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INTRODUCTION: When encountered, the ideal management of lithiasis in deceased donor kidneys is not well-defined. With advances in endourological techniques, minimally invasive treatments are becoming an increasingly viable option. We set out to describe our experience performing ex-vivo ureteroscopy on cadaveric donor kidneys, including one in which the procedure was completed on-pump. METHODS: A retrospective chart review was undertaken to identify patients who had undergone ex-vivo ureteroscopy prior to cadaveric renal transplant. Four patients were identified, including one in which the procedure was done with the kidney remaining on-pump. The surgical technique and subsequent data were reviewed. RESULTS: Ex-vivo ureteroscopy was successfully completed in all four instances without intraoperative complication. All kidneys were endoscopically stone-free. Creatinine nadirs ranged from 0.8-1.4. All four patients remained stone-free at a mean followup of 13 months. CONCLUSIONS: Our series provides further evidence as to the safety and efficacy of ex-vivo ureteroscopy prior to transplantation in cadaveric renal transplants and describes a novel technique in the form of on-pump ex-vivo ureteroscopy.
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BACKGROUND: Anticipating poor recovery due to impaired self-management and appointment-keeping, clinicians may consider serious mental illness (SMI) a significant concern in organ transplantation. However, little empirical evidence exists regarding posttransplantation outcomes for patients with SMI. METHODS: This study analyzed health services data to evaluate posttransplantation 3-year survival by SMI status in a nationwide cohort of patients in the Veterans Health Administration (VHA). RESULTS: A total of 960 recipients of solid organ or bone marrow transplants were identified from Veterans Health Administration administrative data extracts for fiscal years 2006 to 2009. Of these, 164 (17%) had an SMI diagnosis before transplantation (schizophrenia, posttraumatic stress, major depressive, and bipolar disorders); 301 (31%) had some other mental illness diagnosis (such as anxiety, adjustment reactions, or substance abuse); and 495 (52%) had no mental health diagnosis. Twenty-two patients (2%) required retransplantation and 208 patients (22%) died during follow-up. Data on whether these were primary or repeat transplantations were unavailable. Rates of attendance at postoperative outpatient visits and number of months for which immunosuppressive drugs fills were recorded were similar among mental illness groups, as were rates of diagnosed immunological rejection. Three-year mortality was equivalent among mental health groups: no mental health (19%) versus other mental illness (23%) versus SMI (27%; χ(2) = 5.11; df = 2; P = .08). In adjusted survival models, no effect of mental health status was observed. CONCLUSIONS: Serious mental illness diagnosis does not appear to be associated with adverse transplantation outcomes over the first 3 years; however, a potentially diverging survival curve may portend higher mortality at 5 years.
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Trasplante de Médula Ósea/psicología , Conocimientos, Actitudes y Práctica en Salud , Trastornos Mentales/psicología , Trasplante de Órganos/psicología , Aceptación de la Atención de Salud , Salud de los Veteranos , Veteranos/psicología , Adulto , Anciano , Atención Ambulatoria , Trasplante de Médula Ósea/efectos adversos , Trasplante de Médula Ósea/mortalidad , Distribución de Chi-Cuadrado , Femenino , Humanos , Inmunosupresores/uso terapéutico , Estimación de Kaplan-Meier , Masculino , Cumplimiento de la Medicación , Trastornos Mentales/diagnóstico , Trastornos Mentales/mortalidad , Salud Mental , Persona de Mediana Edad , Análisis Multivariante , Trasplante de Órganos/efectos adversos , Trasplante de Órganos/mortalidad , Modelos de Riesgos Proporcionales , Estudios Retrospectivos , Factores de Riesgo , Índice de Severidad de la Enfermedad , Tasa de Supervivencia , Factores de Tiempo , Resultado del Tratamiento , Estados Unidos/epidemiologíaRESUMEN
BACKGROUND: To optimize available organs, kidneys from young donors traditionally believed to be suboptimal are transplanted to adults. The purpose of this study is to compare graft survival (GS) of en bloc kidney (EBK) from young pediatric donors to other deceased donor transplants in adult recipients. METHODS: We analyzed United Network of Organ Sharing/STAR data on primary deceased donor kidney transplants to adult recipients (1988-2006). EBK (age younger than 5 years, n=1696) was compared with solitary pediatric (SP; age younger than 5 years) kidneys (n=1502), and matched standard adult donors (age 18-59 years, n=9594) and expanded criteria donor (ECD; n=6396). The adjusted GS was obtained using Cox proportional hazard model and hazard ratios were calculated. RESULTS: EBK had lowest acute rejection rates (6.0%) but similar to standard adult transplants (6.3%), and lower than SP and ECD (9.0% and 8.2%; P<0.0001). Delayed graft function rates were lowest in EBK (17.9%), highest in ECD (34.8%; P<0.0001), and similar among SP and standard adult transplants (24.4% and 24.2%). The estimated glomerular filtration rate (eGFR) was best in EBK and worst in ECD (P<0.0001). The eGFR of EBK and SP transplants continuously improved but the eGFR of standard adult and ECD declined. Graft loss was higher in EBK and SP transplants than adult donor transplants during the first 6 months. Despite the highest thrombosis rates in EBK (5.0%) (SP, 3.3%; standard adult, 1.8%; ECD, 2.0%, P<0.0001), GS of EBK became similar to standard adult donor transplants by 5 years and best at 10 years posttransplant (64.0%) and worst in ECD (39.6%; P<0.0001). CONCLUSION: EBK had the best long-term outcomes among deceased donor transplants and offer unique options for adult kidney transplant recipients.
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Selección de Donante , Rechazo de Injerto/etiología , Supervivencia de Injerto , Trasplante de Riñón/efectos adversos , Donantes de Tejidos/provisión & distribución , Adolescente , Adulto , Factores de Edad , Preescolar , Femenino , Tasa de Filtración Glomerular , Rechazo de Injerto/fisiopatología , Rechazo de Injerto/terapia , Humanos , Masculino , Persona de Mediana Edad , Modelos de Riesgos Proporcionales , Sistema de Registros , Diálisis Renal , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Trombosis/etiología , Factores de Tiempo , Trasplante Homólogo , Resultado del Tratamiento , Estados Unidos , Adulto JovenRESUMEN
Immunosuppression for immunologically high-risk renal transplant patients usually involves antithymocyte globulin induction with triple drug maintenance therapy. Alemtuzumab, a humanized anti-CD52 antibody, has shown promise in tolerogenic induction protocols, requiring minimal maintenance immunosuppression. In this prospective, open-label, randomized, controlled trial, we enrolled 21 high immunological risk patients (i.e., panel reactive antibody>20% or previous transplant). Patients received either single-dose alemtuzumab given before graft reperfusion, with tacrolimus monotherapy, or four doses of Thymoglobulin with tacrolimus, mycophenolate, and steroids. Median follow-up was 377 days. One patient in the Thymoglobulin group who suffered primary graft nonfunction died. One-year cumulative graft survival was 85.7% for the alemtuzumab group and 87.5% for the Thymoglobulin group. Two alemtuzumab and three Thymoglobulin patients suffered rejection episodes. Infection rates were similar. Early results of this ongoing study indicate that a tolerogenic protocol with alemtuzumab induction and tacrolimus maintenance monotherapy is safe in immunologically high-risk renal transplant patients.
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Anticuerpos Monoclonales/uso terapéutico , Anticuerpos Antineoplásicos/uso terapéutico , Inmunosupresores/uso terapéutico , Trasplante de Riñón , Tacrolimus/uso terapéutico , Tolerancia al Trasplante/efectos de los fármacos , Adulto , Alemtuzumab , Anticuerpos Monoclonales/efectos adversos , Anticuerpos Monoclonales Humanizados , Anticuerpos Antineoplásicos/efectos adversos , Suero Antilinfocítico , Quimioterapia Combinada , Femenino , Estudios de Seguimiento , Rechazo de Injerto/epidemiología , Supervivencia de Injerto , Humanos , Incidencia , Trasplante de Riñón/mortalidad , Masculino , Persona de Mediana Edad , Ácido Micofenólico/uso terapéutico , Factores de Riesgo , Esteroides/uso terapéuticoRESUMEN
We evaluated patient sera for flow PRA, FCXM, and end-point donor-antigen titer, and we correlated the results with graft survival. You cannot accurately predict a positive or negative FCXM result-not even when the sera have donor-specific antigens-unless you actually perform a crossmatch. Using fluorescence intensity as a surrogate for antibody concentration does not correlate quantitatively with the occurrence of a positive or negative crossmatch. Therefore, it is imperative to give each recipient a chance at being offered a donor organ by performance of a real-time crossmatch and not rely on a virtual evaluation.