Multivariate analysis of prognostic factors for survival following doxorubicin-eluting bead transarterial chemoembolization for hepatocellular carcinoma.

PURPOSE: To identify prognostic factors for survival in patients with hepatocellular carcinoma (HCC) treated with transarterial chemoembolization with doxorubicin-eluting beads (DEBs). MATERIALS AND METHODS: In a retrospective, single-center analysis, tumor- and patient-related factors were recorded for univariate and multivariate analyses via Kaplan-Meier and Cox regression. Infiltrative HCC phenotype and portal vein invasion (PVI) were correlated, and patients with either or both were classified as having radiographically advanced (RAdv) HCC. The primary endpoint was overall survival, which was calculated from the time of first DEB chemoembolization procedure. RESULTS: A total of 168 patients underwent 248 procedures, of which 215 (86.7%) were outpatient procedures. Mean length of stay was 0.33 days, and 25 patients (10.1%) were readmitted within 30 days. A total of 33 patients underwent liver transplantation and were excluded from survival analyses. A total of 130 had cirrhosis; 62, 50, and 18 had Child class A, B, and C disease, respectively. Forty-one patients had infiltrative HCC phenotype, 28 of whom also had PVI. Multivariate analysis of survival in all patients showed α-fetoprotein (AFP), performance status (PS), RAdv HCC, Child classification, albumin level, and ascites to predict survival. In patients without RAdv HCC, AFP, PS, Child classification, albumin level, and International Normalized Ratio were independent predictors. Increased bilirubin level was not an independent risk factor for death. CONCLUSIONS: Independent prognostic factors in patients with HCC undergoing DEB chemoembolization have been identified. Increased bilirubin level was not an independent risk factor. These data can be used in HCC patient selection and counseling for DEB chemoembolization.

Post-Streptococcal Glomerulonephritis in Two Patients Following Deceased Donor Kidney Transplant.

BACKGROUND Post-streptococcal glomerulonephritis (PSGN) is a well-known cause of renal injury. This disease is caused by a prior infection with specific nephritogenic strains of group A beta-hemolytic streptococcus resulting in formation of immune complexes in the glomeruli. Clinical presentation can range from asymptomatic, microscopic hematuria to the nephritic syndrome which is defined by red to brown urine, nephrotic range proteinuria, edema, hypertension, and acute kidney injury. A few reports have described PSGN in kidney transplant recipients in the post-transplantation period. However, biopsy-proven, donor-derived, PSGN in kidney transplant recipients has not been described. CASE REPORT Kidneys were donated from a 25-year-old Caucasian female with no history of hypertension or diabetes who had anoxic brain death in the setting of sepsis due to group A Streptococcus pyogenes bacteremia. The recipients were a 55-year-old male and a 68-year-old female, both of whom had end stage renal disease (ESRD) secondary to hypertensive nephrosclerosis. The recipients had kidney biopsies, one at the time of implantation and the other on post-operative day (POD) 2. Both biopsies showed streptococcal-associated glomerulonephritis. The prompt recognition and treatment of this disease in the immediate post-operative period resulted in histological resolution of the disease as well as good graft outcomes. CONCLUSIONS Utilizing kidneys from donors with streptococcal bacteremia is possible while maintaining a high degree of suspicion for possible streptococcal-associated glomerulonephritis.

Massive Leiomyomatous Uterine Proliferation Following Kidney Transplantation: A Case Report and Literature Review.

Uterine fibroids are the most common benign uterine tumors affecting > 50% of premenopausal women. The incidence, burden and symptoms from uterine fibroids are higher in women of African descent compared to Caucasians. Despite increasing number of African American females being evaluated for and undergoing kidney transplantation (KT), perioperative management guidelines for uterine fibroids currently do not exist. We present a case of a 40 y/o African American female with known symptomatic uterine fibroids preoperatively and medically managed, who underwent a successful KT and 4 years later progressively developed massive leiomyomatous uterine proliferation, causing a complete lateral displacement of the transplanted kidney with severe hydronephrosis, transplant ureteral obstruction and secondary urinary tract infections with bacteremia. This obstruction required a percutaneous nephrostomy tube placement followed by an interval transabdominal hysterectomy, which was complicated by transplant ureteral transection requiring ureteral reimplantation, resulting in prolonged hospitalization, follow-up and outpatient antibiotic regimen. There is a need for management guidelines for uterine fibroids incidentally encountered during the KT evaluation process to avoid similar preventable post-KT complications in patient populations most commonly affected. Literature review and perioperative management/surveillance strategies are provided.

Complete Chain of the First Global Kidney Exchange Transplant and 3-yr Follow-up.

BACKGROUND: Global Kidney Exchange (GKE) offers an opportunity to expand living renal transplantation internationally to patients without financial means. These international pairs are entered into a US kidney exchange program that provides long-term financial support in an effort to identify opportunities for suitable exchanges for both these international pairs and US citizens. OBJECTIVE: While the promise of GKE is significant, it has been met with ethical criticism since its inception in 2015. This paper aims to demonstrate the selection process and provide >3 yr of follow-up on the first GKE donor and recipient from the Philippines. DESIGN, SETTING, AND PARTICIPANTS: The first GKE transplant occurred with a young Filipino husband and wife who were immunologically compatible, but lacked the financial means to continue hemodialysis or undergo a kidney transplant in their home country. The pair was enrolled in the Alliance for Paired Donation matching system, several alternative kidney exchanges were identified, and the pair subsequently underwent renal transplantation and donation in the USA financed by philanthropy. The resulting nonsimultaneous extended altruistic chain provided transplantation for the Filipino husband and 11 US patients. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The Filipino donor and recipient were followed by transplant professionals in both the Philippines and the USA. Follow-up data were maintained as required by the Organ Procurement and Transplantation Network in the USA. RESULTS AND LIMITATIONS: The Filipino donor has normal blood pressure and renal function, and the Filipino recipient is doing well 3.5 yr after their donation and transplantation. CONCLUSIONS: While criticisms of GKE highlight concerns for possible exploitation of financially disadvantaged groups, these results demonstrate that these concerns did not come to fruition, and the outcome experienced by the GKE donor and recipient (and other US participants) was successful. PATIENT SUMMARY: The first Filipino Global Kidney Exchange (GKE) donor-recipient pair continues to be followed by both US and Filipino transplant centers. Both are in good health, support the GKE program, and advocate for its expansion.

Graft loss from recurrent glomerulonephritis is not increased with a rapid steroid discontinuation protocol.

BACKGROUND: The risk of recurrence of glomerulonephritis in kidney transplant recipients on a steroid-free maintenance immunosuppression protocol is unknown. METHODS: We studied the 4-year graft and patient survival in 105 adult kidney transplant recipients who received their transplant for glomerulonephritis (GN) and were treated with a protocol incorporating rapid discontinuation of prednisone for 5 days (group 1). We compared these outcomes to two control groups; 439 concurrent recipients who received a transplant for causes other than GN (group 2) and to 260 kidney transplant recipients who received an allograft for GN between 1994 and 1999 and were maintained on a steroid-based immunosuppressive protocol (group 3). RESULTS: The 4-year graft and patient survival were similar in the three groups. Acute rejection-free survival was also similar. Serial annual serum creatinine and estimated GFR were also comparable amongst the three groups. Two grafts were lost in group 1 from biopsy-proven recurrent GN and eight other subjects had evidence of histological recurrence at 11.2+/-11.9 months. Seven grafts were lost for recurrent disease in group 3 and 15 others had evidence of histological recurrence at 29.1+/-32.6 months. The mean time to graft loss from recurrence was 52+/-22 months. CONCLUSION: A regimen that utilizes rapid discontinuation of steroids conveys no added risk of graft loss from recurrent GN in the short term but longer follow-up is needed. A consideration should be made to discontinue corticosteroids in the potential recipients who are on them at the time of transplantation.

Arteriosclerosis in kidneys from healthy live donors: comparison of wedge and needle core perioperative biopsies.

CONTEXT: Although risks associated with live kidney donation are low, there are few pathologic studies of kidneys from live donors, and possible risk factors for development of hypertension or renal insufficiency remain unknown. There are many studies of histopathologic changes in deceased donor kidneys and how these changes affect subsequent graft function; most are based on wedge rather than needle core biopsies. OBJECTIVE: To examine the frequency and severity of arterial fibrointimal thickening and other pathologic lesions in kidneys from healthy live donors and compare wedge and needle core biopsies as methods for evaluating these changes. DESIGN: For 36 of 332 live donor renal transplantations performed from January 2004 through November 2006, a wedge biopsy of the transplanted kidney was done prior to and/or after implantation, and a needle core biopsy was done postimplantation or during the ensuing 7 days. For these 36 allografts, we compared pathologic features of the wedge and core perioperative biopsies. RESULTS: Findings on core and wedge biopsies were similar, except for arterial fibrointimal thickening. Moderate thickening (Banff cv2) was present on 13 core biopsies, and mild thickening (cv1) was present on another 10; by contrast, no wedge biopsies showed cv2 lesions, and only 8 showed cv1. Arterial thickening on core but not wedge biopsies correlated significantly with increasing patient age. CONCLUSIONS: The findings indicate that needle core biopsies are superior to wedge biopsies for evaluating vascular changes in donor kidneys, and they suggest a need for studies correlating such changes with long-term outcomes of live donors, particularly older donors.

Laparoscopic donor distal pancreatectomy for living donor pancreas and pancreas-kidney transplantation.

With the proliferation and expanding applications of laparoscopic techniques, we determined the applicability of the laparoscopic approach to living pancreas donation. We performed the first laparoscopic donor distal pancreatectomy in 1999. We herein present our initial experience with five hand-assisted laparoscopic donor pancreatectomies. Three donors underwent distal pancreatectomy alone; two underwent a simultaneous left nephrectomy. The mean donor age was 48.4+/-8.7 years with a body mass index of 23.7 kg/m2. The donor and recipient survival rate was 100% at up to 3 years of follow-up. There were no episodes of pancreatitis, leaks, or pseudocysts. All donors returned to their preoperative state of health and to work. None of the donors have required oral anti-diabetic medications or insulin. We conclude that laparoscopic donor distal pancreatectomy is a safe and efficient procedure; hand-assisted laparoscopic distal pancreatectomy appears to be preferable, because of the added margin of safety from increased tactile feedback and ease of pancreatic dissection. The procedure can be accomplished with a single 6-cm periumbilical incision and only two 12-mm ports, resulting in excellent cosmesis and high donor satisfaction.

A prospective randomized trial of steroid-free maintenance regimens in kidney transplant recipients--an interim analysis.

We compared three maintenance immunosuppressive regimens in a rapid discontinuation of prednisone protocol. From March 1, 2001, through December 31, 2003, 239 first and second kidney transplant recipients (166 LD; 73 DD) were randomized. All recipients were treated with Thymoglobulin; all received steroids intraoperatively and for 5 days postoperatively. Randomization was to cyclosporine-mycophenolate mofetil (n = 85); high-level tacrolimus (TAC) (8-12 ng/mL)-low-level sirolimus (SRL) (3-7 ng/mL) (n = 72); or low-level TAC (3-7 ng/mL)-high-level SRL (8-12 ng/mL) (n = 82). We found no difference at 24 months between groups in patient, graft, death-censored graft, or acute rejection-free graft survival, or in kidney function. Wound complications were more common in SRL-treated recipients (p = 0.02); we found no other differences between groups in complication rates. Our data suggest that excellent patient and graft survival and low rejection rates can be obtained using a variety of maintenance protocols without prednisone.

Risk factors and impact of delayed graft function after pancreas transplants.

Delayed graft function (DGF) occurs after many pancreas transplants (PTx), but is poorly characterized. We studied its incidence, course, and impact in a series of 531 pancreas transplants. Between January 1997 and September 2002, we performed 531 technically successful primary PTx. Of these 531 recipients, 176 (33%) had DGF, defined by their need for exogenous insulin at the time of hospital discharge. The incidence of DGF was roughly equivalent in the three transplant categories: SPK (36%), PAK (32%), and PTA (31%) (p = NS). By 3 months posttransplant, only 19 (3.5%) of all recipients remained on insulin. Only three recipients (0.56%) did not achieve insulin independence. The mean donor age of recipients with DGF was 35.1 years vs. 28.8 years without DGF (p = 0.003). By multivariate analysis, the most significant risk factor for DGF was donor age > 45 years (RR = 4.3, p = 0.0001). For SPK recipients with DGF, graft survival was 87% at 1 year and 82% at 3 years posttransplant; without DGF, 94% at 1 year and 87% at 3 years (p = 0.07). For PAK and PTA recipients, no difference was noted. Acute rejection rates were somewhat higher in recipients with DGF, but this did not reach statistical significance.