Techniques to Ameliorate the Impact of Second Warm Ischemic Time on Kidney Transplantation Outcomes.

Anastomosing the renal artery and vein in transplant recipients without a cooling mechanism exposes the kidney to temperatures exceeding the metabolic threshold (15°C to 18°C), at which the protective effects of renal hypothermia are lost. This anastomotic time, or second warm ischemic time, can be deleterious to graft outcomes, especially if it is prolonged. Techniques to ameliorate organ warming prior to reperfusion have been designed, and range from simpler surface cooling techniques, to organ immersion in bags of ice slush, and the application of 'jackets' that incorporate their own internal cooling mechanism. The efficacy of these methods with respect to the minimization of kidney temperature prior to reperfusion and subsequent effects on graft outcomes are discussed using clinical and experimental data, in the setting of open, laparoscopic, and robotic kidney transplantation.

A pre-operative clinical model to predict microvascular invasion and long-term outcome after resection of hepatocellular cancer: The Australian experience.

BACKGROUND: Hepatocellular cancer (HCC) is a leading cause of mortality worldwide. Liver resection or transplantation offer the best chance of long-term survival. The aim of this study was to perform a survival and prognostic factor analysis on patients who underwent resection of HCC at two major tertiary referral hospitals, and to investigate a pre-operative prediction model for microvascular invasion (MVI). METHODS: Clinico-pathological and survival data were collected from all patients who underwent liver resection for HCC at two tertiary referral centres (Royal North Shore/North Shore Private Hospitals and Westmead Hospital) from 1998 to 2012. An overall and disease-free survival analysis was performed and a predictive model for MVI identified. RESULTS: The total number of patients in this series was 125 and the 5-year overall and disease-free survival rates were 56% and 37%, respectively. MVI was the only factor to be independently associated with a poor prognosis on both overall and disease-free survival. Age ≥64 years, a serum alpha-fetoprotein (AFP) ≥400 ng/ml (×40 above normal) and tumor size ≥50 mm were independently associated with MVI. An MVI prediction model using these three pre-operative factors provides a good assessment of the risk of MVI. CONCLUSION: MVI in the resected specimen of patients with HCC is associated with a poor prognosis. A preoperative MVI prediction model offers a useful way to identify patients at risk of relapse. However, more precise predictive models using molecular and genetic variables are needed to improve selection of patients most suitable for radical surgical treatment.

Kidney damage during organ retrieval: data from UK National Transplant Database. Kidney Advisory Group.

BACKGROUND: Kidney damage at organ retrieval is believed to be an increasing problem that is under reported. We aimed to identify the true rate of such damage and assess the effects on transplant survival. METHODS: Data from the UK National Transplant Database were analysed on all cadaveric kidneys donated over a 5-year period in the UK. Records indicated whether kidneys had been retrieved by a liver or renal surgical team and whether damage was noted at the time of retrieval or at the transplant procedure. Multivariate Cox's regression models were fitted to 1-year and 3-year transplant-survival data in those kidneys that were transplanted between 1992 and 1994. FINDINGS: Of 9014 kidneys retrieved, 96 could not be transplanted because of damage sustained at retrieval. Damage was reported in 1726 (19%) kidneys although by both donor and recipient centres in only 270 (3%). 1070 (62%) of the damaged organs were from donors aged 40 years or older. Reported kidney damage was more likely for retrievals of kidney only by a renal team (503 [26%]) than for multiorgan retrieval (454 [21%]), the proportion was lower when a liver team retrieved both liver and kidneys (415 [17%]). 794 (14%) kidneys retrieved and retained locally were reported as damaged, compared with 932 (29%) kidneys which had been exported. Donors' age had a significant effect on both 1-year and 3-year transplant survival (p<0.01 for both) but kidney damage did not (1 year p=0.40; 3 year p=0.81). INTERPRETATION: Despite the high rate of damage to kidneys at retrieval, most of the organs can be transplanted with no adverse effect on transplant survival. Kidney damage is least likely to occur with kidneys from young donors, and when liver teams or centres undertaking more than 50 retrievals per year do the retrieval.

Aortoiliac aneurysm with arteriocaval fistula treated by a bifurcated endovascular stent-graft.

A 71-year-old patient with high-output cardiac failure was found to have an aneurysmal distal aorta with evidence of an arteriocaval fistula on ultrasound scanning. CT demonstrated an aneurysm of the distal aorta and right common iliac artery and an intraarterial digital subtraction angiogram confirmed an arteriocaval fistula. In view of the patient's cardiac failure and general condition an endovascular stent was considered. The right internal iliac artery was occluded with Tungsten coils prior to the insertion of a bifurcated stent-graft. This resulted in total occlusion of the aneurysm and obliteration of the arteriocaval fistula. To our knowledge such a case has not been previously reported.

Audit of introduction of hand-held Doppler and duplex ultrasound in the management of varicose veins.

Hand-held Doppler (HHD) examination and duplex ultrasound scanning of patients with varicose veins are more accurate than clinical assessment alone. To assess how the introduction of HHD and the availability of duplex ultrasound scanning affects patient management, a retrospective review was carried out comparing the year before the introduction with the subsequent 2 years. Information was extracted from a computer database containing details of all new venous outpatients, their initial management and investigations and subsequent operations. HHD and duplex ultrasound resulted in a marked increase in secondary investigations (16% versus 41%) and fewer patients being listed directly for surgery (47% versus 29%). Operations on the long saphenous vein decreased from 84% to 76% whereas short saphenous surgery increased from 6% to 21% during this time.

Xenotransplantation: an examination of the adhesive interactions between human lymphocytes and porcine renal epithelial cells.

Specific adhesion molecules stabilize the binding between lymphocytes and antigen bearing cells; this intercellular adhesion is vital to both the affector and effector phases of an immune response. It is not known whether adhesion molecules and their counter-receptors can form the cross-species interactions that will facilitate human T cell recognition of xenogeneic porcine target cells. In this report it is demonstrated that a higher proportion of mitogen-activated than of resting human lymphocytes adhere to cultured porcine renal epithelial cells. Furthermore, antibody blocking experiments demonstrated that at least part of this cell-cell binding is stabilized by the human adhesion molecules LFA-1 (lymphocyte function-associated antigen-1) and the alpha 4-containing integrins. It is possible that this capacity for cross-species adhesion will play a role during the cell-mediated rejection of clinical porcine xenografts.