A New Approach to the Hostile Bladder in Transplantation.

The intravesical and extravesical techniques for ureteral reimplantation, traditionally described, cannot be applied to a very small, contracted bladder, especially in the morbidly obese patient. An alternative approach using a pull-through technique of ureterocystostomy is described in 6 patients with excellent 2-year follow-up.

Use of spiral vein graft in living donor renal transplantation.

Prosthetic material or vascular homografts have been used for vascular reconstruction in organ transplants. An alternative procedure using the spiral saphenous vein graft to lengthen 19 short-living donor kidney vessels is described.

Revascularization of the gastroepiploic artery in pancreas transplant.

Thrombosis accounted for 52.0% of all transplant failures in one recent large series and is felt to result from devascularization of the pancreas during organ procurement. A technique to revascularize the pancreas is described. The operative notes and angiograms of 110 consecutive pancreas transplants were reviewed. Eight pancreata were found deprived of blood supply to the head and the neck of the pancreas on indigocarmine-renograffin table angiograms. During back table reconstruction a distal branch of the superior mesenteric artery (SMA) was dissected and anastomosed end to end to the gastroepiploic artery using 8-0 monofilament suture. Repeated table angiogram showed excellent blood supply to the head of the pancreas, the duodenum and the body and tail of the pancreas. The pancreas transplantation proceeded with iliac artery graft inflow, portal venous outflow and enteric drainage. Simultaneous quadruple therapy with thymoglobulin, CNI, MMF and a 4-day course of steroids was used. All patients became insulin independent and euglycemic. No duodenal leak was observed in the entire series. In summary, 1-ligation of the gastroduodenal artery (GDA) is not a safe procedure, especially when arterial blood supply from the inferior pancreaticoduodenal artery is poor or inexistent, 2-table angiogram helps delineate the high risk hypo-perfused pancreas, 3-preservation of the right gastroepiploic artery and the branches of the SMA allows an easy revascularization of the pancreatic graft.

Significance of microvascular thrombosis in renal allografts: role of ex vivo thrombolytic therapy.

BACKGROUND: Microvascular thrombosis is an uncommon pathologic finding in cadaveric kidneys. It is associated with disseminated intravascular coagulation most frequently associated with head injuries and massive blood transfusions. The high rate of non-function published in the literature portends an ominous significance for transplanted organs, which have been discarded by many transplant centers. METHODS: In this report, we document the effectiveness of ex vivo thrombolytic therapy with activase, a plasminogen activator, injected intra-arterially in 12 kidneys with extensive histologic intraglomerular microvascular thrombosis prior to transplantation. All cold stored cadaveric kidneys were flushed for 50 min with 50 mg of activase diluted in University of Wisconsin solution. Pre-flush and post-flush wedge biopsies were performed on the allografts. RESULTS: All biopsies showed complete resolution of the intraglomerular microthrombi following activase flush. One kidney clotted in the third week. Three patients developed delayed graft function (25%) of which one experienced allograft thrombosis following one month after transplantation. All remaining grafts are still functioning at a mean follow up of 55.1 months (range: 23-71) with a mean serum creatinine of 1.8 mg/dL (range: 0.8-2.5). CONCLUSIONS: Back table flush with activase rapidly lyses severe intraglomerular microthrombi making them successfully transplantable. Pre-treatment with activase seems to be an effective therapeutic intervention for kidneys with massive intraglomerular thrombosis.

Steroid avoidance in renal transplant patients maintained on a cyclosporine-based protocol.

OBJECTIVE: The aim of this study was to analyze the effect of steroid avoidance, as compared with our pre-existing protocol that contained steroids, on renal allograft and patient survival. Secondary outcomes included body weight, diabetes, hyperlipidemia, and infection. MATERIALS AND METHODS: This retrospective chart review of the results of steroid avoidance was performed in 169 patients who had undergone renal transplant between January 2000 and March 2002 and had received an immunosuppression regimen of cyclosporine, mycophenolate mofetil, and prednisone; and 148 patients who had undergone transplant between November 2002 and November 2004 who had received induction immunosuppression with a steroid taper by postoperative day 4 and were maintained on cyclosporine and mycophenolate mofetil. RESULTS: One-year allograft survival rates, rejection-free graft survival rates, and patient survival rates were 88%, 76%, and 97%, respectively, in the steroid-maintenance group compared with 90%, 74%, and 96%, respectively, in the steroid-avoidance group (P = NS). No differences were detected in multiple secondary variables related to the metabolic effects of steroid therapy. CONCLUSIONS: These data suggest that steroid avoidance can be performed safely and effectively in patients on a cyclosporine-based protocol of immunosuppression. Longer follow-ups are suggested to determine the effects of limited steroid exposure on the metabolic profiles of patients.

Superiority of pediatric en bloc renal allografts over living donor kidneys: a long-term functional study.

BACKGROUND: Growing waiting list for kidney transplantation in the United States makes it imperative to expand donor pool to use of pediatric kidneys. Because en bloc pediatric kidneys double nephron numbers, it would be interesting to learn how they fare compared to living donor kidneys long term. METHODS: Retrospective chart review was performed on all 72 pediatric en bloc and 75 live adult donor kidney recipients transplanted between January 1990 and December 2001. Long term graft function was assessed with glomerular filtration rate (GFR) using the abbreviated modification of diet in renal disease (MDRD) formula. RESULTS: Pediatric donor was 16.9 +/- 11.2 months old and weighed 10.7 +/- 3.8 kg. Nine en bloc kidneys thrombosed at a mean of 4.2 days posttransplantation. Proteinuria was detected later posttransplantation in en bloc group (45.6 +/- 33.6 months vs. 23.4 +/- 16.3 months, P = 0.002). Pediatric en bloc recipients had significantly higher GFR up to 8 years posttransplantation. One-year graft survival was significantly better in live donor group (93.3% vs. 81.9%, P = 0.041) but five-year graft survival rates were similar (86.7% vs. 76.3%, P = 0.125). One-year and five-year patient survival rates were similar between en bloc and live donor groups (97.3% vs. 98.6%, P = 0.585 and 94.6% vs. 93.0%, P = 0.688, respectively). CONCLUSION: Early postoperative graft thrombosis remain a challenge with pediatric en bloc renal transplants, but once the allografts survive early postoperative course, they provide better long-term function than living donor kidney transplants. In order to alleviate burden on waiting list, pediatric en bloc kidneys should be transplanted more often when available.

Simultaneous double adult kidney transplantation using single arterial and venous anastomoses.

INTRODUCTION: To provide optimal nephron mass, two adult kidneys can be transplanted into a single recipient. TECHNICAL CONSIDERATIONS: All techniques described to date have been based on the sequential transplantation of each transplant in a separate iliac fossa. We report on an operative technique allowing the simultaneous transplantation of both kidneys into the same iliac fossa, with simultaneous revascularization through a single arterial and single venous anastomosis in 12 patients. CONCLUSIONS: This technique reduces the surgical dissection, anesthesia exposure, and risk to elderly recipients and can be added to the armamentarium of the transplant surgeon.

Quality of life after organ transplantation in type 1 diabetics with end-stage renal disease.

UNLABELLED: Quality of life (QOL) should be an important consideration while choosing therapeutic options for patients with type 1 diabetes mellitus (DM) and end-stage renal disease (ESRD) including dialysis, cadaver (CKT) or living kidney transplant (LKT) or simultaneous pancreas-kidney (SPK) transplant. METHODS: QOL was assessed in four groups of patients with history of type 1 DM and ESRD: recipients of SPK (n = 43), CKT (n = 43), LKT (n = 11) and wait listed (WL) patients (n = 23). Diabetes Quality of Life (DQOL), Short Form-36 (SF-36) and Quality of Well-Being (QWB) questionnaires were utilized. A subset of SPK (n = 19) and CKT (n = 12) recipients underwent longitudinal QOL evaluation. RESULTS: On DQOL questionnaire, SPK group had better satisfaction subscore compared with CKT (1.8 +/- 0.5 vs. 2.2 +/- 0.6, p < 0.01) LKT (1.8 +/- 0.5 vs. 2.4 +/- 0.7, p < 0.05) and WL (1.8 +/- 0.5 vs. 2.6 +/- 0.6, p < 0.001) groups and better impact subscore compared with CKT (1.7 +/- 0.6 vs. 2.1 +/- 0.6, p < 0.05) and WL (1.7 +/- 0.6 vs. 2.3 +/- 0.6, p < 0.01) groups. There were no significant differences on physical/mental composite scores of SF-36. QWB score was better in SPK group vs. WL group (0.62 +/- 0.11 vs. 0.55 +/- 0.04, p < 0.05). Longitudinal decline in satisfaction (2.3 +/- 0.5 vs. 2.6 +/- 0.9, p = 0.058) and impact (2.0 +/- 0.5 vs. 2.2 +/- 0.5, p = 0.019) subscores of DQOL were noted in CKT group. There were no significant changes in the composite scores of SF-36 in both groups. QWB scores declined in the CKT group (0.67 +/- 0.10 vs. 0.61 +/- 0.05, p = 0.01). CONCLUSION: QOL was better in type 1 diabetics with ESRD following transplantation when compared with remaining on WL. SPK transplantation had significant positive effect on diabetes-related QOL which was sustained longitudinally but it was difficult to show an overall improvement in general QOL.

Intraperitoneal catheter drainage of lymphocele: an outpatient procedure.

Laparoscopic marsupialization of lymphocele carries 13% recurrence rate, 6% injury to other organs, 12% omentoplasty, 6% open conversion and 1.8 average hospital days. A novel, simplified technique of intraperitoneal catheter drainage of lymphocele is described. Under ultrasound guidance and using the Seldinger technique, a 13F Hickman catheter was introduced into the lymphocele and connected subcutaneously to a small peritoneal window performed 5 cm apart. During the last 8 years the procedure was performed under local anesthesia in 14 patients on an outpatient basis with success (e.g. resolution of both hydronephrosis and lymphocele). One wound infection required removal of the catheter without recurrence. In another patient laparoscopy showed retraction of the catheter under the peritoneum as cause for lymphocele recurrence. In all cases absence of injury to the GU tract was confirmed by absence of extravasation of indigo carmine given intravenously. Intraperitoneal catheter drainage of post-transplant lymphocele is an effective outpatient procedure. It avoids the drawbacks of general anesthesia required by open and laparoscopic marsupialization procedures and deserves to be evaluated in a multicenter study.

Assessment of quality of life after simultaneous pancreas-kidney transplantation.

It is unclear if simultaneous pancreas-kidney (SPK) transplantation adds to the general quality of life (QOL) achieved with kidney transplantation alone (KTA). This case-controlled study matched 27 successful SPK transplant recipients with 27 successful KTA recipients. Cases were matched for gender, age (+/- 7 years), and year of transplant (+/- 2 years). Both groups had type 1 diabetes and end-stage renal disease. Diabetes-related QOL was assessed using the Diabetes Quality of Life (DQOL) questionnaire. General QOL was assessed using Medical Outcome Health Survey Short Form-36 (SF-36) and Quality of Well Being (QWB) questionnaires. Morbidity data were obtained through chart review. There was a trend for a lower prevalence of coronary artery disease (5 of 27 versus 13 of 27) and peripheral vascular disease (5 of 27 versus 9 of 27) in SPK recipients (P = not significant). Satisfaction with diabetes-related QOL was significantly better in SPK recipients (1.8 +/- 0.5 versus 2.3 +/- 0.5; P < 0.05). SPK and KTA recipients' SF-36 physical (66 +/- 21 and 64 +/- 19) and mental (76 +/- 17 and 71 +/- 22) composite scores were similar. QWB scores also were similar for SPK (0.67 +/- 0.12) and KTA (0.63 +/- 0.10) recipients. In the first 3 months after transplantation, SPK recipients had a significantly higher number of hospital admissions per patient (1.9 +/- 0.9 versus 1.4 +/- 0.6; P < 0.05), more hospital days per patient (25.1 +/- 13.8 days versus 10.1 +/- 4.4 days; P < 0.005), and more intensive care unit days per patient (7.9 +/- 7.1 days versus 0.8 +/- 1.5 days; P < 0.005). Although SPK transplantation enhanced diabetes-related QOL, there was no improvement in overall QOL.