Implantation of Right Kidneys: Is the Risk of Technical Graft Loss Real?

BACKGROUND: The left kidney (LK) is preferred by transplant surgeons, because its vein is always of good length and has a thick wall that enables safe suturing. On the other hand, the right renal vein is generally shorter and thinner walled, and well known for its technical difficulty during venous anastomosis, and can result in graft loss. We examined our living (LD) and deceased donor (DD) recipient data and compared the incidence of technical graft loss and early graft function in right and left kidneys. METHODS: A cohort of 58 adult and pediatric recipients received an LD or DD kidney between January 2015 and December 2016. The donor and recipient data were retrieved and retrospectively analyzed. Technical graft loss was defined as graft thrombosis within the 7 days after transplant. RESULTS: Right kidneys (RKs) were not a risk factor for technical graft loss, and no graft was lost for technical reasons in either LD or DD transplants. Early graft function in LK and RKs was also comparable in the LD cohort, and there were no LKs in the DD cohort. CONCLUSION: Based on our data, the use of RKs was not a risk factor for technical graft loss and early graft function was comparable to LKs.

Is warm ischemia not a risk factor for delayed graft function in a living-donor kidney transplant?

The association between prolonged donor warm ischemia time and poor early graft function has been challenged, but with little evidence. We intend to remove ambiguities and present evidence from the current literature. All donor surgeons must strive to limit warm ischemia to reduce poor early graft function and improve long-term outcomes.

ERCP in the management of early versus late biliary leaks after liver transplantation.

The role of endoscopy in the management of bile leaks following liver transplantation has been controversial. Bile leak after liver transplantation has an incidence of approximately 10% to 15%, and the choice of observation, laparotomy, or endoscopic retrograde pancreatography (ERCP), usually with sphincterotomy and/or placement of a bile duct stent, has depended on the transplant groups' experience and the availability of skilled endoscopists. We report our experience in the management of bile leaks following orthotopic liver transplantation. Between July 11, 1995, and January 22, 2003, there were 174 whole-liver-graft orthotopic liver transplant procedures performed at the University of Kentucky. In 158 of these, the initial bile duct management was by choledochocholedochostomy (duct-to-duct anastomosis) over a small-caliber T-tube. Bile leaks were diagnosed in 21 of 158 patients, with an incidence of 13.3%. Of the early leaks (<30 days post-transplantation), 2 were managed with observation alone, and 12 underwent ERCP. This revealed five anastomotic leaks requiring laparotomy. Of the seven leaks occurring later, six were managed by ERCP and one required laparotomy. With a median follow-up period of 18 months, 18 patients (85.7%) are alive with no further biliary tract problems. ERCP remains a useful adjunct in the management of post-liver transplant bile leaks. It is, however, less likely to be successful in the definitive management of early leaks.

Transjugular intrahepatic portosystemic shunt migration in patients undergoing liver transplantation.

Transjugular intrahepatic portosystemic shunt (TIPS) is a useful procedure for patients with variceal bleeding and refractory ascites. Migration of TIPS can potentially complicate the subsequent transplant procedure. The aim of this study was to compare survival, operating time, and blood transfusion requirements in patients with migrated and nonmigrated TIPS undergoing liver transplantation. Of 152 patients, 21 received TIPS; stent migration was noted in seven patients-six distally and one proximally. Mean age of the patients was 54 +/- 11 years (range, 27-65 years), and there were 12 men and 9 women. The etiology of liver disease included the following: hepatitis C virus, six patients; cryptogenic cirrhosis, seven patients; alcoholic cirrhosis, four patients; primary biliary cirrhosis, three patients; and autoimmune hepatitis, one patient. The mean Child-Pugh-Turcotte score was 10 +/- 2. Mean length of hospital stay for patients with migrated TIPS was 22.2 days and for nonmigrated TIPS was 23.5 days. Patient and graft survival (actual) was 81% in both groups with a mean follow-up of 27.9 months. Migration of TIPS is not rare, and in our study it did not affect survival, length of surgery, or blood transfusion requirements compared with patients in whom TIPS had not migrated.