Association between donor kidney cysts and donor and recipient outcomes after living donor kidney transplantation.

INTRODUCTION: Incidental kidneys cysts are typically considered benign, but the presence of cysts is more frequent in individuals with other early markers of kidney disease. We studied the association of donor kidney cysts with donor and recipient outcomes after living donor kidney transplantation. METHODS: We retrospective identified 860 living donor transplants at our center (1/1/2011-7/31/2022) without missing data. Donor cysts were identified by review of pre-donation CT scan reports. We used linear regression to study the association between donor cysts and 6-month single-kidney estimated glomerular filtration rate (eGFR) increase, and time-to-event analyses to study the association between donor cysts and recipient death-censored graft failure. RESULTS: Among donors, 77% donors had no kidney cysts, 13% had ≥1 cyst on the kidney not donated, and 11% only had cysts on the donated kidney. In adjusted linear regression, cysts on the donated kidney and kidney not donated were not significantly associated with 6-month single-kidney eGFR increase. Among transplants, 17% used a transplanted kidney with a cyst and 6% were from donors with cysts only on the kidney not transplanted. There was no association between donor cyst group and post-transplant death-censored graft survival. Results were similar in sensitivity analyses comparing transplants using kidneys with no cysts versus 1-2 cysts versus ≥3 cysts. CONCLUSIONS: Kidney cysts in living kidney donors were not associated with donor kidney recovery or recipient allograft longevity, suggesting incidental kidney cysts need not be taken into account when determining living donor candidate suitability or the laterality of planned donor nephrectomy.

Association of Implantation Biopsy Findings in Living Donor Kidneys With Donor and Recipient Outcomes.

RATIONALE & OBJECTIVE: Some living donor kidneys are found to have biopsy evidence of chronic scarring and/or glomerular disease at implantation, but it is unclear if these biopsy findings help predict donor kidney recovery or allograft outcomes. Our objective was to identify the prevalence of chronic histological changes and glomerular disease in donor kidneys, and their association with donor and recipient outcomes. STUDY DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: Single center, living donor kidney transplants from January 2010 to July 2022. EXPOSURE: Chronic histological changes, glomerular disease in donor kidney implantation biopsies. OUTCOME: For donors, single-kidney estimated glomerular filtration rate (eGFR) increase, percent total eGFR loss, ≥40% eGFR decline from predonation baseline, and eGFR<60mL/min/1.73m2 at 6 months after donation; for recipients, death-censored allograft survival. ANALYTICAL APPROACH: Biopsies were classified as having possible glomerular disease by pathologist diagnosis or chronic changes based on the percentage of glomerulosclerosis, interstitial fibrosis/tubular atrophy, and vascular disease. We used logistic regression to identify factors associated with the presence of chronic changes, linear regression to identify the association between chronic changes and single-kidney estimated glomerular filtration rate (eGFR) recovery, and time-to-event analyses to identify the relationship between abnormal biopsy findings and allograft outcomes. RESULTS: Among 1,104 living donor kidneys, 155 (14%) had advanced chronic changes on implantation biopsy, and 12 (1%) had findings suggestive of possible donor glomerular disease. Adjusted logistic regression showed that age (odds ratio [OR], 2.44 per 10 years [95% CI, 1.98-3.01), Hispanic ethnicity (OR, 1.87 [95% CI, 1.15-3.05), and hypertension (OR, 1.92 [95% CI, 1.01-3.64), were associated with higher odds of chronic changes on implantation biopsy. Adjusted linear regression showed no association of advanced chronic changes with single-kidney eGFR increase or relative risk of eGFR<60mL/min/1.73m2. There were no differences in time-to-death-censored allograft failure in unadjusted or adjusted Cox proportional hazards models when comparing kidneys with chronic changes to kidneys without histological abnormalities. LIMITATIONS: Retrospective, absence of measured GFR. CONCLUSIONS: Approximately 1 in 7 living donor kidneys had chronic changes on implantation biopsy, primarily in the form of moderate vascular disease, and 1% had possible donor glomerular disease. Abnormal implantation biopsy findings were not significantly associated with 6-month donor eGFR outcomes or allograft survival. PLAIN-LANGUAGE SUMMARY: Kidney biopsies are the gold standard test to identify the presence or absence of kidney disease. However, kidneys donated by healthy living donors-who are extensively screened for any evidence of kidney disease before donation-occasionally show findings that might be considered "abnormal," including the presence of scarring in the kidney or findings suggestive of a primary kidney disease. We studied the frequency of abnormal kidney biopsy findings among living donors at our center. We found that about 14% of kidneys had chronic abnormalities and 1% had findings suggesting possible glomerular kidney disease, but the presence of abnormal biopsy findings was not associated with worse outcomes for the donors or their recipients.

Variations in deceased donor kidney procurement biopsy practice patterns: A survey of U.S. organ procurement organizations.

BACKGROUND: Procurement biopsies have become a common practice in the evaluation and allocation of deceased donor kidneys in the United States despite questions about their value and reproducibility. We sought to determine the extent of OPO-level differences in criteria used to decide which deceased donor kidneys undergo a procurement biopsy and to assess the degree of variability in procurement biopsy technique and interpretation across OPOs. METHODS: Each of the country's 58 OPOs were invited to participate in the survey. OPOs were divided into two groups based on organ availability ratio and deceased donor kidney discard rate. RESULTS AND CONCLUSIONS: Fifty-out-of-fifty-eight invited OPOs (86% response rate) responded to the survey between November 2020 and December 2020. Thirty (60%) OPOs reported that they have formal criteria for performing kidney procurement biopsy, but for 29 of these OPOs, transplant centers can request biopsy on kidneys that do not meet criteria. OPOs used a total of seven different variables and 12 different numerical thresholds to define impaired kidney function that would prompt a procurement biopsy. Additionally, wide variability was seen in biopsy technique and procedures for biopsy interpretation and reporting of findings to transplant programs. These findings identify a clear opportunity for standardization of procurement biopsies to best practices.

Arthroscopic classification of intra-articular hip pathology demonstrates at best moderate interrater reliability.

PURPOSE: The purpose of this study was to report several novel classification systems for intra-articular lesions observed during hip arthroscopy, and to quantify the interrater reliability of both these novel systems and existing classifications of intra-articular lesions when tested by a group of high-volume hip arthroscopists. METHODS: Five hip arthroscopists deliberated over shortcomings in current classification systems and developed several novel grading systems with particular effort made to capture factors important to the treatment and outcomes of hip arthroscopy for labral injury. A video learning module describing the classifications was then developed from the video archive of surgeries performed by the senior author and reviewed by study participants. Following review of the module, a pilot study was completed using five randomly selected videos, after which participating surgeons met once more to discuss points of disagreement and to seek clarification. The final video collection for testing reliability was composed of 29 videos selected with the intent of capturing all sublevels of each classification scheme. Study participants recorded their assessments using each classification scheme, and interrater reliability was calculated by a study participant not involved in grading. RESULTS: The average kappa coefficients for the classification schemes ranged from 0.38 to 0.54, with the interrater reliability of all classification schemes except labral degeneration qualifying as moderate. The percent of cases with absolute agreement ranged from 17.2% to 51.7% across the classification systems. CONCLUSIONS: Even among a group of high-volume hip arthroscopists who engaged in several discussions about the proposed classification schemes, grades were found to have at best moderate interrater reliability. Moderate interrater reliability is demonstrated for novel grading systems for describing labral tear complexity, labral bruising, labral size, and extent of synovitis, and fair reliability is demonstrated for labral degeneration. Further development and refinement of multifactorial grading systems for describing labral injury are indicated. Evaluating the multifactorial nature of intra-articular lesions in the hip is an important part of intraoperative decision-making and defining reliable classifications for intra-articular lesions is a critical first step towards developing generalizable criteria for guiding treatment type. LEVEL OF EVIDENCE: Level III.

The Reliability of Commonly Used Radiographic Parameters in the Evaluation of the Pre-Arthritic Hip: A Systematic Review.

BACKGROUND: Radiographs play a central role in the evaluation of the extent of arthritic change and the quantification of morphological parameters characteristic of femoroacetabular impingement (FAI) and/or dysplasia. Reporting of these parameters is widespread in the literature, occasionally as an instrument for data pooling in collaborative research endeavors. Yet, the metrological properties of commonly used radiographic descriptors of acetabular and femoral architecture relevant to the field of hip preservation have not been reviewed systematically. The purpose of the present review was twofold: (1) to identify the current body of data available on the reliability of commonly used radiographic descriptors of the pre-arthritic hip and (2) to collate best practices and methodological pearls and pitfalls from the existing investigations that have explored the reliability of these radiographic measures. METHODS: Article screening methodology involved an extensive search of 2 databases (PubMed Central, Embase). Metrological reliability data and best practices and frequencies with which these practices have been reported in existing investigations were extracted from the methods of the included studies. The radiographic parameters that were chosen as a focus for the present review were based on a discussion among a number of experienced hip-preservation surgeons. RESULTS: Forty-three articles met all inclusion criteria and were included in this review. Eleven recurring components of study design were isolated from the included investigations as being critical for minimizing bias in the assessment of the reliability of these radiographic morphological parameters. Sixteen (37.2%) of the included studies reported the use of at least 1 quality-control measure for ensuring radiographic integrity. The radiographic parameters with the most reliability data included the lateral center-edge angle (22 studies), the Tönnis angle (14 studies), and the alpha angle (18 studies). Categorical markers of acetabular retroversion and the extent of osteoarthritis have been less-frequently studied with respect to their reliability, with the exception of the crossover sign, which was evaluated in 11 of the included studies. CONCLUSIONS: The radiographic parameter with the most metrological evidence in support of its reliability was the lateral center-edge angle (with 22 [100%] of 22 studies reporting acceptable reliability), whereas the Tönnis grade of osteoarthritis consistently demonstrated subpar interrater and intrarater reliability. Side-arm investigations for testing reliability may be needed by individual studies to prove the validity of data-pooling practices as collaborative endeavors continue to become more widespread.

Outcomes Following Interposition Arthroplasty of the First Metatarsophalangeal Joint for the Treatment of Hallux Rigidus: A Systematic Review.

BACKGROUND: Interposition arthroplasty of the first MTP joint has recently experienced renewed interest as a treatment for hallux rigidus. The purpose of this study was to systematically review the rapidly expanding literature on PRO following interposition arthroplasty of the first MTP joint. METHODS: PubMed Central, Embase, and the Cochrane Central Register for Controlled Trials (CENTRAL) were searched. Inclusion criteria included length of time to follow-up, number of patients, outcome measure, and use of allogeneic or autogenous soft tissue or a synthetic matrix as interposition. RESULTS: 20 studies were included in the review, comprising 498 patients and 539 feet with mean time to follow-up of 4.5 years. The most common substance used for interposition in the included studies was autogenous first MTPJ capsular tissue, a technique reported on in 12 (60.0%) of the included articles. In studies reporting preoperative and postoperative outcomes by way of a standardized outcome scoring system, mean group improvements exceed minimal clinically important differences in the majority of studies. Eighty-five percent of the studies included in this review were of Level IV quality evidence, and of this subset of studies, 70.6% were of a retrospective nature. Progression to further surgery was observed in 3.8% of toes. The most common complication reported was transfer metatarsalgia of 1 or more lesser toes, observed in up to 57.9% of patients in one study. CONCLUSION: Interposition arthroplasty appears to be a viable option for the treatment of moderate to severe hallux rigidus in patients looking to salvage motion through the first metatarsophalangeal joint. A wide array of autogenous, allogeneic, and synthetic implant materials have surfaced in recent years, but long-term follow-up and prospective, comparative study designs with low risk of bias are limited. LEVEL OF EVIDENCE: Level IV, systematic review of Level III-IV studies.

Arthroscopic labral reconstruction using fascia lata allograft: shuttle technique and minimum two-year results.

The purpose of this study was to describe the shuttle technique of acetabular labral reconstruction using allograft fascia lata and report minimum two-year clinical outcomes in a prospective patient cohort. We present a shuttle technique to introduce and fixate the allograft, by which the need to fix the free end of the graft from inside the joint is avoided. Between October 2010 and March 2014, 693 hip arthroscopic surgeries were performed by the senior author. Of these 693 patients, 34 patients underwent a labral reconstruction procedure using allograft fascia lata and the shuttle technique and met inclusion criteria. Outcome measures were collected at minimum two years postoperatively. 91.2% (31) of reconstruction patients were available for follow-up at minimum two years after surgery with 12.9% (4) of these patients converting to total hip arthroplasty at average time 27.9 months post-surgery. For the remaining reconstruction patients, mean mHHS increased from 64.0 preoperatively to 84.6 postoperatively (P = 0.0015), SF-12 Physical from 38.9 to 49.0 (P = 0.0004), SF-12 Mental from 49.5 to 55.6 (P = 0.0095), iHOT-12 from 36.4 to 68.1 (P = 0.0017), HOS-ADL from 62.6 to 81.6 (P = 0.0032) and HOS-SS from 32.9 to 65.7 (P < 0.0001). Arthroscopic acetabular labral reconstruction using fascia lata allograft and a shuttle technique appears to be an effective procedure for the treatment of labral pathology through minimum two-year follow-up. While it is difficult to discern the direct influence of the labral reconstructive procedure given the treatment of often concomitant intra-articular pathology, this patient cohort has fared similarly to other cohorts of labral reconstruction patients. No major adverse events are reported.

A Characterization of Sensory and Motor Neural Dysfunction in Patients Undergoing Hip Arthroscopic Surgery: Traction- and Portal Placement-Related Nerve Injuries.

BACKGROUND: There is a paucity of prospectively collected data as they relate to nerve injuries after hip arthroscopic surgery. Studies describing the relationship of neurological injuries to portal placement and the duration and magnitude of traction force with regular and standardized patient follow-up protocols are limited. PURPOSE/HYPOTHESIS: The purpose of this study was to characterize nerve deficits in a series of patients undergoing hip arthroscopic surgery as these deficits relate to axial traction and portal placement. It was hypothesized that in patients who presented without nerve deficits after surgery, the magnitudes of traction-related measurements would exceed previous recommendations based on expert opinion (<50 lb). Additionally, it was hypothesized that sensory disturbance would commonly be observed (≥16%) localized to the distal anterolateral thigh related to portal placement. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A total of 45 patients scheduled to undergo hip arthroscopic surgery between July 2012 and February 2014 were included in this study. Traction force was measured and recorded every 5 minutes during surgery, and patients were assessed by a physical examination for deficits in light touch sensitivity at all lower extremity dermatomes preoperatively and at 3 weeks, 6 weeks, 3 months, and 1 year postoperatively. Patients were also tested for strength deficits and rated on the manual muscle testing grading scale. Patients reported modified Harris Hip Score (mHHS), Hip Outcome Score-Activities of Daily Living and -Sport subscales (HOS-ADL and HOS-Sport, respectively), Short Form-12 (SF-12) mental and physical component summaries, and international Hip Outcome Tool-12 (iHOT-12) scores preoperatively and at 1 year postoperatively. RESULTS: Thresholds for maximum traction force, mean traction force, duration of traction, and traction impulse were 120 lb, 82 lb, 61 minutes, and 7109 lb·min, respectively, below which no patients presented with sensory or motor dysfunction thought to be related to traction. A minority (17.8%) of patients presented with highly localized, distal anterolateral sensory deficits suggestive of injuries related to portal placement, and 2.2% of patients presented with perineal numbness localized to the distribution of the pudendal nerve. All nerve deficits had resolved by 1-year follow-up. CONCLUSION: This study suggests that it may be possible to apply more axial traction force for a longer duration than expert opinion has previously suggested, without significant and, in the majority of cases (82.2%), any traction-related short-term complications. Transient traction- and portal placement-related nerve injuries after hip arthroscopic surgery may be more frequent (31.1% in this study) than have been reported historically.