors report additional areas of content that applicants thought would be useful to view. CONCLUSIONS: The content, and not necessarily the aesthetic quality, of an RWS is important to residency applicants. The residency program Web site would seem to be an important factor in the applicant's decision to apply. The applicant's perspective provides training program directors and administrators with focused direction in Web site development or for upgrading existing RWSs for use by future applicants.