Retrieved but not transplanted kidneys: how to limit the losses? A retrospective national study.

Despite the organ shortage, a significant number of deceased donor kidneys are retrieved but not transplanted (RNTK). This study aims to describe and analyze the main causes of potential grafts discard and to propose adequate solutions. We collected data from the Cristal database of the French Biomedicine Agency about RNTK over one year. Expert opinion was taken from urologists with extensive expertise in renal transplantation. They retrospectively analyzed each record to assess the appropriateness of each graft refusal and subsequent kidney discard. Of 252 kidneys were retrieved but not transplanted in France over one year. The main reasons for discard were vascular abnormalities in 43.7% (n = 110), suspicion of malignant tumor in 18.7% (n = 47), and severe histological lesions on preimplantation biopsy in 12.3% (n = 31). The reason for kidney refusal was undetermined in 4.8% (n = 12). Iatrogenic lesions were responsible for 26.2% (n = 66). Overall, 46.0% (n = 16) and 25.0% (n = 63) of the grafts were, respectively, properly and improperly denied, and the analysis was not possible in 29.0% (n = 73). In total, 36.9% of RNTK could have been transplanted. Reduction of iatrogenic lesions, improvement of microsurgical repair skills, and proper histological examination are necessary to reduce the number of RNTK. A prospective study applying the proposed principles is undoubtedly essential to complete this work.

Effectiveness and efficiency of teleimaging in the transplantation process: a mixed method protocol.

BACKGROUND: The transplantation process usually takes place without transplant teams being able to use imaging data to assess graft quality. The decision of whether to go get the graft or not is therefore limited and suboptimal. "Cristal images" is a teleimaging project allowing real-time visualization of images of the organs of the donor. The objective of our study is to assess whether the use of a secure teleimaging can improve the effectiveness and efficiency of the procurement and transplantation processes. METHODS: We will use the exhaustive national registry of organ allocation and transplantation, and compare outcomes before the deployment of "Cristal images" (years 2015-2016) and after it becomes operational (years 2018-2019) for heart, lung, liver and kidney transplant in a before-after study, combined with a preference elicitation study. The primary endpoint will be the number of successful organ transplantations. Secondary endpoints will be related to the efficiency of the transplant process (decision making, transportation, cost) and a preference elicitation study will determine the relative preferences of transplant teams towards few "Cristal images"' components or potential developments, which are yet to be determined through a qualitative analysis based on interviews with professionals. DISCUSSION: This study will provide stakeholders data on the efficiency of real-time visualization for transplant teams and identify the levers likely to influence the technology use among these teams. TRIAL REGISTRATION: clinicaltrials.gov: NCT03201224 , 13 June 2017, retrospectively registered.

Evaluation of outcomes in renal transplantation with hypothermic machine perfusion for the preservation of kidneys from expanded criteria donors.

In 2012, an expert working group from the French Transplant Health Authority recommended the use of hypothermic machine perfusion (HMP) to improve kidney preservation and transplant outcomes from expanded criteria donors, deceased after brain death. This study compares HMP and cold storage (CS) effects on delayed graft function (DGF) and transplant outcomes. We identified 4,316 kidney transplants from expanded criteria donors (2011-2014) in France through the French Transplant Registry. DGF occurrence was analyzed with a logistic regression, excluding preemptive transplants. One-year graft failure was analyzed with a Cox regression. A subpopulation of 66 paired kidneys was identified: one preserved by HMP and the other by CS from the same donor. Kidneys preserved by HMP (801) vs CS (3515) were associated with more frequent recipient comorbidities and older donors and recipients. HMP had a protective effect against DGF (24% in HMP group and 38% in CS group, OR = 0.49 [0.40-0.60]). Results were similar in the paired kidneys (OR = 0.23 [0.04-0.57]). HMP use decreased risk for 1-year graft failure (HR = 0.77 [0.60-0.99]). Initial hospital stays were shorter in the HMP group (P < 0.001). Our results confirm the reduction in DGF occurrence among expanded criteria donors kidneys preserved by HMP.

Thoracoscopy in children less than 20 kg for the management of spinal disorders: efficacy at long-term follow-up.

BACKGROUND: Thoracoscopy is now considered a safe and feasible method for surgical management of spinal disorders in both adults and children. Nevertheless, a weight less than 20 kg has been reported as a relative contraindication because of the small volume of the thoracic cage and the anticipated difficulties of single-lung ventilation. The aim of this study was to evaluate the feasibility, as well as the safety and efficacy, of thoracoscopic procedures in such patients. METHODS: This study was a retrospective analysis of a consecutive group of patients less than 20 kg weight, who underwent a thoracoscopy between 1998 and 2005. Results were evaluated radiologically, and intraoperative and postoperative complications were reported. A minimum 2-year follow-up was required. RESULTS: Seventeen patients were included. Age at surgery averaged 3 years and 4 months (±1.25). The mean weight was 13.3 kg (±2.8). Fourteen of the patients had congenital scoliosis, 9 due to hemivertebrae and 5 due to segmentation failures. The other 3 suffered from evolutive kyphosis, 2 caused by Pott disease, and 1 caused by congenital anterior failure of segmentation. The mean follow-up was 6 years and 9 months (±1.5). Lung exclusion time averaged 114 minutes (±20). The intended procedure was possible in all cases and no conversion to open thoracotomy was required. The mean operating time was 139 minutes (±10). A posterior arthrodesis was associated and performed during the same anesthesia in 15 cases. The selective breathing was efficient and well tolerated in all cases. No intraoperative respiratory complication was observed. For patients with congenital scoliosis, the average improvement of the main curve between preoperative and latest follow-up was 55%, with an average Cobb angle improvement of 19.1 degrees (±10.5). For the 3 cases of kyphosis, the curve progression stopped, with a mean reduction of the regional kyphosis of 6 degrees (±11.5). Fusion was obtained radiologically in all cases. CONCLUSIONS: This study confirms the feasibility, safety, and efficacy of thoracoscopy for the management of spinal disorders in children less than 20 kg weight. Thoracoscopy can still be considered as an option in very young children, even though the small chest cavity creates additional technical challenges and the diminutive bronchial tree necessitates a dedicated method of single-lung ventilation. LEVEL OF EVIDENCE: IV.

Retroperitoneal laparoscopic nephrectomy in children: at last the gold standard?

PURPOSE: We analyzed our experience with retroperitoneal laparoscopic nephrectomy giving special attention to the learning curve, morbidity, and feasibility in a teaching institution. MATERIAL AND METHODS: Between 1996 and 2004, we performed 104 laparoscopic nephrectomies in 88 children. Only four were performed via the transperitoneal approach, the others being via the retroperitoneal approach; the files of the latter were analyzed. Mean age was 5 years (20 days-15 years). Main indications were pretransplant nephrectomy for arterial hypertension, nephrotic syndrome or uremic hemolytic syndrome (51%), non-functioning kidney secondary to obstruction, reflux or ectopic ureter (38%), and multicystic dysplastic kidney (11%). Bilateral nephrectomy was performed in 13 children. RESULTS: The lateral retroperitoneal approach was feasible in all cases even for those who had previous renal surgery. Conversion was not needed in any patient. No significant blood loss was observed. Mean operative time was 97 min (range 44-240) for unilateral nephrectomy; 46 nephrectomies were done in less than 90 min. In bilateral cases the mean operative time was 260 min (range 160-390). The operative time was less than 4 h in seven bilateral cases. Postoperative course was uneventful. Hospital stay was 1.9 days (range 1-3) for urological indications and 5 days (range 3-7) for patients with terminal renal disease. The procedure was initially performed by one surgeon, but was then expanded to other surgeons of the team, and safely taught to residents and fellows. CONCLUSIONS: The procedure is safe, the learning curve is reasonable, teaching is feasible, operating time becomes with experience closer to open surgery without morbidity, and cosmetic results are excellent. This procedure may be considered as the gold standard for nephrectomy in children.

High-performance liquid chromatographic analysis of S-adenosylmethionine and its metabolites in rat tissues: interrelationship with changes in biogenic catechol levels following treatment with L-dopa.

A method is described for the simultaneous analysis of S-adenosylmethionine (SAM) and its metabolites, S-adenosylhomocysteine (SAH) and decarboxylated S-adenosylmethionine along with the natural polyamines, putrescine, spermidine and spermine. The separation is obtained by a reversed-phase ion-pair liquid chromatographic procedure with gradient elution followed by dual detection. The UV absorbance at 254 nm is used for the analysis of SAM and of the SAM metabolites, whereas the polyamines and some major amino acids, e.g., methionine, tyrosine and tryptophan, are analyzed by fluorescence detection after UV-cell derivatization with o-phthalaldehyde. A separate ion-pair reversed-phase high-performance liquid chromatographic (HPLC) procedure using isocratic elution and electrochemical detection is employed to analyse in the same tissue extracts the catechols and 5-hydroxyindoles, 3,4-dihydroxyphenylalanine (DOPA), dopamine, norepinephrine, 3,4-dihydroxyphenylacetic acid, homovanillic acid, 4-hydroxy-3- methoxyphenylalanine , tryptophan, 5-hydroxytryptophan, serotonin and 5- hydroxyindolacetic acid. The sample preparation for the two HPLC procedures requires only homogenization of the tissues in perchloric acid and centrifugation before injection onto the column. The two chromatographic procedures have been applied to study the interrelationship, in various tissues of rats, between the SAM and SAH levels and the biogenic catechols after different treatments with L-DOPA alone or in combination with alpha- monofluoromethyl -DOPA, a potent enzyme-activated irreversible inhibitor of aromatic L-amino acid decarboxylase.

Chronic elevation of brain GABA by gamma-vinyl GABA treatment does not alter the sensitivity of GABAergic or dopaminergic receptors in rat CNS.

Rat brain GABA levels were elevated chronically by daily administration of gamma-vinyl GABA, an enzyme-activated, irreversible inhibitor of GABA:2-oxo-glutarate aminotransferase (GABA-T; EC2.6.1.19). Following various periods of drug treatment and withdrawal, the sensitivity of dopamine and GABA receptors in the CNS was determined by biochemical and behavioral evaluations. In contrast to chronic haloperidol treatment, none of the treatment schedules with gamma-vinyl GABA had any significant effect on parameters such as apomorphine induced locomotor activity, [3H] spiperone binding or dopamine-stimulated adenylate cyclase in the corpus striatum; nor did gamma-vinyl GABA treatment affect [3H] GABA binding or GABA-activated [3H] diazepam binding in the cerebral cortex. Moreover, co-administration of gamma-vinyl GABA and haloperidol did not alter the ability of the neuroleptic to induce supersensitivity in the striatal dopaminergic system. Thus, it appears that, in contrast to reported studies using chronic administration of other less specific GABA-T inhibitors such as gamma-acetylenic GABA, amino-oxyacetic acid and isonicotinic acid hydrazide or direct GABA agonists such as THIP (4,5,6,7-tetrahydroisoxazolo (5,4-c-)-pyridin-3-ol) or kojic amine, gamma-vinyl GABA does not alter the sensitivity of the striatal dopaminergic system.