Kidney allograft dysfunction due to ipsilateral thigh arteriovenous graft.

Arteriovenous graft in the thigh is used not infrequently for hemodialysis. Outcomes with this lower extremity dialysis access are generally comparable to upper extremity access and superior to long-term catheter use. However, it could have significant implications in a patient getting a kidney transplant. Here we describe a case of thigh arteriovenous graft causing kidney allograft dysfunction in a new transplant recipient, and this resolved with graft ligation.

Outcome after extracorporeal membrane oxygenation-bridged lung retransplants: a single-centre experience.

OBJECTIVES: A lung retransplant has been shown to be a valid option in selected patients with chronic lung allograft dysfunction (CLAD). However, a subgroup of patients may require, in addition to invasive mechanical ventilation, extracorporeal membrane oxygenation (ECMO) as a bridge to a retransplant. Overall and CLAD-free survival after ECMO-bridged retransplants are compared to first transplants with and without bridging ECMO and to retransplants without bridging ECMO. METHODS: We reported a retrospective, single-institution experience based on a prospective data set of all patients undergoing lung transplants between January 2004 and December 2016 with a mean follow-up of 51 ± 41 months. RESULTS: A total of 230 patients (96 men, 134 women, mean age 47.3 years) had lung transplants: 200 had first transplants without bridging ECMO; 13 had first transplants with bridging ECMO; 11 had retransplants without bridging ECMO; and 6 had retransplants with bridging ECMO. The 3- and 5-year survival rates were 81%/76%, 68%/68%, 69%/46% and 50%/25%, respectively. There was no significant difference in overall survival between those who had first transplants with and without bridging ECMO or retransplants without bridging ECMO. In contrast, patients undergoing ECMO-bridged retransplants had a significantly lower overall survival rate than those with a first transplant without bridging ECMO (P = 0.007). In addition, the post-transplant CLAD-free survival curves varied significantly among the 4 treatment groups (P = 0.041), paralleling overall survival. CONCLUSIONS: Patients requiring ECMO as a bridge to a retransplant had lower overall and CLAD-free survival rates compared to those who had a first transplant with and without bridging ECMO and a retransplant without bridging ECMO.

Impact of Mechanical Circulatory Support on Posttransplant Outcomes.

Mechanical circulatory support (MCS) has markedly improved the likelihood of transplant among patients with advanced heart failure. Transplant survival following MCS is similar for supported and unsupported recipients. Transplant survival is only reduced following left ventricle assist device (LVAD) support complicated by infection, total artificial heart support, and extracorporeal life support. Despite allosensitization and a higher incidence of vasoplegia syndrome, posttransplant survival for durable LVADs is similar to patients with inotropes alone at the time of transplant. MCS as a bridge to transplant offers significant benefits over waiting without support.

Impact of ureteral stricture and treatment choice on long-term graft survival in kidney transplantation.

We aimed to evaluate the influence of urological complications occurring within the first year after kidney transplantation on long-term patient and graft outcomes, and sought to examine the impact of the management approach of ureteral strictures on long-term graft function. We collected data on urological complications occurring within the first year posttransplant. Graft survivals, patient survival, and rejection rates were compared between recipients with and without urological complications. Male gender of the recipient, delayed graft function, and donor age were found to be significant risk factors for urological complications after kidney transplantation (P < .05). Death censored graft survival analysis showed that only ureteral strictures had a negative impact on long-term graft survival (P = .0009) compared to other complications. Death censored graft survival was significantly shorter in kidney recipients managed initially with minimally invasive approach when compared to the recipients with no stricture (P = .001). However, graft survival was not statistically different in patients managed initially with open surgery (P = .47). Ureteral strictures following kidney transplantation appear to be strongly negatively correlated with long-term graft survival. Our analysis suggests that kidney recipients with ureteral stricture should be managed initially with open surgery, with better long-term graft survival.

Kidney Graft Salvage Strategies for Vascular Complications During Kidney Transplantation: A Single-center Experience.

BACKGROUND: Kidney-related unknown vascular injuries are rare and usually diagnosed only after reperfusion. Hemorrhage that makes in situ reconstruction impossible can lead to graft loss. In an era of organ shortage and an increasing number of patients on the waiting list for transplantation, a kidney graft salvage procedure consisting of graft nephrectomy, reperfusion, reconstruction, and reimplantation should be undertaken whenever possible as a contribution to extending the organs available for transplantation. METHODS AND PATIENTS: From January 2010 to December 2015, in total five patients suffered from intraoperative or immediate postoperative vascular complication and were included for this retrospective analysis. Age, sex, etiology of kidney failure, delayed graft function, kind of vascular complications and therapy, presence of aortoiliac calcification, cold and warm ischemia time, and length of hospital stay were analyzed. RESULTS: By applying this "one-step-back" procedure in three consecutive patients and a structured in situ repair in two patients, all grafts were saved. Two of five patients developed delayed graft function requiring hemodialysis. At discharge, graft function was excellent in all five patients. Reconstructed vasculature showed 100% patency. CONCLUSION: These graft salvage strategies are safe with excellent outcome and should be considered in the event of an acute vascular complication during kidney transplantation.

Surgical Repair of a Living-Donor Kidney Graft Artery Kink by a Postanastomotic External Iliac Artery Rotation and Reanastomosis.

A 61-year-old man received a living-donor kidney graft for an end-stage renal disease. In the postoperative course, the patient was oliguric and needed dialysis. The postoperative Doppler showed a normal peak systolic velocity and maintained parenchymal perfusion associated with a parvus tardus signal. The patient was operated, and a kinked renal artery was found. To reposition the artery, the distal iliac artery was clamped, sectioned, shortened, and reanastomosed after a 90° axial rotation. This innovative technic allowed restoration of a normal flow in the parenchyma and avoided an additional clamping, cooling, ischemia, and reanastomosis/reperfusion of the graft. Postoperative diuresis immediately raised >100 mL/hr and creatinine durably returned to normal values.

Immediate Vascular Complications After Kidney Transplant: Experience from 2100 Recipients.

OBJECTIVES: Vascular complications, especially immediate events during kidney transplant, are the major cause of graft loss, and prompt surgical intervention is important for salvage of the graft and recipient. In this study, our aim was to show our experiences with vascular interventions and their effects on graft outcomes in transplant patients with suspected immediate vascular events. MATERIALS AND METHODS: Over 24 years (from 1990 to 2014), 2100 renal transplant procedures (1562 living and 538 deceased donors) were performed by one fixed team. We reviewed the recipients to find cases with immediate vascular complications, including artery or vein kinking or torsion, renal artery thrombosis, and renal vein thrombosis. Diagnosis of a vascular event was suspected when urinary output suddenly stopped and was confirmed by color Doppler ultrasonography or immediate exploration. Characteristics of the patients and events, surgical interventions for saving grafts, and graft outcomes were assessed. RESULTS: Our study included 28 vascular accidents (1.3% of total renal transplants). Arterial kinking or torsion, venous kinking or torsion, renal artery thrombosis, and renal vein thrombosis occurred in 11 (0.52%), 2 (0.09%), 12 (0.57%), and 3 patients (0.14%). Nine of the 11 cases of arterial kinking occurred with use of internal iliac artery. Eleven of 13 grafts with vascular kinking or torsion were saved by immediate surgical intervention, but only 4 grafts in patients with renal artery thrombosis and only 1 graft in patients with renal vein thrombosis were saved by surgical intervention. Delayed graft function occurred in all cases of saved renal artery and renal vein thrombosis but only in 5 cases (4 arterial and 1 venous) of vascular kinking or torsion. CONCLUSIONS: The incidence of immediate vascular complications was 1.3% in our study. Sudden cessation of urine after renal transplant is a warning sign, and immediate diagnosis of vascular events will help salvage the graft with proper intervention.

Performing a Right Hemihepatectomy Sequentially After Deceased Donor Liver Transplantation--The Solution for a Large-for-size Graft: A Case Report.

BACKGROUND: Large-for-size (LFS) is a serious problem that can develop during liver transplantation (LT) and is related to morbidities such as insufficient blood supply causing graft dysfunction or impractical closure of the abdominal wall leading to graft compression. LFS is usually discussed in pediatric LT and is often managed by reducing the size of the graft before implantation. In contrast, only a few cases about managing unexpected LFS during adult LT have been reported, and no case after the vascular anastomosis has been completed has been reported. CASE REPORT: A 36-year-old, 43-kg woman underwent an emergency LT using a deceased donor, although the estimated graft/recipient weight ratio was 3.98%. After completing the vascular anastomosis, a severe hepatic venous outflow obstruction from the graft developed due to compression of the inferior vena cava from the hypertrophied right posterior lobe of the graft. We performed a right hemihepatectomy sequentially after LT, and hepatic blood flow recovered sufficiently based on a Doppler sonogram. The postoperative clinical course was uneventful without vascular or ductal complications, and the primary abdominal wall closure was successfully achieved without wound complications. CONCLUSIONS: Performing a right hemihepatectomy sequentially after completing the vascular anastomosis during LT could be a very simple and effective solution for unexpected LFS during LT.

Donor characteristics that are associated with survival in liver transplant recipients older than 70 years with grafts.

INTRODUCTION: The use of grafts from donors older than 70 years of age is increasing due to the decrease in the number of donors and the increase in waiting list patients. MATERIAL AND METHODS: We undertook a univariate and multivariate analysis of 980 adult recipients of whole liver grafts, 129 of them from donors aged 70 years or older. RESULTS: No differences were found in patient survival compared with recipients of younger grafts. There were no higher rates of rejection, vascular or biliary complications, postoperative bleeding, or infections, but older grafts were associated with graft dysfunction (P = .01) and a higher frequency of postoperative refractory ascites (P = .007), but without a greater need for retransplantation. As graft-associated factors, the joint presence in the donor of diabetes (P = .00; confidence interval [CI] = 0.04-0.117), hypertension (P = .00; CI = 0.22-0.39), and weight of more than 90 kg (P = .031; CI = 0.05-0.104) were suggestive of poor prognostic factors in recipient survival. Survival in hepatitis C virus (HCV) recipients or recipients aged older than 60 years was worse with donors aged older than 70 years, although not significantly so. With grafts from donors aged older than 80 years (n = 15), although patient survival rate was good (70% at 10 years), there was a higher rate of retransplantation (20%) and the early mortality rate was 13.3%. CONCLUSIONS: Use of grafts from donors aged older than 70 years is safe, with similar survival to patients with younger grafts. The appearance of initial dysfunction with prolonged ascites may be due to a delay in reaching a correct functionality, but was not associated with increased mortality, complications, or need for retransplantation. It should also be avoided in recipients older than 60 years or with HCV. Grafts older than 80 years were associated with a good long-term patient survival but at the expense of a higher rate of retransplantation. However, it helps to reduce the time on the waiting list and, thus, mortality. We noted decreased survival associated with donor hypertension, diabetes, and obesity, so these donors should be selected more rigorously.

Comparison of short- and long-term outcomes after early versus late liver retransplantation: a single-center experience.

BACKGROUND: As the survival of patients after liver transplantation (LT) improves, the requirement of liver retransplantation (reLT) for late graft failure has grown. Although some have reported that the short-term outcome of late reLT was comparable with that of early reLT, it remains unknown whether long-term survival of late reLT is inferior to that of early reLT patients. MATERIALS AND METHODS: We reviewed early (<6 mo after primary LT) and late (≥6 mo after primary LT) reLT cases performed between January 2000 and December 2010. RESULTS: Sixteen early and 32 late reLT cases were analyzed. There was no significant difference regarding the number of units of red blood cells transfused during the transplantation between the groups, whereas operative time was significantly longer in the late reLT cases. Graft loss within 3 mo after early and late reLT was 18.6% and 15.6%, respectively. Patient and graft survival rates after 1, 3, 5, and 10 y in the late reLT group were 80.6%, 73.3%, 73.3%, and 67.7% and 80.7%, 69.1%, 63.3%, and 54.3%, respectively, whereas those in the early reLT group were 75.0%, 75.0%, 64.3%, and 64.3% and 81.3%, 75.0%, 64.3%, and 32.1%, respectively. There was no significant difference in patient or graft survival rates between the groups (P = 0.91 and 0.91, respectively). CONCLUSIONS: Acceptable short- and long-term survival were provided in early and late reLT. The time between the primary LT and reLT does not seem to play significant role in the prognosis of reLT in the long term.

Kidney transplant ureteroneocystostomy: comparison of full-thickness vs. Lich-Gregoir techniques.

Despite a variety of urinary tract reconstructive techniques, urinary complications are the most frequent technical adverse event following kidney transplantation. We examined outcomes of two ureteroneocystostomy techniques, the full-thickness (FT) technique and the Lich-Gregoir (LG) technique in 634 consecutive kidney-alone transplants (327 FT and 307 LG) between December 2006 and December 2010. Urological complications at one yr post-transplantation occurred in 27 cases (4.3%) including 16 ureteral strictures (2.5%), four ureteral obstructions (0.6%) owing to donor-derived stones or intrinsic hematoma, and seven urine leaks (1.1%). Compared with LG, the FT technique was associated with similar proportions of ureteral complications overall (3.9% vs. 4.6%, p = 0.70), ureteral strictures (3.7% vs. 1.3%, p = 0.08), urinary stones/hematoma (1.0% vs. 0.3%, p = 0.36), and overall urinary leaks (1.6% vs. 0.6%, p = 0.22); however, the FT technique was associated with somewhat fewer urine leaks at the ureterovesical junction (0% vs. 1.3%, p = 0.05). There were no differences between the two groups in terms of length of stay, delayed graft function, urinary tract infection with the first post-transplant year, estimated glomerular filtration rate, and overall graft and patient survival. The FT technique of ureteroneocystostomy is technically simple to perform and has a similar incidence of urinary complications compared with the LG technique.

Early diagnosis of primary nonfunction and indication for reoperation after liver transplantation.

Initial graft function is a major factor influencing the clinical outcome after liver transplantation (LTX), but a reliable method for assessing and predicting graft dysfunction directly after LTX is not available. Ninety-nine patients undergoing deceased-donor LTX were studied in a prospective pilot study to evaluate the LiMAx test, the indocyanine green test, and conventional biochemical parameters with respect to their sensitivity and prognostic power for the diagnosis of initial graft dysfunction. Patients suffering from initial graft dysfunction (defined as technical complications or primary nonfunction (n = 8)) had significantly decreased LiMAx readouts (43 +/- 18 versus 184 +/- 98 mug/kg/hour, P < 0.001) immediately after LTX. Univariate analysis also showed significant differences for serum bilirubin, ammonia, glutamate dehydrogenase, and the international normalized ratio (P < 0.05), but multivariate analysis revealed LiMAx as the single independent predictor of initial dysfunction (P = 0.008) with an area under the receiver operating characteristic curve (AUROC) of 0.960 (95% confidence interval = 0.921-0.998, P < 0.001). In addition, the diagnosis of primary nonfunction (n = 3) was evaluated with LiMAx and aspartate aminotransferase (AST) activity on the first postoperative day. The calculated AUROC values were 0.992 (0.975-1.0, P = 0.004) for LiMAx and 0.967 (0.929-1.0, P = 0.006) for AST. By a combination of test results obtained directly after LTX and on the first day, LiMAx indicated primary nonfunction with a sensitivity of 1.0 (0.31-1.0) and a positive predictive value of 1.0 (0.31-1.0), whereas AST classification showed a sensitivity of 0.67 (0.13-0.98) and a positive predictive value of 0.29 (0.05-0.70). In conclusion, the assessment of initial graft function using the LiMAx test might be effective for identifying critical complications that could threaten graft survival within 24 hours after LTX.

Preemptive cadaveric renal transplantation: fairness and utility in the case of high donation rate-pilot experience of Tuscany region.

Preemptive kidney transplantation is performed before the initiation of chronic dialysis. Preemptive transplantation is the best treatment modality for patients reaching end-stage renal disease. The Tuscany region has experienced, in the last years, a marked increase in donation rate. Starting from 2006, the first Italian cadaveric preemptive transplant program was activated. The aim of our study was to investigate the characteristics and preliminary results of this program. Among 163 patients entered on to the waiting list for renal transplantation from October 2006 to October 2008, 120 (73.6%) were on dialysis for 21.3 +/- 17.8 months, whereas 43 patients (26.4%) had not yet been on dialysis (preemptive). Eighty two patients (50.3%) resided in Tuscany and 81 (49.7) outside Tuscany; 36.6% of Tuscany patients and 16% of extraregional patients (P = .003) were listed as preemptive. Fifty-eight of 163 (35.6%) patients were transplanted during the period after a mean waiting time of 10.3 +/- 6.4 months. The estimated overall man waiting time was 17.5 months (confidence interval (CI) = 15.8-19.2). Upon Cox multivariate analysis, the probability of transplantation was similar for preemptive and dialysed patients (relative risk [RR] 1.02, P = NS). According to local allocation policy, only residents of Tuscany showed a significant advantage in both groups (RR = 0.43, CI = 0.24-0.75, P = .003). Two-year graft and patients survivals were similar, but delayed graft function was lower in the preemptive group (13% vs 42%, P = .007). The 1-year serum creatinine was 1.56 +/- 0.43 in the preemptive group and 1.68 +/- 0.92 in the dialysis group (P = NS). No differences were observed concerning rejection rate. The preemptive listing rate for cadaveric renal transplantation was more than 35% for Tuscany patients.

Transfer of ureteral carcinoma in a transplanted kidney presenting by early stenosis of the proximal ureter.

A 71-yr-old male kidney transplant recipient suffered from delayed graft function. Eighty days after transplantation complete obstruction of the proximal ureter was observed, complicated by recurrent urinary tract infections. Two months later, the donor kidney was removed because of infectious complications and inadequate arterial perfusion. Histological examination of the removed graft showed signs of rejection as well as a low-grade papillary urothelial cell carcinoma of donor origin in the ureter. The remaining donor ureter was removed subsequently and showed no further signs of malignancy. Follow-up of the patient until 12 months after surgery did not reveal recurrence of the tumor. This case report is the first to describe accidental transfer of urothelial cell carcinoma in the ureter by transplantation, highlighting the possibility of malignancy when early stenosis is not related to the anastomosis. It again emphasizes the need for precise and cautious screening of organ donors, especially those of higher age.

Liver retransplantation for primary nonfunction: analysis of a 20-year single-center experience.

Initial graft function following liver transplantation is a major determinant of postoperative survival and morbidity. Primary graft nonfunction (PNF) is uncommon; however, it is one of the most serious and life-threatening conditions in the immediate postoperative period. The risk factors associated with PNF and short-term outcome have been previously reported, but there are no reports of long-term follow-up after retransplant for PNF. At our institution, 52 liver transplants had PNF (2.22%) among 2,341 orthotopic liver transplants in 2,130 patients from 1984 to 2003. PNF occurred more often in the retransplant setting. Female donors, donor age, donor days in the intensive care unit, cold ischemia time, and operating room time were significant factors for PNF. Patient as well as graft survival of retransplant for PNF was not different compared to retransplant for other causes. However, PNF for a second or third transplant did not demonstrate long-term survival, and hospital mortality was 57%. In conclusion, retransplant for PNF in the initial transplant can achieve relatively good long-term survival; however, if another transplant is needed in the setting of a second PNF, the third retransplant should probably not be done due to poor expected outcome.