Access of non-residents to transplantation of deceased donor organs: practices and strategies in the European setting.

The access of non-resident patients to the deceased donor waiting list (DDWL) poses different challenges. The European Committee on Organ Transplantation of the Council of Europe (CD-P-TO) has studied this phenomenon in the European setting. A questionnaire was circulated among the Council of Europe member states to inquire about the criteria applied for non-residents to access their DDWL. Information was compiled from 28 countries. Less than 1% of recipients of deceased donor organs were non-residents. Two countries never allow non-residents to access the DDWL, four allow access without restrictions and 22 only under specific conditions. Of those, most give access to non-resident patients already in their jurisdictions who are in a situation of vulnerability (urgent life-threatening conditions). In addition, patients may be given access: (i) after assessment by a specific committee (four countries); (ii) within the framework of official cooperation agreements (15 countries); and (iii) after patients have officially lived in the country for a minimum length of time (eight countries). The ethical and legal implications of these policies are discussed. Countries should collect accurate information about residency status of waitlisted patients. Transparent criteria for the access of non-residents to DDWL should be clearly defined at national level.

Donation after circulatory death today: an updated overview of the European landscape.

Donation after circulatory death (DCD) has become an accepted practice in many countries and remains a focus of intense interest in the transplant community. The present study is aimed at providing a description of the current situation of DCD in European countries. Specific questionnaires were developed to compile information on DCD practices, activities and post-transplant outcomes. Thirty-five countries completed the survey. DCD is practiced in 18 countries: eight have both controlled DCD (cDCD) and uncontrolled DCD (uDCD) programs, 4 only cDCD and 6 only uDCD. All these countries have legally binding and/or nonbinding texts to regulate the practice of DCD. The no-touch period ranges from 5 to 30 min. There are variations in ante and post mortem interventions used for the practice of cDCD. During 2008-2016, the highest DCD activity was described in the United Kingdom, Spain, Russia, the Netherlands, Belgium and France. Data on post-transplant outcomes of patients who receive DCD donor kidneys show better results with grafts obtained from cDCD versus uDCD donors. In conclusion, DCD is becoming increasingly accepted and performed in Europe, importantly contributing to the number of organs available and providing acceptable post-transplantation outcomes.

Current vascular allograft procurement, cryopreservation and transplantation techniques in the Czech Republic.

BACKGROUND: Vascular allotransplantations are performed worldwide in selected patients suffering from vascular prosthesis infection or critical limb ischemia. Either fresh or cryopreserved vascular allograft may be used. OBJECTIVES: In various points, we address several aspects (allograft procurement, cryopreservation and transplantation technique) of the program of vascular allotransplantations in the Czech Republic. MATERIAL AND METHODS: Vascular grafts retrieval has been done within multiorgan harvests using no-touch technique. Very short time of cold ischemia is achieved due to close cooperation with Tissue Establishment where the following processing of cryopreservation is performed. Meeting all necessary quality criteria is a prerequisity for releasing grafts for clinical application. Standardized thawing protocol and surgical handling aims to minimize microfractures before implantation. RESULTS: Based on experimental and clinical work, the first validation of cryopreserved arterial and venous grafts for clinical use was performed between 2011 and 2013 in the Czech Republic. The developement of storage of vascular tissue in banks was stimulated in 2000-2010 by the issue of EU directives and national harmonized norms, aimed at assurance of high quality and safety of cells and tissues used for transplantations in humans. CONCLUSIONS: There are several crucial moments affecting final quality, including graft retrieval within a multiorgan harvest, short ischemic time, cryopreservation and thawing technique used. The recommended surgical handling during implantation may also affect results and graft-related complications.

Organization model for allotransplantations of cryopreserved vascular grafts in Czech Republic.

The transplantation of fresh or cryopreserved vascular allografts in patients with a prosthetic graft infection or critical limb ischemia is necessary for their limb salvage and, in many cases, represents a lifesaving procedure. While transplantation of fresh allografts has a long history in the Czech Republic, the standard use of cryopreserved vascular allografts was introduced into the clinical practice in 2011 as a result of the implementation of EU Directive 2004/23/EC into national legislation (Human Cell and Tissue Act No. 296/2008 Coll.). The authors present an organizational model based on cooperation between the majority of Czech Transplant Centers with a tissue establishment licensed by the national competent authority. In various points, we are addressing individual aspects of experimental and clinical studies which affect clinical practice. Based on experimental and clinical work, the first validation of cryopreserved arterial and venous grafts for clinical use was performed between 2011 and 2013. The growing number of centers participating in this programme led to a growing number of patients who underwent transplantation of vascular allografts. In 2015 the numbers of transplanted fresh versus cryopreserved allografts in the Czech Republic were almost equal. Cooperation of the participating centers in the Czech Republic with the licensed Tissue Establishment made it possible to achieve a full compliance with the European Union Directives, and harmonized national legal norms and assured a high quality of cryopreserved vascular allografts.

Application of gentamicin-collagen sponge shortened wound healing time after minor amputations in diabetic patients - a prospective, randomised trial.

INTRODUCTION: Diabetic foot infections are frequently polymicrobial. The lower tissue concentration of systemically administered antibiotics in diabetic patients was reported. Collatamp(®)EG (Syntacoll GmbH Saal/Donau, Germany) is a bioabsorbable, gentamicin impregnated collagen spongeused for local treatment. The aim of this randomized trial was to assess influence of gentamicin-collagen sponge applied to a wound on surgical outcomes after minor amputations in diabetic patients. MATERIAL AND METHODS: Fifty diabetic patients indicated for minor amputation in 2009 at our surgery department were included in the study. Patients were pre-operatively randomised into two groups. Twenty-five patients in group A were treated with gentamicin impregnated collagen sponge applied into wound peri-operatively while 25 patients in group B had minor amputation without gentamicin sponge. RESULTS: There was no significant difference in the demographic data, procedures performed, diabetes duration and peripheral vascular disease severity between the groups. The median glycosylated haemoglobin was 6.0% (range: 4.6-9.5%) in group A and 6.2% (range: 4.0-8.4%) in control group B (non-significant). Median TcPO2 level was 44 (range: 13-67) in group A and 48 (range: 11-69) in control group B (non-significant). The median of wound healing duration in group A was 3.0 weeks (range: 1.7-17.1 weeks) compared to 4.9 weeks (range: 2.6-20.0 weeks) in control group B. This was with a statistically significant difference (p < 0.05). CONCLUSIONS: Application of gentamicin impregnated collagen sponge shortened wound healing duration after minor amputations in diabetic patients by almost 2 weeks.

Immunosuppressive protocol with delayed use of low-dose tacrolimus after aortic transplantation suppresses donor-specific anti-MHC class I and class II antibody production in rats.

BACKGROUND: Arterial allografts are used as vascular conduits in the treatment of prosthetic graft infection. Immunosuppression decreases their rupture risk rate. However, immunosuppression can be unprofitable in florid infection. Previously, we confirmed inhibition of cell-mediated destruction of rat aortic grafts by delayed use of tacrolimus. In this work, we studied the influence of this protocol on the antibody-mediated rejection. MATERIAL AND METHODS: Flow cytometry was used for the retrospective analysis of day 0, 14, and 30 sera obtained from Lewis rat recipients of isogeneic fresh infrarenal aortic grafts (group A) or Brown-Norway rat aortic grafts (group B,C,D) for the presence of donor-specific anti-MHC class I and II antibodies. Tacrolimus in daily dose of 0.2 mg/kg was administered from day 1 to day 30 (group C) or from day 7 to day 30 (group D). RESULTS: Inhibition of fluorescence-labeled anti-BN MHC class I and MHC class II antibodies binding to BN-splenocytes was observed only by day 14 and day 30 sera of allogeneic non-immunosuppressed Lewis rats (group B). The day 30 sera significantly decreased anti-MHC I (42±3%) and anti-MHC II antibody binding (56±3%) compared to day 0 (76±9%, p=0.005 and 79±5%, p=0.003, respectively). Deposition of immunoglobulins G into the tunica media was observed only in non-immunosuppressed aortic allografts on day 30. CONCLUSIONS: Fresh aortic allografts induce donor-specific anti-MHC class I and anti-MHC class II antibody production. Delayed administration of tacrolimus completely suppressed antibody production and antibody-mediated destruction of aortic allografts.

Dual kidney transplant: a single-center experience and review of the literature.

OBJECTIVES: Adult dual kidney transplant is a strategy to overcome the imbalance between limited nephron mass supplied from an older donor and a recipient with a metabolic request. MATERIALS AND METHODS: In our report, we review the literature and present our single-center experience. From June 2007 until July 2012, nine hundred twenty-eight single and seventeen dual kidney transplants from deceased donors were performed. RESULTS: The average donor was 71.5 ± 3.6 years of age with an average serum creatinine, creatinine clearance, and an average number of sclerotic glomeruli, 106.1 ± 44.2 µmol/L, 0.97 ± 0.37 mL/s, and 22.4 ± 14.2. Immediate graft function and acute rejection episodes were observed in 75% and 6% of patients. The overall patient survival rates at 1 and 2 years after transplant were 93%. The overall graft survival rates at 1 and 2 years were 88%. CONCLUSIONS: Previous studies and our single-center experience suggest that the dual transplant procedure may help improve results of kidney transplants from expanded criteria donors and extend the donor pool by using kidneys that would be discarded otherwise.

Early and late outcomes of hybrid endovascular and open repair procedures in patients with peripheral arterial disease.

BACKGROUND: Hybrid endovascular and open reconstructions are used increasingly often for multilevel revascularization for lower limb ischaemia. The aim was to evaluate outcomes after such procedures in a single-center non-randomized retrospective study. PATIENTS AND METHODS: Consecutive patients with multilevel arterial disease who underwent single session hybrid procedures were analyzed depending on the type of ischaemia and the type of revascularization. RESULTS: 164 patients were included with a median follow up time of 14 months (range: 0 - 70). Indication was claudication (group 1, 47 %), critical limb ischaemia (group 2, 33 %) and acute limb ischaemia (group 3, 20 %). Technical success rate was 99.3 %, perioperative mortality 2 %. Primary, assisted-primary and secondary patency rates at one year were 60 %, 61 % and 64 %, respectively. Primary, primary assisted and secondary patency were lower in group 2 and 3 compared to group 1 (all p < 0.05). Results were better when endovascular repairs were performed above compared to below the open repair site (all p < 0.05). Limb salvage at 1 year in groups 1 - 3 were 98 %, 92 % and 90 %, respectively. The risk of major amputation was highest in group 3 compared to group 1 (p = 0.001) or group 2 (p < 0.04). CONCLUSIONS: The results depend on the type of ischaemia and the localization of endovascular procedures.

Prevalence and risk factors of polyomavirus BK replication in simultaneous pancreas/kidney transplant recipients from a single transplant center.

BACKGROUND: BK virus (BKV) replication is considered as a marker of risk for polyomavirus BK-associated nephropathy (PVAN). We evaluated the occurrence and risk factors for BKV DNA positivity following simultaneous pancreas/kidney transplantation (SPK). METHODS: Point prevalence of BK viruria and viremia was assessed in 183 SPK recipients. Real-time polymerase chain reaction was used with a detection threshold of 10(3) copies/mL. High-level BKV positivity was defined as viruria and/or viremia >10(7) and >10(4) copies/mL, respectively. BKV-positive patients were retested after 4-13 months and underwent an additional six-month clinical follow-up. RESULTS: Urine and serum BKV positivity was detected in 28 (17.3% of available samples) and 7 (3.8%) patients, with high-level viruria and viremia occurring in 6 (3.7%) and 3 (1.6%) patients, respectively. PVAN was biopsy-confirmed in 1 and suspected as a cause of progressive renal failure in another SPK recipient. Patients with single low-level viruria did not progress to high-level positivity or PVAN at follow-up. In multivariate analysis, pre-transplant diabetes duration and delayed graft function were independently associated with BKV positivity. CONCLUSIONS: Point prevalence of high-level BKV positivity and PVAN was low in SPK recipients from a single center. Diabetes duration and delayed graft function were independent risk factors for BKV replication.

Polypropylene mesh repair of incisional hernia after kidney transplantation: single-center experience and review of the literature.

BACKGROUND: Incisional hernia after kidney transplantation increases patient morbidity and impacts quality of life. Reports of hernia mesh repair after kidney transplantation are rare; thus, the benefit of mesh hernioplasty in transplanted patients is assumed. However, it is also assumed that transplant patients are susceptible to incisional and mesh infections. MATERIAL/METHODS: Between January 1, 2005 and December 31, 2010, we performed 1067 kidney transplantations. Twenty-eight patients developed incisional hernias (2.6%), and mesh repair was performed in 20 of them (8 women, 12 men; median age 59.5 years, range 43 to 68 years). We retrospectively studied this latter group. We also reviewed the literature regarding the results of this treatment. RESULTS: Postoperative mortality was zero, but postoperative wound bleeding led to surgical revision in 1 patient. Wound infection did not occur. During the follow-up period we observed 4 hernia recurrences (20%). CONCLUSIONS: In conclusion, our retrospective study and review of the literature confirmed the safety and low incidence (1.1% to 3.8%) of mesh hernia repair in chronic immunosuppressed patients after renal transplantation, which has a minimal risk of wound infection and no higher risk of hernia recurrence than in non-transplant patients.

[Specific program for perioperative care in paediatric liver transplantation]. / Specifika perioperacní péce o pediatrické pacienty podstupující transplantaci jater.

With increasing survival rates, liver transplantation has reached the mainstream of medical care. Due to the experience acquired with adult liver transplantation, the program of paediatric liver transplantation develops. The surgery technique and perioperative care have to reflect anatomic and physiologic differences in childhood. This report describes organisation and outcomes of the program of paediatric liver transplantation in Transplantcentre IKEM.

[Eversion carotid endarterectomy: evaluation of results after changing the operation technique]. / Everzní endarterektomie arterie carotis interna: hodnocení výsledku po zmene operacní techniky.

BACKGROUND: Stroke is the third most common cause of mortality, and carotid artery stenosis causes up to 30% of all ischemic strokes. Eversion CEA (ECEA) has been proposed as an acceptable alternative to the standard bifurcation endarterectomy in many patients. This study was designed to analyze the long-term durability of ECEA in symptomatic and asymptomatic patients. Data were retrospectively reviewed to determine the incidence of major adverse cardiovascular events (MACEs) within 30 days of surgery, late survival, and the incidence of restenosis. METHODS AND RESULTS: From January 1999 to June 2010, 344 ECEAs were performed on 324 patients (34% female, 38% symptomatic). The mean follow-up period was 30 months. CONCLUSIONS: MACEs occurred in 28 patients (8.6%). The overall incidence of stroke or death after ECEA was 1.7% and 0.9% at discharge. The overall incidence of stoke or death after CEA was 4.3% and 21% (14 strokes, 69 deaths, 8 of which were stroke-related). The overall occurrence of any restenosis (> 50%) after CEA was 4.3% (14 of 324 procedures).

[Long-term follow-up of the first 500 liver transplant recipients transplanted at the Institute for Clinical and Experimental Medicine in Prague]. / Výsledky dlouhodobého sledování prvních 500 pacientu po transplantaci jater provedených v institutu klinické a experimentální medicíny v Praze.

BACKGROUND: Between April 1995 and November 2005, 500 liver transplantations were performed in 476 patients of age from 3, till 70, at the Transplantation center of the Institute of Clinical and Experimental Medicine (IKEM) in Prague. The most common indications for liver transplantation were alcoholic liver cirrhosis (23%), hepatitis C cirrhosis (17%), and cholestatic cirrhosis (PBC and PSC, 9% each). Mean MELD score of recipients at the transplantation was 15-18 for each year of transplantation. Ten-years patient survival was 79.1 +/- 2.2%, and graft survival 74.1 +/- 2.1% respectively. Best patient and graft survival was achieved among patients transplanted for autoimmune liver diseases, the worst in group of patients with alcoholic cirrhosis. Malignancies were the most common cause of death during the period of follow-up (17 patients). METHODS AND RESULTS: Patients were followed longitudinally at the Department of hepatogastroenterology IKEM according to prospective protocol included protocol biopsies. Hypertension (in 71% of recipients), and overweight or obesity (in 56.3%), were the most prevalent medical complications among long-term survivors. Diabetes was found in 28.6%, of which 14.7% was de-nove diabetes after transplantation. Renal insufficiency (S-creatinin > 150 micromol/l) was present in 61 of 348 (17.6%) survivors. Out of these, 16 needed chronic hemodialysis, and 12 underwent kidney transplantation subsequently. Protocol biopsy at 5 years after transplantation was evaluated in a sample of 102 unselected liver transplant recipients. Normal liver was found in 4% of recipients, minor non-specific changes in 36% of them. Disease recurrence was present in all of 16 recipients transplanted for HCV cirrhosis, in one third of them graft cirrhosis was already present. Disease recurrence was found in patients transplanted for autoimmune disease frequently, PBC in 40%, PSC in 25%, and autoimmune hepatitis in 60% of recipients. Graft steatosis greater than 33% was present in 13% of recipients. CONCLUSIONS: Liver transplantation is highly effective method of treatment of end stage liver disease. Despite frequent medical complications, and disease recurrence on histological examination almost 80% of recipients transplanted in the liver transplantation program in IKEM survived more than 10 years after procedure. The survival achieved was far above that of the European liver transplant registry.

[Liver transplantation in patients with portal vein thrombosis]. / Transplantace jater u pacientu s trombózou v. portae.

BACKGROUND: Portal vein thrombosis has (PVT) long been an absolute contraindication to liver transplantation. In patients scheduled for liver transplantation, portal vein thrombosis occurs in 4-15%. METHODS AND RESULTS: The authors retrospectively collected data on 740 patients who underwent an initial orthotopic liver transplant at the authors' institution between 1996 and 2009. Mean follow-up was from 1 day to 6 years. There were 437 male patients and 303 female patients. We have performed this procedure in 57 recipients with PVT; this constitutes 7.7% of the overall transplant population. There was a 10.5% incidence of liver graft dysfunction, 10.5% of hepatic artery thrombosis, 19.3% of acute rejection and 17.5% of biliary complications. The overall incidence of relaparotomy for bleeding was 28% (16 patients). In-hospital mortality and late mortality were 15.8% and 31.6%, respectively. Volumes transfused were 17.1 (0-425) transfusion units of red blood cell, 27.1 (0-132) of fresh-frozen plasma and 2.6 (0-20) of platelets respectively. CONCLUSIONS: We confirm that PVT is not a contraindication to LTx at the present time.

[The influence of surgical complications on renal graft function]. / Vliv chirurgických komplikací na funkci transplantované ledviny.

BACKGROUND: Kidney transplantation is the method of choice for patients with end stage kidney disease. Surgical complications remain a serious clinical problem and can lead to loss of graft function. AIM: Analysis of surgical complications in patients after single kidney transplant from cadaver donors and their influence on the function of the transplanted graft. METHODS: Patients after a single kidney transplant from a cadaver donor (n = 566) between 1/2006-4/2009 in the Institute of Clinical and Experimental Medicine. RESULTS: Individual surgical complications did not affect the delayed onset of graft function. A significantly higher serum creatinine in the 3rd month was observed in the group of patients with urinary leak (p = 0.02) compared with a group of patients without complications. The serum creatinine at 6th month was not affected by any surgical complication. Serum creatinine at 12th month was statistically significantly higher in the group of patients with lymphocele (p = 0.028) compared with a group of patients without complications. The surgical complications which had a significant effect on one year graft survival were infectious wound complications in the recipient (p < 0.05), renal artery stenosis (p < 0.05) and renal vein thrombosis (p < 0.01). CONCLUSIONS: The onset of graft function was not affected by surgical complications. The group of patients with urinary leak had higher serum creatinine in 3rd month and patients with lymphocele in 12th month. Infectious wound complications, renal artery stenosis and renal vein thrombosis decrease the 1-year graft survival.

Successful surgical treatment of multilevel aortic aneurysms combined with renal transplantation.

The concomitant presence of a thoracic aortic aneurysm and an abdominal aortic aneurysm in patients considered for renal transplantation is extremely rare. To our knowledge, this is the first case report of the successful treatment of multilevel aortic aneurysms together with renal transplantation. The treatment modalities in renal transplant patients with concomitant aortic aneurysms are discussed.

Combined infrainguinal reconstruction and infrapopliteal intraluminal angioplasty for limb salvage in critical limb ischemia.

The aim of this retrospective study was to assess the success rates of limb salvage, and the primary and secondary patency rates of reconstructions of critical limb ischemia (CLI) patients undergoing combined infrainguinal reconstruction and intraluminal angioplasty of crural arteries. In 2000-2005, infrainguinal reconstruction with concomitant intraluminal angioplasty of crural arteries was performed in 30 patients with CLI, mean age was 63 years (S.D.=10); according to the Fontaine classification, 28 (93%) patients had stage IV and 2 (7%) stage III ischemia. During mean follow-up of 12.9 (S.D.=16.9) months, primary 1-year patency of vascular reconstruction was seen in 16 (52.6%) patients of our group. Secondary 1-year patency over the same follow-up period was documented in 17 (56.2%) patients and 1-year limb salvage was obtained in 25 (82.6%) patients. Based on this finding, we consider a combined surgical and endovascular procedure to be the method of choice in limb salvage in patients with CLI not allowing for an isolated endovascular procedure.

Coronary calcium score in renal transplant recipients.

BACKGROUND: Coronary calcium score (CCS) is established as an index for the risk of coronary heart disease (CHD). The aim of this prospective study was to assess changes in CCS in patients 1 year after kidney transplantation (KTx). METHOD: A total of 221 consecutive renal transplant recipients were enrolled in our prospective study (140 males/81 females). CCS was analyzed by spiral multidetector CT at baseline and 1 year after KTx. Bone mineral density (BMD) was measured in the lumbar spine (L-BMD) and femur (F-BMD). RESULTS: The mean CCS was 539 +/- 1,033 at baseline. 33% of the patients had a CCS of 0, and 33% of patients had a CCS of >401. A negative correlation was found between F-BMD and CCS, but no correlation was found between L-BMD and CCS. Using CCS, a positive correlation was found between total cholesterol and the age of patients, but no correlation of CCS was found with other biochemical markers of bone and lipid metabolism. One year after transplantation, the mean CCS was 703 +/- 1,253; in 75% of patients the CCS was the same and 25% had a higher CCS. CONCLUSION: A high risk of CHD was found in 33% of renal graft recipients. No improvement in CCS was found 1 year after KTx.

Epidermal innervation in type 1 diabetic patients: a 2.5-year prospective study after simultaneous pancreas/kidney transplantation.

OBJECTIVE: To assess the effect of normoglycemia following simultaneous pancreas/kidney transplantation (SPK) on neurological function and intraepidermal nerve fiber density (IENFD) in patients with type 1 diabetes. RESEARCH DESIGN AND METHODS: We performed vibration perception threshold (VPT) testing and autonomic function testing (AFT) and assessed IENFD in skin biopsies from the lower thigh and upper calf in 14 healthy control subjects and 18 patients with type 1 diabetes at the time of and at 21-40 (median 29) months post SPK. RESULTS: At baseline, significantly increased VPTs, pathological AFT results, and severe reduction in IENFD were present in SPK recipients. After SPK, an increase of IENFD in the thigh of more than one epidermal nerve fiber per millimeter was noted in three patients (median 4.1, range 1.9-10.2), but changes were not significant for the group as a whole. CONCLUSIONS: We conclude that either irreversible nerve damage might be present in some SPK recipients or that longer periods of normoglycemia might be needed to allow nerve regeneration.

Kidney retransplantation following graft loss to polyoma virus-associated nephropathy: an effective treatment option in simultaneous pancreas and kidney transplant recipients.

Polyomavirus-associated nephropathy (PVAN) has emerged as an important cause of graft loss following kidney transplantation. Experience with kidney retransplantation (reKT) in PVAN is very limited, especially in the setting of uninterrupted immunosuppression protecting the still functioning pancreatic graft after simultaneous pancreas/kidney transplantation (SPK). We present a review of five cases of reKT in four SPK recipients with Type 1 diabetes mellitus from a single centre (a second reKT was performed in one patient following first reKT failure due PVAN recurrence). Pre-emptive nephrectomy of the failed graft was performed in three of the cases and all kidney grafts for reKT were harvested from cadaveric donors. All patients are dialysis- and insulin-independent at 30 (9-55), median (range), months following last reKT with maintenance immunosuppression consisting of tacrolimus/sirolimus in three and cyclosporine A/mycophenolate mofetil in one patient. In conclusion, reKT represents an effective treatment option in SPK patients with kidney failure on account of PVAN. Use of interventions designed to reduce active viral replication, including pre-emptive nephrectomy of the failed graft, should be considered before reKT.