Recurrent thromboses and major vessel compressions in autosomal dominant polycystic kidney disease.

A 41-year-old man with autosomal dominant polycystic kidney disease (ADPKD), who had multiple previous unprovoked thrombotic events and without a known coagulopathic disorder, presented with symptomatic extensive thrombus distal to the compression site of the left common iliac vein by a dominant cyst in the left inferior renal pole. This was managed with inferior vena cava filter insertion, left nephrectomy and warfarinization. Later, there was inferior vena cava compression by the right polycystic kidney, leading to elective right nephrectomy. Post-renal transplantation, he had further episodes of partial dialysis access stenosis and extensive thromboses in the left deep and right superficial venous systems of the lower limbs despite absence of extrinsic compression. This represents the first report of recurrent mass effect and thromboembolic events in ADPKD, both before and after nephrectomy and anticoagulation. The potential increased thromboembolic risks among patients with ADPKD warrant further investigation.

Appendicitis and ganglioneuroma-an unusual co-existence.

Ganglioneuromas are benign, fully differentiated mature tumours related to neuronal tissues and usually seen in the gastrointestinal tract, retroperitoneum and mediastinum. The few cases of appendiceal ganglioneuromas that were previously described in the literature belong to the paediatric population and were associated with genetic mutations and syndromes. We present a unique case of an Aboriginal Australian adult with acute appendicitis and concurrent ganglioneuroma diagnosed using histopathology and immunohistochemistry using Neu-N, S100 and Sox-10. The patient had no history of any of the syndromes associated with ganglioneuromatosis and had no other relevant family history.

Long-Term Impact of Arteriovenous Fistula Ligation on Cardiac Structure and Function in Kidney Transplant Recipients: A 5-Year Follow-Up Observational Cohort Study.

Background: The long-term effects of arteriovenous fistula (AVF) ligation on cardiovascular structure following kidney transplantation remain uncertain. A prospective randomized, controlled trial (RCT) examined the effect of AVF ligation at 6 months on cardiovascular magnetic resonance imaging (CMR)-derived parameters in 27 kidney transplant recipients compared with 27 controls. A mean decrease in left ventricular mass (LVM) of 22.1 g (95% CI, 15.0 to 29.1) was observed compared with an increase of 1.2 g (95% CI, -4.8 to 7.2) in the control group (P<0.001). We conducted a long-term follow-up observational cohort study in the treated cohort to determine the evolution of CMR-derived parameters compared with those documented at 6 months post-AVF ligation. Methods: We performed CMR at long-term follow-up in the AVF ligation observational cohort from our original RCT published in 2019. Results were compared with CMR at 6 months postintervention. The coprimary end point was the change in CMR-derived LVM and LVM index at long-term follow-up from imaging at 6 months postindex procedure. Results: At a median of 5.1 years (interquartile range, 4.7-5.5 years), 17 patients in the AVF ligation group were studied with repeat CMR with a median duration to follow-up imaging of 5.1 years (IQR, 4.7-5.5 years). Statistically significant further reductions in LVM (-17.6±23.0 g, P=0.006) and LVM index (-10.0±13.0 g/m2, P=0.006) were documented. Conclusions: The benefit of AVF ligation on LVM and LVM index regression appears to persist long term. This has the potential to lead to a significant reduction in cardiovascular mortality.

Correlation between computed tomography volumetry and nuclear medicine split renal function in live kidney donation: a single-centre experience.

BACKGROUND: Potential live renal donors undergo both renal computed tomography angiogram (CTA) and nuclear imaging dimercaptosuccinic acid (DMSA) scans. Each kidney's renal function and vascular anatomy influences the choice of donor side. Although DMSA measures differential blood flow, it is a surrogate for renal function and nephron mass. Computed tomography techniques can provide volumetry information. The aim of this study was to determine the relationship between measured split renal volumes on computed tomography versus renal volumes derived from DMSA split function in live donors. METHODS: Prospective data of live kidney donors assessed at a single Australian centre from 2014 to 2017 were reviewed. All patients had pre-operative CTA and DMSA imaging. Renal volume was determined via semi-automated software calculation from CTA three-dimensional image reconstructions by one investigator. Measured split renal volume was compared against calculated renal volume using measured DMSA split function (percentage split function multiplied by total renal volume). RESULTS: Fifty-three patients were included in the study. Split renal volumes on three-dimensional CTA images correlate to calculated split volumes determined from DMSA (Pearson coefficient 0.95 for right renal volume, 0.95 for left). The decision of which kidney to remove can be achieved with CTA only. Omitting a DMSA scan would reduce the radiation load by 0.70 mSv (35 chest X-rays) and potential cost saving of AU$1062.00 per donor. CONCLUSION: CTA technology allows accurate assessment of renal volumes that correlate well with DMSA split function. Avoiding a DMSA scan results in cost and radiation reduction in the assessment of a live kidney donor.

Development and implementation of an enhanced recovery after surgery protocol for renal transplantation.

BACKGROUND: Successful implementation of enhanced recovery after surgery (ERAS) in kidney transplantation requires multidisciplinary consultation, education and attention to protocol. This study discusses the process implementation pathway of the ERAS protocol and its outcome. METHODS: A standardized ERAS protocol was designed for the renal transplant recipient and implemented in July 2017. Data collected prospectively of recipients transplanted from July 2017 to December 2018 were compared to prospectively collected data of recipients who were transplanted prior to ERAS implementation from January 2016 to July 2017 from our renal database. The parameters of interest included length of stay, incidence of delayed graft function and readmission rate. RESULTS: There was no difference in the demographics and the incidence of delayed graft function across both groups, although subgroup analysis suggested a significantly lower incidence of delayed graft function with kidneys donated after circulatory death in the cohort that were managed by the ERAS protocol. The median length of stay for patients on the ERAS protocol was 5 days (range 3-16 days). This was 2 days shorter than the median length of stay for patients not on the ERAS protocol (7 days; range 5-14, P < 0.001). This statistically significant difference in length of stay was consistent across all donor subgroups (living donor, donor after cardiac death and donation after brainstem death). Seventy-nine percent of the patients on the ERAS protocol were discharged on post-operative day 4. CONCLUSION: An ERAS protocol for renal transplant patients is feasible. Our data show that successful implementation of ERAS in kidney transplantation is possible and results in significant cost savings due to shorter length of stay.

Effects of Arteriovenous Fistula Ligation on Cardiac Structure and Function in Kidney Transplant Recipients.

BACKGROUND: Cardiovascular morbidity and mortality remain high in recipients of a kidney transplant. The persistence of a patent arteriovenous fistula (AVF) after transplantation may contribute to ongoing maladaptive cardiovascular remodeling. The ability to reverse this maladaptive remodeling by ligation of this AVF is unknown. We conducted the first randomized controlled trial to evaluate the effect of AVF ligation on cardiac structure and function in stable kidney transplant recipients. METHODS: In this randomized controlled trial, kidney transplant recipients (>12 months after transplantation with stable graft function) were randomized to AVF ligation or no intervention. All participants underwent cardiac magnetic resonance imaging at baseline and at 6 months. The primary outcome was the change in left ventricular (LV) mass. Secondary outcomes included changes in LV volumes, left and right atrial areas, LV ejection fraction, NT-proBNP (N-terminal pro-B-type natriuretic peptide) levels, cardiac output/index, brachial flows (ipsilateral to AVF), and pulmonary artery velocity. RESULTS: A total of 93 patients were screened, of whom 64 met the inclusion criteria and were randomized to the AVF ligation (n=33) or control (n=31) group. Fifty-four participants completed the study: 27 in the AVF ligation group and 27 in the control group. On the second cardiac magnetic resonance scan, a mean decrease of 22.1 g (95% CI, 15.0-29.1) was observed in LV mass in the AVF ligation group compared with a small increase of 1.2 g (95% CI, -4.8 to 7.2) in the control group ( P<0.001). Significant decreases in LV end-diastolic volumes, LV end-systolic volumes, cardiac output, cardiac index, atrial volumes, and NT-proBNP were also seen in the AVF closure group ( P<0.01). No significant changes were observed in LV ejection fraction ( P=0.93) and pulmonary artery velocity ( P=0.07). No significant complications were noted after AVF ligation. No changes in estimated glomerular filtration rate or systolic and diastolic blood pressures were observed between cardiac magnetic resonance scans. CONCLUSIONS: Elective ligation of patent AVF in adults with stable kidney transplant function resulted in clinically significant reduction of LV myocardial mass. CLINICAL TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry URL: https://www.anzctr.org.au . Unique Identifier: ACTRN12613001302741.

Laparoscopic-assisted Ex Vivo Reconstruction of Renal Artery Aneurysm with Internal Iliac Artery and Auto-transplantation.

Renal artery aneurysms (RAA) represent a complex and an often incidentally found disease commonly treated with endovascular approaches. In cases where in situ approaches are unsuitable, laparoscopic-assisted ex vivo repairs offer significant advantages during and post-surgery. We present a case of a female patient who presented with a long-standing right-sided flank pain. She was diagnosed with bilateral asymptomatic RAAs positioned well into the hilum, therefore making in situ repair infeasible. A laparoscopic-assisted ex vivo repair of the renal artery was performed using a graft from the internal iliac artery, which is a novel approach.

A Single Center Experience With Adult Dual Kidney Transplant.

OBJECTIVES: Our renal transplant center in South Australian has been at the forefront of dual kidney transplants in Australia. In this study, we reviewed the 17 adult dual kidney transplants performed at our center between 1998 and 2014. MATERIALS AND METHODS: We retrospectively reviewed the 17 adult dual kidney transplants performed at our center since 1998 and report data pertaining to donor demographics, preimplant function, and histology of donor kidneys, as well as postoperative outcomes of transplant recipients. RESULTS: The mean age of donors was 68.5 ± 7.27 years, with 47% presenting with comorbid disease adversely affecting renal function (diabetes or hypertension). Histologic sampling of donor kidneys showed high rates of glomerular obsolescence, scarring, and vascular sclerosis. The mean age of recipients was 57.18 ± 10.93 years, with 10 patients receiving kidneys that were implanted bilaterally in each iliac fossa and 7 patients having both kidneys implanted into 1 iliac fossa. Early surgical complications (within the first 2 wk) were found in 6 patients (4 bilateral, 2 unilateral). In patients with bilaterally placed grafts, 2 developed a urinary leak, 1 lost both grafts secondary to renal vein thrombosis, and 1 lost a single graft due to renal vein thrombosis. In patients with unilaterally placed grafts, 1 had wound infection and 1 had double graft loss related to renal vein thrombosis. CONCLUSIONS: Adult dual kidney transplants offer an alternative use of kidneys from marginal donors.

Role of inflammatory markers as predictors of laparotomy in patients presenting with acute abdomen.

BACKGROUND: There is a need for an ideal indicator of surgery in patients presenting with acute abdomen. Several markers have been analysed, but the search still continues as none have proven effective. This study aimed to analyse and compare the predictive value of plasma procalcitonin (PCT) strip test in patients presenting with acute abdomen and identify a useful cut-off value to differentiate patients that would benefit with surgery from those that require conservative management. METHODS: A prospective study was conducted in the department of general surgery from June 2012 to June 2013. Plasma PCT was estimated by the semi-quantitative strip test. The levels of plasma PCT and other routinely used markers of inflammation were analysed and compared. RESULTS: Of the total of 58 patients, 44 patients (76%) were men with a mean age of 45 years. Forty patients required emergency surgical intervention. A plasma PCT value of >0.5 ng/mL at admission was 80% sensitive and 100% specific for predicting need for antibiotics in patients with acute abdomen that were managed conservatively. The mean plasma PCT value in the patients undergoing surgery (5.0-10.0 ng/mL) was significantly more than in those managed conservatively (0.5-2.0 ng/mL). Using receiver operating characteristic (ROC) curves a cut-off for plasma PCT of >5.0 ng/mL was 75% sensitive and 100% specific for considering surgical intervention in patients presenting with acute abdomen. CONCLUSIONS: Plasma PCT (value >5 ng/mL) could be used as an adjunct to clinical examination to predict requirement of surgery in patients presenting with acute abdomen.

Procalcitonin Strip Test as an Independent Predictor in Acute Pancreatitis.

Plasma procalcitonin (PCT) is a highly specific marker for the diagnosis of bacterial infection and sepsis. Studies have demonstrated its role in the setting of sepsis and acute pancreatitis. This study aims to analyze and compare the prognostic efficacy of plasma procalcitonin strip test in acute pancreatitis. A prospective study was conducted in the department of general surgery from June 2012 to June 2013. Plasma procalcitonin was estimated by the semiquantitative strip test. The study included a total of 50 patients diagnosed to have acute pancreatitis. Data was collected and statistically analyzed using SPSS version 17. Thirty-nine out of the 50 patients (78 %) were males with a mean age of 46.8 years (range, 25-78 years) and 25 patients (50 %) had ethanol-induced pancreatitis, while 13 patients (26 %) had gall stone pancreatitis. Plasma PCT values were found to correlate better than CRP levels and total leukocyte count with the total duration of hospitalization, ITU, and ICU stay, as well as with the progression to severe acute pancreatitis. A cut off for plasma PCT of >2 ng/mL was found to be 100 % sensitive and 100 % specific and a cut off for CRP of >19 mg/dL was 70 % sensitive and 65 % specific for predicting the progression to severe acute pancreatitis. Plasma PCT also correlated well with antibiotic requirement. A cut off value of >0.5 ng/mL for plasma PCT was 100 % sensitive and 80 % specific and a cut off value of >18 mg/dL for CRP was 86 % sensitive and 63 % specific for predicting antibiotic requirement. Plasma procalcitonin is an early and reliable prognostic indicator in acute pancreatitis. The procalcitonin strip test is a rapid test which is useful in analyzing prognosis in patients with acute pancreatitis.

Evolution of minimally invasive surgery for donor nephrectomy and outcomes.

BACKGROUND: Laparoscopic donor nephrectomy was introduced into Australia in 1997 by this unit. However, some donors may be considered unsuitable, and few modifications to the existing technique can tailor this procedure for an individual donor. Recently, further changes including clustering of ports and single-port methods have been investigated. METHODS: The laparoscopic method was offered to all but 3 donors from May 1997 to October 2009. Data were collected on all 289 donors who underwent laparoscopic procedures. RESULTS: All but 5 donor procedures were completed laparoscopically, and in 4 of them conversion to open was necessary due to hemorrhage. The fifth was a planned conversion in our first right LDN. Delayed graft function was seen in 7 recipients and 5 required dialysis postoperatively. Two kidneys were lost due to arterial thrombosis, and 5 patients underwent segmental infarction with decreased renal function. Mean hospital stay was 2.35±1.67 days. There were no donor deaths or serious morbidity. CONCLUSIONS: Although the benefits to the donor of the laparoscopic method are well recognized, our modifications will benefit those who may be precluded from this method.

Transplantation of kidneys with renal artery aneurysm.

BACKGROUND: The use of kidneys from a select group of living and deceased donors with renal artery aneurysms (RAA) is a novel way to increase the number of organs available for transplantation. Published literature on the outcome of transplanted kidneys with correctable vascular pathology has been reviewed. MATERIALS AND METHODS: The outcome of six transplant recipients who received kidneys after the repair of RAA is presented. RESULTS: Aneurysm was an incidental finding in two live donors, and two were noticed while preparing the deceased donor grafts for transplantation. Two kidneys were salvaged after nephrectomy as the choice of treatment for the aneurysm. All grafts functioned immediately with no post-operative complications. CONCLUSIONS: While there is scarcity for donor kidneys, these repaired kidneys should not be overlooked. Live donor kidneys with aneurysms can be transplanted successfully after appropriate surgical corrections.

Perspectives of laparoscopic donors toward a new procedure: transvaginal donor nephrectomy.

BACKGROUND: Interest in natural orifice transluminal endoscopic surgery (NOTES) is increasing. Transvaginal NOTES (TVNOTES) donor nephrectomy with subsequent removal of the kidney via the vagina is technically possible. This approach may minimize the surgical insult to the donor and allow improved cosmesis. The acceptability to patients of such a technique is, however, unknown. The aim of this article is to explore the attitudes of women who have previously undergone laparoscopic donor nephrectomy (LDN). METHODS: A 15-point questionnaire was designed by a multidisciplinary group of surgeons interested in minimally invasive surgery to obtain the views of women who had previously undergone LDN at the Queen Elizabeth Hospital, Adelaide. It was sent to 150 female donors, and their views with regard to the acceptability of a TV approach to the peritoneal cavity for donor nephrectomy were recorded. RESULTS: Forty-nine patients returned the completed questionnaire. The majority (90%) of these women did not have adverse feelings toward scars. Thirty-seven percent of women would consider a TVNOTES donor nephrectomy; however, this was increased to 51% if they could be reassured that TVNOTES was as safe as LDN. Concerns regarding a negative impact on sexual function after this procedure were raised by 33% of patients. The majority (88%) did not cite surgeon gender as an important factor when deciding for or against this procedure. CONCLUSIONS: This study demonstrates that less postoperative pain, better cosmesis, and safety are factors that may influence a patient's decision to choose TVNOTES donor nephrectomy. The majority, however, would still prefer LDN.

Characterization of cardiac remodeling in a large animal "one-kidney, one-clip" hypertensive model.

OBJECTIVE: The aim of this study is to characterize cardiac remodeling in a large animal model of hypertension. METHODS: 23 sheep were subjected to unilateral nephrectomy followed by clamping of the remaining renal artery to 60% ("one kidney-one clip", 1K1C) 3 weeks later. Blood pressure (BP) was monitored invasively over 73+/-28 days. Cardiac function was assessed with magnetic resonance imaging and compared with 12 size-matched controls. Detailed atrial histopathological analysis was performed. RESULTS: In the 1K1C animals, BP rose from baseline to reach a plateau by 4 weeks (systolic BP: 107+/-12 to 169+/-27, diastolic BP: 71+/-10 to 118+/-29 mmHg, both p< 0.0001); cardiac hypertrophy was significant when compared with controls with increased left ventricular weight [left ventricular (LV)/body wt: 2.7+/-0.5 vs 2.1+/-0.2 g/kg, p=0.01] as well as bi-atrial enlargement (right atrial, RA: 22.9+/-4.9 vs 15.7+/-2.8g, p=0.003; left atrial, LA: 35.5+/-6.7 vs 20.9+/-4.1g, p=0.0003); cardiac magnetic imaging demonstrated significantly increased LA volumes (end-diastolic volume: 42.9+/-6.8 vs 28.7+/-6.3 ml, p< 0.0001) and reduced LA ejection fraction (24.1+/-3.6 vs 31.6+/-3.0%, p=0.001) while LV function was relatively preserved (42.3+/-4.7 vs 46.4+/-4.1%, p=0.1); degeneration and necrosis of atrial myocytes were evident with increased atrial lymphocytic infiltration and interstitial fibrosis. CONCLUSIONS: The ovine 1K1C model produces reliable and reproducible hypertension with demonstrable cardiac end-organ damage.

Transvaginal natural orifice translumenal endoscopic surgery (NOTES): a survey of women's views on a new technique.

BACKGROUND: Laparoscopic and minimally invasive surgery has changed the surgical landscape irrevocably. Natural orifice translumenal endoscopic surgery (NOTES) offers the possibility of surgery without visible scars. Transvaginal entry offers potential benefits because it gains access to the peritoneal cavity without the need to open an abdominal viscus. Much of the discussion pertaining to NOTES focuses on technical and training issues, with little attention to date paid to the opinions of women. The perceptions of female health care workers and patients were sought in relation to their views on transvaginal NOTES. METHODS: This study surveyed 300 women using a 12-point questionnaire devised by a multidisciplinary group of surgeons interested in minimally invasive surgery. The questionnaire was designed to establish the opinions of women with respect to NOTES surgery versus standard laparoscopic procedures. Responses were de-identified. RESULTS: Three-fourths of the women surveyed were neutral or unhappy about the prospect of a NOTES procedure, and this remained constant even when it was stipulated that laparoscopic cholecystectomy and NOTES had equivalent safety and efficacy. Younger nulliparous women were most concerned about the potential negative effect of NOTES on sexual function. A minority were concerned about the cosmetic effect of surgery, although surgical scars were perceived as more important to younger respondents. CONCLUSIONS: Potentially, NOTES surgery offers women a scarless operation with the possibility of less pain than experienced in standard laparoscopic surgery. Few women, however, were troubled about the cosmetic effect of surgery. The effect of NOTES on sexual function was expressed as a particular concern by younger women. In all groups and across all ages, peritoneal access using the transvaginal route was met by significant scepticism. In Australia, women remain to be convinced about the potential advantages of the emerging NOTES technology.

Pediatric renal transplantation: the Bangalore experience.

A retrospective analysis was done on 47 pediatric renal transplants performed over last 16 years at Bangalore, Karnataka. The median age and weight of the recipients at transplantation were 120 months and 21 kg respectively; male to female ratio was 30 to 17. Twenty two children had underlying glomerular disease and 23 had tubulointerstitial disease. Preemptive transplantation was done in 33.3% of patients, 57.2% received hemodialysis and 9.5% received peritoneal dialysis prior to transplantation. The mean duration of dialysis was 2.6 months. The most common source of donor organ was the mother. Immunosuppression medications included cyclosporine, azathioprine, and corticosteroids. Graft survival at 1 year, 5 years, and 10 years was 80%, 45.8% and 37.5% respectively. Renal transplantation is the most optimal way to manage children with ESRD with satisfactory long term results.