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.

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.

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.

Transection of the renal pelvis by endocatch bag during laparoscopic donor nephrectomy.

A case of inadvertent transection of the renal pelvis by the Endocatch bag during laparoscopic donor nephrectomy is reported. This is the second reported injury resulting from the Endocatch bag. We have successfully managed the injury with continuing good renal function after 3 years. The aim of this report is to increase the awareness of this potential complication and how it can be prevented.

Laparoscopic live donor nephrectomy.

BACKGROUND: The demand for renal transplants is greater than the available kidneys. Live donation is one way of increasing the supply. Laparoscopic removal of the donor kidney appears to reduce morbidity for the donors. Some who are hesitant because of the morbidity associated with open nephrectomy are willing to consider the laparoscopic donor nephrectomy. METHODS: Laparoscopic donor nephrectomy was offered to all but three donors since the commencement of the programme in 1997. Data were collected both prospectively and retrospectively for the first 120 donors. Venous and arterial anatomy was assessed preoperatively by computed tomographic angiography. RESULTS: All but four donor procedures were completed laparoscopically. Three of these were for bleeding that could not be safely controlled laparoscopically and the fourth was a planned conversion to deal with the renal vessels, in the first right nephrectomy. Two kidneys were lost due to arterial thrombosis and two underwent segmental infarction after the loss of one of two or three separately anastomosed vessels. Three recipients had delayed function and two of them required dialysis postoperatively. Other minor complications occurred but were uncommon. CONCLUSIONS: Laparoscopic live donor nephrectomy is safe for the donor and the transplant kidney. It offers the advantage of decreased morbidity for the donor, with a shorter hospital stay, earlier return to normal activity and, for some, early return to work.

Final report from the ASERNIP-S audit of laparoscopic live-donor nephrectomy.

The Australian Safety and Efficacy Register of New Interventional Procedures--Surgical (ASERNIP-S) audit of laparoscopic live-donor nephrectomy commenced in 1999 and concluded in 2003. Six centres in Australia and New Zealand contributed data for 219 donor patients regarding perioperative and postoperative outcome of surgery and short-term follow-up. These data were compared with a recent systematic review of LLDN. The Australasian experience to date compared favourably with worldwide practice, both in terms of efficacy and safety for donors (at least in the short term). The collection of audit data, as this technique was introduced into the Australasian healthcare system, has allowed the local experience with this technique to be pooled and shared, resulting in the development of Australasian practice in line with world's best practice in this area.

A systematic review of laparoscopic live-donor nephrectomy.

BACKGROUND: A systematic review was undertaken to assess the safety and efficacy of laparoscopic live-donor nephrectomy (LLDN) compared with open live-donor nephrectomy (OLDN). METHODS: Literature databases were searched from inception to March 2003 inclusive. Comparative studies of LLDN versus OLDN (randomized and nonrandomized) were included. RESULTS: There were 44 included studies, and the quality of the available evidence was average. There was only one randomized controlled trial and six nonrandomized comparative studies with concurrent controls identified. In terms of safety, for donors, there did not seem to be any distinct difference between the laparoscopic and open approaches. No donor mortality was reported for either procedure, and the complication rates were similar although the types of complications experienced differed between the two procedures. The conversion rate for LLDN to an open procedure ranged from 0% to 13%. In terms of efficacy, LLDN seemed to be a slower operation with longer warm ischemia times than OLDN, but this did not seem to have resulted in increased rates of delayed graft function for recipients. Donor postoperative recovery and convalescence seemed to be superior for LLDN, making it a potentially more attractive operation for living donors. Although in the short-term, graft function and survival did not seem to differ between the two techniques, long-term complication rates and allograft function could not be determined and further long-term follow-up is required. CONCLUSIONS: LLDN seems to be at least as safe and efficacious as OLDN in the short-term. However, it remains a technique in evolution. Further high-quality studies are required to resolve some of the outstanding issues surrounding its use, in particular, long-term follow-up of donor complications and recipient graft function and survival.

Two-port and single port laparoscopic appendicectomy.

Minimally invasive surgery for appendicectomy generally involves use of 3 or 4 ports. But if the procedure can be safely performed using two or even a single port, it would be beneficial to the patient, since it is less invasive than standard procedure. The present article describes an experience of laparoscopic appendicectomy using only two ports and occasionally a single port and highlights its efficacy and safety.

Surgical repair of spontaneous renal allograft rupture: a new procedure.

BACKGROUND: The purpose of the present paper is to introduce a new surgical procedure using the external oblique aponeurosis (EOA) for repair of spontaneous renal allograft rupture. METHODS: Thirty-eight cases with spontaneous renal allograft rupture were encountered in 1000 consecutive kidney transplants between April 1991 and August 2000. Thirty-three cases underwent surgical exploration with two grafts undergoing nephrectomy, while a further 31 were repaired using the new surgical procedure. The external oblique aponeurosis (EOA) from the incision was trimmed into 1 cm x 1 cm square pieces. A 2/0 Dexon suture was placed through each piece of the EOA, then through the parenchyma of the kidney perpendicular to the rupture. Each suture was then placed through another piece of EOA and tied. RESULTS: Two repaired grafts were removed on day 7 and day 10, one due to graft re-rupture and another with ischaemia secondary to irreversible acute rejection. The graft function of 29 cases had recovered completely at 30 days following surgical repair with one graft improving rapidly. Thirteen grafts were diagnosed as undergoing mild to moderate acute rejection, whereas a further 20 cases were considered to have acute tubular necrosis on histopathology. The allograft survival rate at 1 year and 5 years post grafting was 86% and 64%, respectively. No patients died from postoperative complications following repair using this procedure. CONCLUSIONS: Spontaneous renal allograft rupture is a relatively common post-transplant complication secondary to either acute tubular necrosis or acute rejection. This new surgical procedure is proposed as a reliable and practical method of repair following graft rupture. Preservation of graft function and viability following rupture appears achievable both in the medium and long-term.

Influence of adhesive drapes on intraperitoneal volume and pressure during laparoscopy.

BACKGROUND: The influence of adhesive skin drapes on abdominal wall compliance during laparoscopy has not previously been studied. METHODS: The effect of removing an adhesive abdominal drape on intraperitoneal volume and pressure was studied in 15 patients undergoing a variety of laparoscopic procedures. The internal consistency of this data was evaluated by comparing the observed response to that which was predicted from analysis based on the theory of elasticity. RESULTS: Removal of an adhesive skin drape after induction of a 15-mmHg pneumoperitoneum was associated with changes in intraperitoneal pressure and volume. These changes were statistically significant, highly predictable and clinically relevant. CONCLUSIONS: On the basis of the present observations, we recommend that extensive coverage by adhesive drapes should be avoided for those patients or procedures in which elevated intraperitoneal pressure may be particularly deleterious.

Uncommon Complications of Renal Transplantation.

As a result of advances in surgical technique and immunosuppressive therapy, the incidence and the consequences of post-transplant surgical complications has decreased. However, surgical complications still cause considerable morbidity and test the skills of the surgical team. Several reviews have been published analyzing the incidence of these complications and the management strategies employed to correct them. We report some uncommon or rare complications encountered in our unit after the introduction of low-dose steroids or steroid-free immunosuppressive protocols.