Changes in abdominal wounds following treatment with sirolimus and steroids in a rat model.

Wound healing complications have been observed in patients receiving sirolimus (SLR). This study examined the degree and duration of delayed healing in various protocols using SLR. Sprague-Dawley rats underwent a standard midline abdominal incision and wound closure. Groups of 6 rats each were randomized to receive different doses of SLR (2 and 5 mg/kg) with or without loading dose (10 mg/kg x3 days), and with or without steroids (20 mg/kg x3 days followed by 5 mg/kg for 2 weeks). Rats were humanely killed on postoperative days 5, 10, or 15. Wound breaking force was measured using the EHMI BIAX-II instrument and tensile strength was calculated. Wounds in control animals had gradual increase in tensile strength during the 15-day observation. In contrast, high and loading doses of SLR caused reduction in wound strength until day 10, but the wounds' tensile strength became equivalent to control by day 15. The addition of steroids prolonged wound recovery with low doses of SLR until day 15 and had very profound effects on healing in high-dose SLR-treated animals (>50% reduction) that continued beyond the 2 weeks of observation. Low doses of SLR in non-steroid-treated animals had a short-term (5-day) impact on wound healing; high dose and loading doses delayed healing for 10 to 15 days. The addition of steroids had a synergistic effect on delayed wound healing, particularly in animals receiving high-dose SLR, which demonstrated prolonged wound weakness. These results may provide practical guidelines for postoperative introduction of SLR in the context of various clinical protocols.

The correlation of Banff scoring with reversibility of first and recurrent rejection episodes.

Recurrent acute rejection remains a significant problem for recipients of renal allografts, with a large proportion of patients progressing to graft loss. The newly introduced Banff schema was used to determine whether the histologic pattern of acute rejection (severity and renal compartment scoring) could discriminate recurring from nonrecurring rejections and to examine whether objective rejection scoring had predictive value for rejection reversal and outcome. A total of 67 biopsies obtained from 50 patients with acute rejection were examined for the occurrence of recurrent allograft rejection. All patients were maintained on a cyclosporine-based triple immunosuppressive protocol and had biopsy-proven acute rejection without chronic changes. Rejection recurred in 13 patients (26%), of whom 4 further developed a third rejection. The majority of the patients developed this first rejection within 2 months posttransplantation. Demographics, prebiopsy renal function, immunosuppression, and peak serum creatinine level at the time of biopsy were similar in patients with multiple and single rejection. Peak levels of reactivity to panel of lymphocytes seemed higher in the group of patients with recurrent rejection, whereas HLA matching was similar for all patients. Banff scores for acute rejection did not discriminate patients at risk of rejection recurrence who had lower vascular (0.6 vs. 1.2), tubular (0.6 vs. 1.1), and lower cumulative SUM (3.0 vs. 4.5) scores on their first rejection when compared with patients with one rejection. Histological scoring was, however, significantly different when first and third episodes were compared in the same patient, indicating increased rejection severity with recurrence. Moreover, the rate of reversal of recurrent rejection by anti-lymphocyte therapy was significantly less than that of first rejection (P<0.05). In conclusion, these data demonstrate that Banff scoring correlated with rejection reversal and steroid responsiveness, yet rejection recurrence was independent of histological score of the first rejection. Furthermore, Banff schema provided an objective histological correlation to the poor clinical outcome seen with recurrent rejection. The data also suggest that patients with early mild rejection continue to be at risk for recurrence and graft loss.

Glomerulosclerosis as a determinant of posttransplant function of older donor renal allografts.

Transplantation of kidneys from older donors is being advocated to expand the organ donor pool. However, the prevalence of atherosclerosis and age-induced renal structural alterations account for the variable function of allografts procured from these older donors. Pretransplant biopsies are sometimes used to evaluate kidneys from older donors, but to date there are no defined criteria correlating the extent of structural alterations in these kidneys to subsequent function. We investigated the effect of glomerulosclerosis, a marker for nephrosclerosis, on graft outcome. Sixty-five baseline biopsies of kidney allografts were retrospectively analyzed to identify a referent point of glomerulosclerosis that correlated with inferior graft outcome. Age and death from nontraumatic cerebrovascular injuries were the main correlates for donor glomerulosclerosis (P < 0.001). Allografts with poor function at 6 months defined as serum creatinine > 2.5 mg/dl (n = 13) or nephrectomy (n = 4) had a mean of 20% glomerulosclerosis at the time of implantation compared with only 2% sclerosis in allografts with good function (P < 0.05). Delayed graft function occurred in 22% and 33% of recipients with no glomerulosclerosis and those with less than 20% glomerulosclerosis, respectively. In contrast, patients receiving kidneys with > 20% sclerosis had an 87% incidence of delayed function (P < 0.05). Moreover, graft loss occurred in 7% of recipients of kidneys with less than 20% sclerosis and in 38% of recipients with > 20% sclerosis (P < 0.04). Measurements of serum creatinine in the donors did not distinguish the different degrees of glomerulosclerosis found on biopsy. Our data indicate that donor glomerulosclerosis greater than 20% increases the risk of delayed graft function and poor outcome of transplanted kidneys. Therefore, we advocate the use of routine biopsies of kidneys from older (> 50 yrs) donors and those donors with nontraumatic cerebrovascular accidents, despite seemingly normal preprocurement serum creatinine.

Utility of standardized histological classification in the management of acute rejection. 1995 Efficacy Endpoints Conference.

BACKGROUND: Standardized histological grading of transplant kidney biopsies has become a primary criterion for diagnosis of rejection in immunosuppression clinical trials. METHODS: A consortium of 19 transplant centers from North America, Europe, and Australia convened in 1995 to examine kidney transplant rejection. Data from the 1995 Efficacy Endpoints Conference were examined for frequency of adoption of Banff schema. Biopsy grading was correlated with clinical parameters of rejection and therapy response. RESULTS: Histological confirmation of rejection episodes occurred in 73% of 953 cases, with Banff criteria adoption increasing in frequency between 1992 and 1995. Banff grading significantly correlated with clinical rejection severity (rejection creatinine: grade I, 2.8+/-0.2 mg/dl; grade II, 3.5+/-0.2 mg/dl; grade III, 4.1+/-0.3 mg/dl; P < 0.001), although nadir creatinines were similar. Response rates of Banff grades I and II to steroid therapy were not different, but only 42% of grade III rejections responded to steroids (P < 0.003. Banff grading also correlated with postrejection creatinine, day 15: grade I, 2.2+/-0.2 mg/dl; grade II, 3.0+/-0.2 mg/dl; grade III, 3.8+/-0.4 mg/dl (P < 0.001), and day 30: grade I, 2.1+/-0.1 mg/dl; grade II, 2.2+/-0.2 mg/dl; grade III, 2.7+/-0.2 mg/dl (P < 0.06). Banff grade III correlated with reduced graft survival at 1 year: grade I, 86%; grade II, 88%; grade III, 70% (P < 0.01). CONCLUSIONS: This multicenter review of rejection severity confirms that standardized histologic classifications such as the Banff schema provide a reliable means for stratifying patient risk of treatment success or failure. These data support the use of Banff criteria in clinical trial design.

Clinical observations of metabolic changes occurring in renal transplant recipients receiving ketoconazole.

Metabolism of cyclosporine is reduced by ketoconazole binding to the monooxygenase responsible for cyclosporine degradation. This isozyme of cytochrome P450, along with other similar monooxygenases, is involved in the regulation of the synthesis and degradation of important metabolic pathways of cholesterol. Monooxygenases throughout these pathways are inhibited by ketoconazole binding causing a decreased metabolism of calcitriol, bile acids, and steroid hormones, and can thereby potentiate altered lipid metabolism, bone metabolism, and weight status of transplant recipients. A group of renal transplant recipients taking ketoconazole (n=25) was compared with a matched cohort not receiving ketoconazole for metabolic changes during the first six months posttransplantation. Lower LDL cholesterol levels were seen in the ketoconazole group (109 +/- 8 mg/dl) than the no ketoconazole group (140 +/- 8 mg/dl) at one month but this difference was not sustained at six months. More bone loss occurred in the ketoconazole group as demonstrated by significant changes in bone density as well as a greater urinary appearance of bone collagen crosslink, deoxy-pyridinoline (29 +/- 4 nmol dpd/mmol creatinine and 18 +/- 4 at six months for the ketoconazole group versus the no ketoconazole group, respectively, P<0.05). Weight gain changes were different between the ketoconazole group and no ketoconazole group (6.4 +/- 1.4 kg versus 5.0 +/- 1.3 kg) at six months and an increased rate of weight gain over time in the ketoconazole group (0.02 kg/day at one month versus 0.05 kg/day at six months, P<0.007). Effectiveness of ketoconazole inhibition of cyclosporine is valuable, but inhibition of other metabolic pathways should be evaluated as well.

Malnutrition as the main factor in morbidity and mortality of hemodialysis patients.

We evaluated the nutritional status of 120 hemodialysis patients using the urea kinetic model. Protein catabolic rate (PCR), an indirect measurement of dietary protein intake, and urea volume of distribution were calculated. Their mid-week predialysis BUN was targeted at 80 +/- 10 mg/dl. The risk factors for chronic hemodialysis patients were analyzed, and since the diabetic patients were unevenly distributed we took them out of the study. This report thus comprises 98 patients distributed in four groups according to their mean PCR and BUN: group 1, mean PCR of 0.63 g/kg/day and BUN of 51 mg/dl; group 2, mean PCR of 0.93 g/kg/day and BUN of 60 mg/dl; group 3, mean PCR of 1.02 g/kg/day and BUN of 79 mg/dl; group 4, mean PCR of 1.2 g/kg/day and BUN of 96 mg/dl. Patients in group 1 had a higher morbidity (number of hospitalizations and number of days in the hospital per patient per year) and a higher mortality (percent per year). The most common causes of hospitalization were infection and congestive heart failure. This group also had an unusually high incidence of pericarditis. Because their risk factors were similar to the other groups, the data suggest that malnutrition was the main cause of these patients' high morbidity and mortality. These patients must be considered at high risk and should be treated aggressively.

Comparison of two cyclosporine formulations in healthy volunteers: bioequivalence of the new Sang-35 formulation and Neoral.

This study was conducted to establish bioequivalence between a newly developed oral cyclosporine formulation, Sang-35 (SangStat Medical Corp., Menlo Park, CA), and the microemulsion formulation Neoral (Novartis Pharmaceuticals, East Hanover, NJ). In a randomized, open-label, two-way crossover study, 36 fasted, healthy male volunteers received a single 500-mg cyclosporine dose formulated either as Sang-35 or Neoral. Mean are under the concentration-time curve to infinity (AUC0-infinity) for Sang-35 was 13,900 microg x hr/L compared with 14,000 microg x hr/L for Neoral, with a 90% confidence interval (CI) of 96% to 103% for the geometric mean ratio of the two formulations. Mean maximum concentration (Cmax) was 1,690 microg/L for Sang-35 and 1,700 microg/L for Neoral, with a 90% CI of 96% to 103%. Geometric mean ratios for both AUC0-infinity and Cmax were within the acceptance criteria for bioequivalence (80-125%). Additional studies showed no differences between Sang-35 and Neoral after high-fat meals (n = 19), in female volunteers (n = 25) and in black volunteers (n = 7). It is concluded that single doses of the oral cyclosporine formulations Sang-35 and Neoral are bioequivalent in healthy fasted subjects, after high-fat meals, in women, and in blacks.

The efficacy of nutrition support in infected patients with chronic renal failure.

Patients with chronic renal failure are at considerable nutritional risk due to restricted diets, poor intake, and dialysis-related protein losses; therefore, they often require specialized nutrition support. It is difficult, however, to gauge the success of the intervention, since the gold standard nitrogen balance cannot be easily employed. We examined the usefulness of three visceral proteins, insulinlike growth factor 1 (IGF-1), fibronectin (FBN), and prealbumin (PA), as markers of nutrition support efficacy in patients with chronic renal failure. Fourteen patients receiving enteral (1) or parenteral (13) nutrition were studied for 7-28 days. The six males and eight females attained intakes of protein and nonprotein energy of 1.3 +/- 0.3 (mean +/- SD) g/kg/day and 34 +/- 6 kcal/kg/day, respectively. Blood samples taken on days 1, 4, 7, 14, 21, and 28 were assayed for IGF-1, FBN, and PA concentrations. Protein levels were correlated with cumulative nonprotein energy and protein intake. Concentrations of IGF-1 at baseline (0.90 +/- 0.48 U/ml) rose significantly by day 4 (1.35 +/- 0.78 U/ml) and remained significantly above baseline at days 7 (1.44 +/- 0.68 U/ml), 14 (1.63 +/- 1.05 U/ml), and 28 (1.59 +/- 0.98 U/ml). Baseline FBN (113 +/- 53 micrograms/ml) and PA (15.3 +/- 7.8 mg/dl) concentrations rose significantly by day 28 (FBN, 163 +/- 51 micrograms/ml; PA, 24.6 +/- 19.0 mg/dl). The PA concentrations correlated significantly with cumulative nonprotein calories and cumulative protein intake (r = 0.37, p less than 0.01; r = 0.43, p less than 0.01, respectively). Both IGF-1 and PA show promise as markers of nutrition support efficacy in this complex patient population.

Nutritional effects of peritonitis in continuous ambulatory peritoneal dialysis (CAPD) patients.

Peritonitis, a major complication of end-stage renal disease patients treated with continuous ambulatory peritoneal dialysis (CAPD), enhances peritoneal protein losses by increasing protein and energy requirements while simultaneously decreasing appetite, usually causing a negative nitrogen balance. The influence of peritonitis on the nutritional status of CAPD patients was evaluated. Fourteen end-stage renal disease patients being treated with CAPD and presenting with peritonitis were randomized to one group with and one without a nutritional supplement. Four CAPD patients without peritonitis served as controls. Anthropometric measurements, laboratory determinations, dietary protein intake, and protein catabolic rate were obtained. The control group lost an average of 9.6 gm protein per 24 hours in the peritoneal fluid vs. an average of 15.1 gm protein per 24 hours lost by patients with peritonitis (p less than .01). Serum albumin did not decrease except in two diabetic patients in whom it dropped an average of 42% and remained low. Nitrogen balance remained positive in all patients except one with diabetes who had very low daily protein intake and caloric intake. The catabolism produced by short uncomplicated peritonitis did not create a negative nitrogen balance in patients eating at least 1 gm protein per kilogram ideal body weight (IBW) and 25 kcal/kg IBW.

Does low protein diet halt the progression of renal insufficiency?

We evaluated 15 adult patients with a mean creatinine clearance of 18.35 ml/min and a mean age of 45.7 years. Four patients had glomerulonephritis, two interstitial nephritis and nine had nephrosclerosis. Paired controls were used. Experimental patients were instructed in a diet with 0.55 grams of protein/kilogram body weight/day; the control group was on an unrestricted diet. Protein intake was evaluated with dietary histories. Protein catabolic rates were calculated and were used for reinforcement. Nutritional status was evaluated with anthropometric measurements and laboratory testing. Progression of renal insufficiency was estimated using the reciprocal of the serum creatinine. The mean follow up was 14.9 months. During this period, three patients started dialysis, four had their creatinine clearance remain stable and six improved their renal function 20%. The rate of change of renal function in the treatment group was slower (p less than 0.05) than in the control group. Body weight, anthropometric measurements and chemical parameters did not change significantly. We conclude that a restricted protein diet stabilizes or improves renal function in most patients with end-stage renal failure without producing malnutrition.

The US multicenter double-blind, randomized, phase III trial of thymoglobulin versus atgam in the treatment of acute graft rejection episodes following renal transplantation: rationale for study design.

In this study intended to establish equivalence between two antibody therapies for acute rejection in kidney transplant recipients, it was important to develop a rigorous protocol. Assurance of the presence of acute rejection was imperative. Therefore, due to the lack of literature support for clinical assessment of renal dysfunction, histologic diagnosis of acute rejection was required for enrollment in the study. Likewise, supportive literature for a correlation between response to anti-rejection therapy and the severity of rejection lead to the decision that the study should be stratified by a measurement of rejection severity for which Banff criteria were used. Finally, quantification of the response to therapy was also measured against the available literature and a large, newly developed international database of kidney transplant rejection episodes (the Efficacy Endpoints database) where serum creatinine, expressed as a percentage of the baseline level at the time of rejection was shown to be the most effective, available clinical marker of rejection response. Therefore, the US Multicenter Phase III Trial for comparing Thymoglobulin to Atgam in the treatment of acute rejection exhibits a unique and detailed study design that could be implemented in future trials as well as in clinical practice to improve assessment of outcomes.

Inadequate dialysis increases gross mortality rate.

The authors correlated the dialysis parameters of 613 patients on hemodialysis with their morbidity and mortality. Dialysis prescription (Kt/V) was calculated according to the dialyzer, blood flow, and dialysis time. Dialysis delivered was calculated using percentage urea reduction (PUR). Eighty patients who underwent dialysis in three units had only predialysis blood urea nitrogen (BUN) values available. Mean predialysis BUN was between 58 +/- 16 and 83 +/- 17 mg/dl. Patients with predialysis BUN > 100 mg/dl ranged from 0-22%, and those with predialysis BUN < 50 mg/dl ranged from 0-41%. Kt/V prescribed was between 0.45 and 1.75. Mean dialysis time was 191 +/- 28 min, and blood flow was 327 +/- 48 ml/min. Delivered dialysis was 78% of that prescribed. Patients who had a prescribed or delivered Kt/V < 0.8 varied from 0-44.8%. Mortality rate per year was between 11.3% and 54%. The authors attributed elevated BUN to increased protein intake or inadequate dialysis. Low BUNs may have been due to residual renal function or malnutrition. None of the dialysis parameters correlated with mortality rate except for a Kt/V < 0.8 (p < 0.001) that was directly related to mortality rate. Inadequate dialysis increases mortality rate.

Effect of Soil Solarization and Cover Crops on Populations of Selected Soilborne Plant Pathogens in Western Oregon.

Field experiments were conducted in silty-clay loam in Corvallis, OR during the summers of 1995 and 1996 to study the effects of green manure cover crops (Sudan grass, rape, and barley), soil solarization, soil fumigation, and combinations of those treatments on population densities of soil pathogens Verticillium dahliae, Phytophthora cinnamomi, Pratylenchus penetrans, and Agrobacterium rhizogenes. Nylon mesh bags containing soil infested with V. dahliae and Phytophthora cinnamomiwere buried 5, 10, 20, and 30 cm deep. Soil solarization was performed over a 54- to 59-day period using a 0.6-mil clear polyethylene film. Maximum soil temperatures recorded at depths of 5, 10, 20, and 30 cm were 53, 48, 39, and 34°C in solarized soil, respectively; these temperatures were 8 to 16°C higher than in corresponding nonsolarized plots. Soil samples were collected before, during, and after solarization to quantify pathogen populations at those four depths. Pot or field studies were conducted subsequent to treatments to determine the effects of treatments on susceptible plants. Soil solarization, cover crops plus solarization, or fumigation with metam sodium resulted in a significant decrease (P< 0.05) in density of P. cinnamomi populations at all four depths and reduced (P< 0.05) V. dahliae at 5 and 10 cm. In greenhouse assays of solarized soils, disease severity was reduced (P< 0.05) for Verticillium spp. on eggplant and Phytophthora spp. on snapdragons. Cover crops alone were not effective in reducing P. cinnamomi and V. dahliae populations. Agrobacterium spp. population densities declined within solarized plots and incidence of crown gall on 'Mazzard' cherry rootstock planted in solarized plots was reduced significantly. Population densities of Pratylenchus penetranswere reduced in the upper 30-cm soil profile by solarization.Solarization for an 8-week period during the warmest months of summer could provide an additional management alternative for several important soilborne pathogens in western Oregon.

Urea kinetics evaluation of hemodialysis and CAPD patients.

Urea kinetics have been used to measure adequacy of hemodialysis. The role of urea kinetics in CAPD has not been clearly established. Using urea kinetics, we studied 71 hemodialysis and 71 CAPD patients. Age was 53 +/- 12 and 45.8 +/- 12 respectively. Urea kinetics in hemodialysis were studied in the standard manner. CAPD patients collected 24 hr, dialysate fluid to measure urea, creatinine, glucose and protein. Urine was collected for 24 hr. to measure urea and creatinine. Protein catabolic rate (pcr) was calculated from the total amount of urea cleared in 24 h. Both groups of patients had similar body weight. Kt/V in CAPD (0.65 +/- 0.1) was at a level considered underdialysis for hemodialysis. In both groups, pcr increased as Kt/V increased. However, CAPD patients had levels of pcr higher than hemodialysis patients at the same level of Kt/V. BUN, serum albumin and serum potassium were significantly lower in CAPD patients. Patients who dialyze more, eat more. Differences in protein intake may be due to a more liberal diet in CAPD, patient selection, removal of middle molecules, or better control of the acidosis.

Evaluation of CAPD prescription.

Adequacy of CAPD has not been established. The recommendation is a Kt/V (K, total urea clearance in ml/min; t. time in minutes on dialysis; and V, total body water which is the volume of distribution of urea) greater than 1.5/week and/or a creatinine clearance (residual + dialysis) greater than 40 l/week/1.73 m2. We followed 20 CAPD patients for 38.6 +/- 28 mo. We measured blood urea nitrogen, serum creatinine, body weight, residual renal function (Kr), normalized protein catabolic rate (NPCR), Kt/V/week and creatinine clearance (CC) l/w/1.73 m2. We obtained the following values: B Wt 72 +/- 16 kg, BUN 56 +/- 13 mg/dl, s. Cr. 12.6 +/- 5 mg/dl, Kr 0.6 +/- 1 ml/min, NPCR 0.84 +/- 0.3 g/kg/day, Kt/V/week 1.8 +/- 0.3 and CC 50.4 +/- 10 l/w/1.73 m2. Patients dialyzed with a wide range of prescription. There was a good correlation between Kt/V and CC. There was no correlation between the dialysis prescription changes in weight and biochemical determinations. There was a direct correlation between Kt/V and NPCR: patients who were dialyzed more eat more. Of the 20 patients, 10 had 24 hospitalizations, and of these were 12 due to peritonitis. Dialysis prescription and biochemical findings of these patients did not differ significantly from nonhospitalized patients. Larger prospective studies are necessary to determine the adequate range of CAPD prescription and its relationship to morbidity and mortality.

Severe visual impairment in older women.

The purpose of this qualitative, phenomenological study was to uncover the meaning of severe visual impairment to older women diagnosed with macular degeneration, a leading cause of blindness in older adults. The research question for the study was, What is the lived experience of severe visual impairment in older women diagnosed with macular degeneration? Participants were eight women, aged 63 to 85 years, who had been diagnosed with macular degeneration and who had severe visual deficits. Data were gathered through audiotaped interviews. Interview recordings were transcribed and later analyzed using a modified Giorgi methodology. The meaning of severe visual impairment emerged as "persisting toward unfolding ways of being in the world sparked by personal discoveries amidst enveloping losses while embracing a realistic awareness with steadfast positivism." Findings from this study were congruent with the theory of Human Becoming. Study findings highlight factors that may place older women with severe visual deficits at risk for lower levels of well-being.

Communicating effectively with elderly surgical patients.

Effective communication promotes trusting, productive nurse/patient relationships. It is the perioperative nurse's responsibility to establish effective communication with each patient. Perioperative nurses strive to provide quality care to all patients, including the elderly. Communication barriers often do exist, however, between nurses and elderly patients. Perioperative nurses are challenged, therefore, to recognize potential communication barriers and to manage each nurse/patient relationship accordingly. Clear communication between nurse and patient enhances the elderly patient's ability to progress smoothly through surgery and recovery.

Older adults and HIV.

As the number of older Americans grows, perioperative nurses increasingly will be called on to provide services to older adults infected with HIV. To provide quality patient care, perioperative nurses must understand the facts about HIV and aging individuals. Finally, perioperative nurses must realize the best defense against exposure to bloodborne pathogens (e.g., HIV) is compliance with standard precautions while caring for all patients, from newborns to older adults.

Outcomes of living donor renal transplants with a negative cross-match and pretransplant donor-specific antibody.

INTRODUCTION: Management of renal transplant recipients with a negative complement-dependent cytotoxicity-antihuman globulin (CDC-AHG) cross-match and pretransplant donor-specific antibody (DSA) is controversial. We sought to compare outcomes of immunologically high-risk living donor (LD) renal transplant recipients with and without DSA. METHODS: We conducted a single-center, retrospective review of all high immune-risk LD renal transplant recipients with a negative CDC-AHG cross-match performed between January 2008 and December 2010. Pretransplant desensitization for DSA was not utilized. Immunosuppression consisted of thymoglobulin induction, followed by tacrolimus, myeophenolate mofetil, and prednisone. DSA was assessed pretransplant and at 1, 3, 6, 9, and 12 months, and every 6 months thereafter. RESULTS: Between January 2008 and December 2010, 44 LD renal transplants were performed in high immune-risk recipients with a negative CDC-AHG cross-match. Outcomes of 14 recipients with pretransplant DSA were compared with 30 recipients with no DSA. After a median follow-up of 26 months (range, 12-40), overall death-censored graft survival was 100%, with no acute rejection episodes in the DSA group and 1 antibody-mediated rejection in the non-DSA cohort. Mean serum creatinines of the DSA and non-DSA groups at 1 year post-transplant were 1.0 ± 0.4 and 1.2 ± 0.6 mg/dL (P = NS), respectively. Among the pretransplant DSA cohort, 5 of the 14 (36%) developed persistent post-transplant DSA at a median of 9 months (range, 3-24) versus 2 of 30 (7%; P = .025) at a median of 12 months post-transplant in the non-DSA cohort. All recipients in the pretransplant DSA group underwent renal biopsy for persistent post-transplant DSA. Three of 5 biopsies showed C4D deposition in peritubular capillaries without glomerulopathy or arteriopathy. CONCLUSIONS: Early post-transplant outcomes for LD recipients with a negative cross-match and pretransplant DSA were excellent. In recipients with good and stable renal function, the significance of persistent post-transplant DSA in combination with C4D deposition on biopsy is unclear at this time.

Mini-incision living donors nephrectomy using anterior muscle-splitting approach with hybrid technique.

BACKGROUND: Significant morbidity is associated with standard open flank living donor nephrectomy. Laparoscopic donor nephrectomy is criticized for a steep learning curve and a tendency to avoid the right kidney. The anterior muscle-splitting technique uses principles or advantages of an open extraperitoneal approach with minimal morbidity and the advantageous muscle-splitting (instead of cutting) procedure. OBJECTIVE: To compare mini-incision laparoscopic instrument-assisted (MILIA) live donor nephrectomy using a muscle-splitting technique to the standard open-flank donor nephrectomy (ODN) approach for efficacy and safety. METHODS: MILIA living donor nephrectomies were performed in 119 donors and compared to a cohort of open-flank nephrectomy donors (n=38) from the same center. Both donor groups were matched for body mass index as well as other personal characteristics. RESULTS: The mean donor age was 35 (range: 18-60) years. The right kidney was procured in 28% of cases. The majority of donors were female (58%) and Caucasian (60%). No differences were observed between MILIA and ODN donors for the age, gender and ethnicity. However, MILIA donors experienced a longer mean±SD operative time (234±47 vs. 197±33 min, p<0.0001) but a shorter hospital stay (4±1 vs. 6±3 days for the ODN group, p<0.0001) and less intraoperative blood loss (215±180 vs. 331±397 mL, p<0.02). No difference was found in the number of units of blood transfused (0.13±0.6 vs. 0.34±1.0 units, p=0.13). Right-sided kidneys were almost equally harvested in both groups (29% of MILIA donors vs. 26% of ODN donors). Post-operatively, MILIA donors had a significantly lower mean pain scores at one week and one month after surgery (p<0.001). They showed significant better post-operative recovery-earlier stopping of pain medications and restoration of other preoperative activities. Moreover, they were better satisfied with their scar appearance. Scores on the short form-36 quality of life questionnaire were comparable for both groups. CONCLUSION: MILIA is a viable option as an alternative for pure laparoscopic donor nephrectomy. MILIA appears to be as safe as open donor nephrectomy and may provide advantages over ODN, such as smaller incision, shorter hospital stay, and less incisional pain. Patient recovery and satisfaction after MILIA are excellent. This technique avoids the possibility of adhesive intestinal obstruction and also improves handling of major complications (e.g., bleeding) of laparoscopic donor nephrectomy. Utilization of this hybrid technique is particularly feasible on smaller (BMI<24 kg/m(2)) and medium-sized (BMI<28 kg/m(2)) donors. We believe that this technique should be adopted by centers that have limited advanced laparoscopic surgical experience and also it could be used selectively for the right donor nephrectomies, even in centers performing hand assisted donor nephrectomies by including a small patch of inferior vena cava for a better quality of right donor kidney during transplantation.