Prophylaxis of Wound Infections-antibiotics in Renal Donation (POWAR): A UK Multicentre Double Blind Placebo Controlled Randomised Trial.

BACKGROUND: Postoperative infection after hand-assisted laparoscopic donor nephrectomy (HALDN) confers significant morbidity to a healthy patient group. Current UK guidelines cite a lack of evidence for routine antibiotic prophylaxis. This trial assessed if a single preoperative antibiotic dose could reduce post HALDN infections. METHODS: Eligible donors were randomly and blindly allocated to preoperative single-dose intravenous co-amoxiclav or saline. The primary composite endpoint was clinical evidence of any postoperative infection at 30 days, including surgical site infection (SSI), urinary tract infection (UTI), and lower respiratory tract infection (LRTI). FINDINGS: In all, 293 participants underwent HALDN (148 antibiotic arm and 145 placebo arm). Among them, 99% (291/293) completed follow-up. The total infection rate was 40.7% (59/145) in the placebo group and 23% (34 of 148) in the antibiotic group (P = 0.001). Superficial SSIs were 20.7% (30/145 patients) in the placebo group versus 10.1% (15/148 patients) in the antibiotic group (P = 0.012). LRTIs were 9% (13/145) in the placebo group and 3.4% (5/148) in the antibiotic group (P = 0.046). UTIs were 4.1% (6/145) in the placebo group and 3.4% (5/148) in the antibiotic group (P = 0.72).Antibiotic prophylaxis conferred a 17.7% (95% confidence interval 7.2%-28.1%), absolute risk reduction in developing postoperative infection, with 6 donors requiring treatment to prevent 1 infection. INTERPRETATION: Single-dose preoperative antibiotic prophylaxis dramatically reduces post-HALDN infection rates, mainly impacting SSIs and LRTIs.

Eight-day consumption of inulin added to a yogurt breakfast lowers postprandial appetite ratings but not energy intakes in young healthy females: a randomised controlled trial.

Increasing feelings of satiety may reduce appetite and energy intake. The role of inulin consumption in impacting satiety is unclear. A randomised double-blind controlled crossover trial aimed to determine the effects of inulin+yogurt on satiety after 1 and 8-d consumption. The preload breakfast included 100 g vanilla yogurt with (yogurt-inulin (YI)) and without (yogurt-control (YC)) 6 g inulin. A total of nineteen healthy females (22·8 (sd 2·7) years) with non-restrained eating behaviour and taking hormonal contraceptives participated in the study. Day 1 and 8 visual analogue scale (VAS) ratings of Hunger, Fullness, Desire to Eat and Prospective Food Consumption (PFC) were collected at fasting and every 30 min for 180 min. Energy intake was calculated from a weighed ad libitum lunch and remainder of day food records. Total AUC was calculated for each VAS. Day 1 (VAS only) and 8 (VAS and energy intakes) data were compared between YI and YC using ANCOVA, and ANOVA was used to compare energy intakes on Day 1. There were no significant differences between Day 1 YI and YC AUC appetite ratings or energy intakes. However, 8-d consumption of YI v. YC was associated with lower Desire to Eat and PFC ratings but similar lunch and total day energy intakes. Therefore, the addition of 6 g inulin to a commercially available yogurt affected feelings of appetite, but not energy intake, after repeated consumption. These results suggest that inulin may be a suitable ingredient to increase dietary fibre consumption, with potential to impact appetite.

Postprandial appetite ratings are reproducible and moderately related to total day energy intakes, but not ad libitum lunch energy intakes, in healthy young women.

Reproducibility and validity testing of appetite ratings and energy intakes are needed in experimental and natural settings. Eighteen healthy young women ate a standardized breakfast for 8 days. Days 1 and 8, they rated their appetite (Hunger, Fullness, Desire to Eat, Prospective Food Consumption (PFC)) over a 3.5 h period using visual analogue scales, consumed an ad libitum lunch, left the research center and recorded food intake for the remainder of the day. Days 2-7, participants rated their at-home Hunger at 0 and 30 min post-breakfast and recorded food intake for the day. Total area under the curve (AUC) over the 180 min period before lunch, and energy intakes were calculated. Reproducibility of satiety measures between days was evaluated using coefficients of repeatability (CR), coefficients of variation (CV) and intra-class coefficients (ri). Correlation analysis was used to examine validity between satiety measures. AUCs for Hunger, Desire to Eat and PFC (ri = 0.73-0.78), ad libitum energy intakes (ri = 0.81) and total day energy intakes (ri​ = 0.48) were reproducible; fasted ratings were not. Average AUCs for Hunger, Desire to Eat and PFC, Desire to Eat at nadir and PFC at fasting, nadir and 180 min were correlated to total day energy intakes (r = 0.50-0.77, P < 0.05), but no ratings were correlated to lunch consumption. At-home Hunger ratings were weakly reproducible but not correlated to reported total energy intakes. Satiety ratings did not concur with next meal intake but PFC ratings may be useful predictors of intake. Overall, this study adds to the limited satiety research on women and challenges the accepted measures of satiety in an experimental setting.

Extraperitoneal renal transplantation in small children results in a transient improvement in early graft function.

Renal transplantation is considered more technically challenging in small children compared to adults, especially when live donor adult kidneys are used. Transplanted kidneys have traditionally been placed intraperitoneally, although over the last decade extraperitoneal positioning has been attempted. The aim of this study was to establish whether there is a difference in kidney function and outcome dependent on the surgical approach to transplantation. The medical notes of all children under the age of six who received a renal transplant at our unit between January 1998 and October 2009 were reviewed. Demographic data, operation details, HLA mismatch, immunosuppression regime, complications, and function of the graft were analyzed. A total of 30 transplants were performed in children under six yr of age. The one-yr patient and graft survival were 97% and 93%, respectively. Eighteen were undertaken via an intraperitoneal approach, with the remaining being placed extraperitoneally. There were no significant differences in the number of complications observed between the two groups, and median length of stay was comparable (extraperitoneal 19.5 days vs. intraperitoneal 20.5 days). The plasma creatinine values for the two groups were compared using multivariate linear regression analysis and adjusted for age, weight, gender and baseline plasma creatinine. Between days 2 and 14 post-operatively, there was a significant difference in absolute plasma creatinine between the two surgical approaches. However, the trend of change in mean plasma creatinine values over time did not differ significantly between the two groups. Extraperitoneal kidney transplantation in small children is safe and technically feasible. From our series, there appears to be early improved function, although there is no long-term difference in function between approaches.

Safety and Efficacy of Kidney Transplants From Older Adult Living Donors: A Comparative Analysis of Donor and Recipient Outcomes.

OBJECTIVES: We investigated the safety of donor nephrectomy from older adult donors (age ≥60 years), as well as long-term donor, recipient, and graft outcomes. MATERIALS AND METHODS: We retrospectively analyzed data from 307 living donor kidney transplants from 1996 to 2016 and defined 2 cohorts based on donor age. Cohort A comprised donors aged 60 years and older, and cohort B comprised donors from 18 to 59 years old. We recorded donor and recipient perioperative complications, outcomes, and survival rates and used SPSS and MedCalc statistical software programs for data analyses. RESULTS: The mean follow-up period for donor-recipient pairs in cohort A was 97 months (SD, 25.1 months) with median 108 months (IQR, 92-108 months) and in cohort B was 100.57 months (SD, 25.45 months) with median 120 months (IQR, 84-120 months). Mean donor age in cohort A was 64.13 years (SD, 3.78 years) with median 63 years (IQR, 61-66.5 years) and in cohort B was 41.08 years (SD, 9.15 years) with median 41 years (IQR, 34.5-48 years) (P < .001, cohort A vs B). Mean recipient age in cohort A was 47.65 years (SD, 14.26 years) with median 48.5 years (IQR, 35.5-61 years) and in cohort B was 43.55 years (SD, 13.15 years) with median 40.5 years (IQR, 33.5-54 years) (P < .001, cohort A vs B). Both cohorts showed no significant differences in perioperative donor and recipient complications. Renal function (measured as estimated glomerular filtration rate) in remaining native kidneys of cohort A showed no significant decline during median 8-year follow-up (P = .089 and P < .414, respectively). There were no significant differences in survival rates for donors, recipients, and grafts. CONCLUSIONS: Living donor kidney transplant from older adult donors is safe and effective with good long-term patient and allograft survival.

Negative pressure wound therapy used to heal complex urinary fistula wounds following renal transplantation into an ileal conduit.

Transplantation into an ileal conduit is an established option for patients with end-stage renal failure and a nonfunctioning urinary tract. Urinary fistulae are more common following these complex transplants. Urinary fistula in this scenario can cause substantial morbidity and even result in graft loss. The management options depend on the viability of the transplant ureter, the level of local sepsis and the overall condition of the patient. Urinary diversion with a nephrostomy and ureteric stents has been described in aiding the healing of urinary leaks in renal transplants into a functioning urinary tract. We describe the successful use of negative wound pressure therapy to eradicate the local sepsis and help the healing of a recurrent urinary fistula following kidney transplantation into an ileal conduit. To our knowledge these are the first such cases reported in the literature.

Deaths in people from Black, Asian and minority ethnic communities from both COVID-19 and non-COVID causes in the first weeks of the pandemic in London: a hospital case note review.

OBJECTIVE: To undertake a case review of deaths in a 6-week period during the COVID-19 pandemic commencing with the first death in the hospital from COVID-19 on 12th of March 2020 and contrast this with the same period in 2019. SETTING: A large London teaching hospital. PARTICIPANTS: Three groups were compared: group 1-COVID-19-associated deaths in the 6-week period (n=243), group 2-non-COVID deaths in the same period (n=136) and group 3-all deaths in a comparison period of the same 6 weeks in 2019 (n=194). PRIMARY AND SECONDARY OUTCOME MEASURES: This was a descriptive analysis of death case series review and as such no primary or secondary outcomes were pre-stipulated. RESULTS: Deaths in patients from the Black, Asian and minority ethnic (BAME) communities in the pandemic period significantly increased both in the COVID-19 group (OR=2.43, 95% CI=1.60-3.68, p<0.001) and the non-COVID group (OR=1.76, 95% CI=1.09-2.83, p=0.02) during this time period and the increase was independent of differences in comorbidities, sex, age or deprivation. While the absolute number of deaths increased in 2020 compared with 2019, across all three groups the distribution of deaths by age was very similar. Our analyses confirm major risk factors for COVID-19 mortality including male sex, diabetes, having multiple comorbidities and background from the BAME communities. CONCLUSIONS: There was no evidence of COVID-19 deaths occurring disproportionately in the elderly compared with non-COVID deaths in this period in 2020 and 2019. Deaths in the BAME communities were over-represented in both COVID-19 and non-COVID groups, highlighting the need for detailed research in order to fully understand the influence of ethnicity on susceptibility to illness, mortality and health-seeking behaviour during the pandemic.

Can plasma ammonia be measured in patients with acute liver disease?

BACKGROUND: Plasma ammonia (PA) measurement is of key importance in the diagnosis and monitoring of some inherited metabolic disorders and to monitor subsequent treatment of hyperammonaemia. METHODS: Over a six-month period, patients' ammonia concentrations were measured in parallel, using an enzymatic-UV kit (Infinity Ammonia Liquid Stable Reagent, Thermo Electron Corporation, Australia) on an Olympus AU640 analyser (Olympus UK Ltd, Hertfordshire) and on our current dry chemistry system (Vitros 250, Ortho Clinical Diagnostic). Alanine amino transferase (ALT) was added to a human plasma sample to investigate its effect on the assessment of ammonia concentration. RESULTS: Both methods correlated well (Infinity kit = 1.12 x Vitros 250 + 39, R2 = 0.95, n = 105). However, clinically important discrepancies ranging from 100 to 380 micromol/L were found in patients with acute liver failure. Ammonia concentration measured with the enzymatic Infinitytrade mark kit increased by 137 micromol/L when ALT was added up to 17,000 IU/L. CONCLUSIONS: ALT produces a positive interference in the enzymatic Infinity kit which may affect interpretation and influence further clinical action. However, this positive interference due to ALT does not fully explain the discrepant results observed between the two methods in patients with acute liver failure.