Local versus distant lung donor procurement does not influence short-term clinical outcomes.

OBJECTIVE: The purpose of this study was to recognize clinically meaningful differences in lung transplant outcomes based on local or distant lung procurement. This could identify if the lung allocation policy change would influence patient outcomes. METHODS: This single-center retrospective cohort study analyzed adult patients who underwent lung transplant from 2006 to 2017. Donor and recipient data were abstracted from a collaborative, prospective registry shared by our local organ procurement organization, and tertiary medical center. Short-term outcomes, 1-year survival, and hospitalization costs were compared between local and distant lung transplants defined by donor service area. RESULTS: Of the 722 lung transplants performed, 392 (54%) had local donors and 330 (46%) had distant donors. Donors were similar in age and cause of death. Recipients were significantly different in diagnosis and local recipients had lower median lung allocation scores (local, 37.3 and distant, 44.9; P < .01). Distant lung transplants had longer total ischemic times (local, 231 ± 52 minutes and distant, 313 ± 48 minutes; P < .01). The rate of major complications, length of hospital stay, and 1-year survival were similar between groups. Distant lung transplants were associated with higher median overall cost (local, $183,542 and distant, $229,871; P < .01). Local lung transplants were more likely to be performed during daytime (local, 333 out of 392 [85%] and distant, 291 out of 330 [61%]; P < .01). CONCLUSIONS: Local lung transplants are associated with shorter ischemic times, lower cost, and greater likelihood of daytime surgery. Short- and intermediate-term outcomes are similar for lung transplants from local and distant donors. The new lung allocation policy, with higher proportion of distant lung transplants, is likely to incur greater costs but provide similar outcomes.

Early Graft Loss after Deceased-Donor Kidney Transplantation: What Are the Consequences?

BACKGROUND: Decreasing kidney discards continues to be of paramount importance for improving organ transplant access, but transplantation of nonideal deceased donor kidneys may have higher inherent risks of early graft loss (EGL). Patients with EGL (defined as graft failure within 90 days after transplant) are allowed reinstatement of waiting time according to United Network for Organ Sharing (UNOS) policy. The purpose of this study was to examine outcomes for patients experiencing EGL. STUDY DESIGN: We performed a single center retrospective review of adult deceased donor kidney transplant (DDKT)-alone recipients from 2001 to 2018, comparing those with EGL (including primary nonfunction [PNF]) to those without. RESULTS: EGL occurred in 103 (5.5%) of 1,868 patients, including 57 (55%) PNF, 25 (24%) deaths, 16 (16%) thrombosis, 3 (3%) rejection, and 2 (2%) disease recurrence. Kidney Donor Profile Index (KDPI) > 85% and donation after circulatory death (DCD) DDKTs did not increase risk of either EGL or PNF unless combined with prolonged cold ischemic time (CIT). For KDPI >85% with CIT >24 hours, the risk of EGL or PNF was tripled (EGL odds ratio [OR] 2.9, 95% CI 1.6-5.2; PNF OR3.6, 95% CI1.7-7.7). For DCD with CIT > 24 hours, increased risks were likewise seen for EGL (OR 2.4, 95% CI 1.3-4.3), and PNF (OR 3.2, 95% CI 1.5-7). One-year and 5-year patient survival rates were 60% and 50% after EGL, 80% and 73% after PNF, and 99% and 87% for controls, respectively. Only 24% of either EGL or PNF patients underwent retransplantation. CONCLUSIONS: EGL and PNF were associated with low retransplantation rates and inferior patient survival. Prolonged CIT compounds risks associated with KDPI > 85% and DCD donor kidneys. Therefore, policies promoting rapid allocation and increased local use of these kidneys should be considered.

Predictors and one-year outcomes of patients with delayed graft function after deceased donor kidney transplantation.

BACKGROUND: Delayed graft function (DGF) is closely associated with the use of marginal donated kidneys due to deficits during transplantation and in recipients. We aimed to predict the incidence of DGF and evaluate its effect on graft survival. METHODS: This retrospective study on kidney transplantation was conducted from January 1, 2018, to December 31, 2019, at the Second Xiangya Hospital of Central South University. We classified recipients whose operations were performed in different years into training and validation cohorts and used data from the training cohort to analyze predictors of DGF. A nomogram was then constructed to predict the likelihood of DGF based on these predictors. RESULTS: The incidence rate of DGF was 16.92%. Binary logistic regression analysis showed correlations between the incidence of DGF and cold ischemic time (CIT), warm ischemic time (WIT), terminal serum creatine (Scr) concentration, duration of pretransplant dialysis, primary cause of donor death, and usage of LifePort. The internal accuracy of the nomogram was 83.12%. One-year graft survival rates were 93.59 and 99.74%, respectively, for the groups with and without DGF (P < 0.05). CONCLUSION: The nomogram established in this study showed good accuracy in predicting DGF after deceased donor kidney transplantation; additionally, DGF decreased one-year graft survival.

Delayed Implantation of Pumped Kidneys Decreases Renal Allograft Futility in Combined Liver-Kidney Transplantation.

BACKGROUND: Combined liver-kidney transplantation (CLKT) improves survival for liver transplant recipients with renal dysfunction; however, the tenuous perioperative hemodynamic and metabolic milieu in high-acuity CLKT recipients increases delayed graft function and kidney allograft failure. We sought to analyze whether delayed KT through pumping would improve kidney outcomes following CLKT. METHODS: A retrospective analysis (University of California Los Angeles [n = 145], Houston Methodist Hospital [n = 79]) was performed in all adults receiving CLKT at 2 high-volume transplant centers from February 2004 to January 2017, and recipients were analyzed for patient and allograft survival as well as renal outcomes following CLKT. RESULTS: A total of 63 patients (28.1%) underwent delayed implantation of pumped kidneys during CLKT (dCLKT) and 161 patients (71.9%) received early implantation of nonpumped kidneys during CLKT (eCLKT). Most recipients were high-acuity with median biologic model of end-stage liver disease (MELD) score of, 35 for dCLKT and 34 for eCLKT (P = ns). Pretransplant, dCLKT had longer intensive care unit stay, were more often intubated, and had greater vasopressor use. Despite this, dCLKT exhibited improved 1-, 3-, and 5-year patient and kidney survival (P = 0.02) and decreased length of stay (P = 0.001), kidney allograft failure (P = 0.012), and dialysis duration (P = 0.031). This reduced kidney allograft futility (death or continued need for hemodialysis within 3 mo posttransplant) for dCLKT (6.3%) compared with eCLKT (19.9%) (P = 0.013). CONCLUSIONS: Delayed implantation of pumped kidneys is associated with improved patient and renal allograft survival and decreased hospital length of stay despite longer kidney cold ischemia. These data should inform the ethical debate as to the futility of performing CLKT in high-acuity recipients.

Operative Versus Nonoperative Management of Hemorrhage in the Postoperative Kidney Transplant Patient.

BACKGROUND: Postoperative hemorrhage has been described at rates of 14% in kidney transplant (KT) literature. The preferred management of postoperative hemorrhage in this population is not well described. We hypothesized a difference in outcomes with operative versus nonoperative management of hemorrhage after kidney transplantation. METHODS: We conducted a retrospective cohort study of consecutive KTs from 2012 to 2019 (living and deceased donors). We defined hemorrhage based on the objective finding of hematoma on either ultrasound or CT scan. Management was defined as operative (surgical intervention with or without transfusion) or nonoperative (with or without transfusion). RESULTS: We performed 1758 KTs of which 135 (8%) demonstrated hematoma on ultrasound or CT scan (66 operative vs 69 nonoperative management). The clinical signs and symptoms of low urine output (P = .044), drop in hemoglobin (P < .001), abdominal pain (P = .005), and MAP < 70 mm Hg (P = .034) were 92.5% predictive of postoperative hemorrhage in our KT patients. There were no differences between groups based on medical history, preop anticoagulation, anastomosis type, cold ischemic time, lowest hemoglobin, delayed graft function, or complications. Patients with nonoperative treatment of postoperative hemorrhage had shorter lengths of stay (P = .003), better graft survival (P = .01), and better patient survival (P = .01). DISCUSSION: We found better outcomes of graft and patient survival with shorter lengths of stay when we utilized nonoperative management of postoperative hemorrhage in KT patients. Our findings suggest a role for conservative nonoperative management in select patients. Ultimately, it is the surgeon's choice on how best to manage postoperative hemorrhage.

Outcomes With Age Combinations in Living Donor Kidney Transplantation.

INTRODUCTION: Reevaluation of donor criteria, including age, is needed to combat organ shortages, lengthy wait times, and anticipated recipient mortality rates. The purpose of this study was to evaluate donor and recipient (D/R) age combinations and patient and graft survival outcomes. METHODS: Single-organ, living donor kidney transplantations (LDKTs) from 2012 to 2018 were retrospectively reviewed. Donors and recipients were placed into "older" and "younger" age categories of 50 years and above or below age 50, then analyzed with SPSS version 25. RESULTS: We performed 347 LDKTs. Younger-to-older pairings had significantly higher rates of smoking in recipient (53.6%) and hepatitis C (5.5%), but shorter hospital stays (5.3 days). Older-to-younger pairings had the longest hospital stays (7.4 days) but the shortest cold ischemic time (2.3 hours). Notably, there was no significant variance in delayed graft function (first-week dialysis) between groups. Regarding complication rates, only bleeding within 30 days, highest in older-to-older pairings (7.7%), and renal complications, highest in older-to-younger pairings, significantly varied between groups. Interestingly, though younger-to-older cases had the longest mean graft survival time, older kidneys lasted 537 days longer in older recipients than in younger recipients. DISCUSSION: These results indicate there is not a one-size-fits-all approach when considering outcomes of donor/recipient age-pairings in LDKT, as significant correlations did not consistently favor one age-pairing over others. Regardless of age-pairing, LDKT provides gold standard treatment and expands the availability of organs. Future research into the impact of age-pairing on specific variables, national or multicenter studies, and protocol development for evaluating donor/recipient age-pairings is needed.

Prediction of pentafecta achievement following laparoscopic partial nephrectomy: Implications for robot-assisted surgery candidates.

BACKGROUND: In clinical practice, objective basis for the choice between laparoscopic partial nephrectomy (LPN) and robot-assisted partial nephrectomy (RAPN) is scarce. To evaluate surgical outcomes, assess the individual benefit from LPN to RAPN, which can guide clinical decision-making. METHODS: Patients underwent LPN or RAPN for a localized renal mass in our center between Jan 2013 and Dec 2016 were included. The surgical outcome of LPN and RAPN was the pentafecta achievement. A multivariable model was fitted to predict the probability of pentafecta achievement after LPN. Model-derived coefficients were applied to calculate the probability of pentafecta achievement in case of LPN among patients treated with RAPN. Locally weighted scatterplot smoothing method was applied to plot the observed probability of pentafecta achievement against the predicted pentafecta probability in case of LPN. RESULTS: RAPN group had a significantly higher pentafecta achievement (54.6% vs. 41.1%, P < 0.001) than LPN. Multivariable analyses identified that tumor size, distance of the tumor to collecting system or sinus, and preoperative eGFR were independent predictors of pentafecta after LPN. When RAPN was chosen over LPN, the increase in the probability of pentafecta achievement was greatest in intermediate-probability patients. With the increase or decrease of the probability of pentafecta, the benefit of RAPN decreased. CONCLUSION: When pentafecta achievement are assessed, the benefit of RAPN over LPN varies from patient to patient. Patients at intermediate-probability of pentafecta achievement after LPN benefit the most from robotic surgery, which may be the potential ideal candidates for RAPN.

Utilization of Donor Kidneys With Acute Kidney Injury in Pediatric Kidney Transplant Recipients.

BACKGROUND: An elevated terminal creatinine is frequently used as a reason for organ refusal in pediatric kidney transplantation. There is increasing evidence that adults who receive kidneys from donors with moderate to severe acute kidney injury (AKI) have similar outcomes to recipients who receive kidneys from donors with none to mild AKI. METHODS: We used the Scientific Registry of Transplant Recipients to determine how many pediatric kidney transplant recipients developed delayed graft function (DGF) between 2000 and 2010. RESULTS: When stratified by the donor terminal creatinine, there was no significant difference in the recipient discharge creatinine or the likelihood of developing DGF. In a logistic regression model, older donor age, male donors, and a longer cold ischemia time but not donor terminal creatinine were independent predictors of DGF. There were very few graft loss events documented in this study. CONCLUSIONS: Our results are in agreement with previously published data; a high donor terminal creatinine is not significantly associated with DGF in pediatric renal transplant recipients. Additional studies investigating the risk of rejection and long-term graft function are needed before adopting the practice of accepting kidneys with moderate to severe AKI in pediatric kidney transplant recipients.

Effects of donor cause of death, ischemia time, inotrope exposure, troponin values, cardiopulmonary resuscitation, electrocardiographic and echocardiographic data on recipient outcomes: A review of the literature.

BACKGROUND: Heart transplantation has become standard of care for pediatric patients with either end-stage heart failure or inoperable congenital heart defects. Despite increasing surgical complexity and overall volume, however, annual transplant rates remain largely unchanged. Data demonstrating pediatric donor heart refusal rates of 50% suggest optimizing donor utilization is critical. This review evaluated the impact of donor characteristics surrounding the time of death on pediatric heart transplant recipient outcomes. METHODS: An extensive literature review was performed to identify articles focused on donor characteristics surrounding the time of death and their impact on pediatric heart transplant recipient outcomes. RESULTS: Potential pediatric heart transplant recipient institutions commonly receive data from seven different donor death-related categories with which to determine organ acceptance: cause of death, need for CPR, serum troponin, inotrope exposure, projected donor ischemia time, electrocardiographic, and echocardiographic results. Although DITs up to 8 hours have been reported with comparable recipient outcomes, most data support minimizing this period to <4 hours. CVA as a cause of death may be associated with decreased recipient survival but is rare in the pediatric population. Otherwise, however, in the setting of an acceptable donor heart with a normal echocardiogram, none of the other data categories surrounding donor death negatively impact pediatric heart transplant recipient survival. CONCLUSIONS: Echocardiographic evaluation is the most important donor clinical information following declaration of brain death provided to potential recipient institutions. Considering its relative importance, every effort should be made to allow direct image visualization.

A Predictive Model for Intracardiac Pressures in Patients Free From Rejection or Allograft Vasculopathy After Pediatric Heart Transplantation.

BACKGROUND: Despite the routine use of hemodynamic assessment in pediatric heart transplant (HT) patients, expected intracardiac pressure measurements in patients free of significant complications are incompletely described. A better understanding of the range of intracardiac pressures in these HT patients is important for the clinical interpretation of these indices and consequent management of patients. METHODS: We conducted a retrospective chart review of pediatric HT recipients who had undergone HT between January 2010 and December 2015 at Lucile Packard Children's Hospital. We analyzed intracardiac pressures measured in the first 12 mo after HT. We excluded those with rejection, graft coronary artery disease, mechanical support, or hemodialysis. We used a longitudinal general additive model with bootstrapping technique to generate age and donor-recipient size-specific curves to characterize filling pressures through 1-y post-HT. RESULTS: Pressure measurements from the right atrium, pulmonary artery, and pulmonary capillary wedge pressure were obtained in 85 patients during a total of 829 catheterizations. All pressure measurements were elevated in the immediate post-HT period and decreased to a stable level by post-HT day 90. Pressure measurements were not affected by age group, donor-recipient size differences, or ischemic time. CONCLUSIONS: Intracardiac pressures are elevated in the early post-HT period and decrease to levels typical of the native heart by 90 d. Age, donor-to-recipient size differences, and ischemic time do not contribute to differences in expected intracardiac pressures in the first year post-HT.

Effect of donor nephrectomy time during circulatory-dead donor kidney retrieval on transplant graft failure.

BACKGROUND: When the blood supply ceases in a deceased organ donor, ischaemic injury starts. Kidneys are cooled to reduce cellular metabolism and minimize ischaemic injury. This cooling is slow and kidneys are lukewarm during nephrectomy. Smaller single-centre studies have shown that prolonged donor nephrectomy time decreases early kidney transplant function, but the effect on long-term outcome has never been investigated in large multicentre cohort studies. METHODS: The relationship between donor nephrectomy time and death-censored graft survival was evaluated in recipients of single adult-to-adult, first-time deceased-donor kidneys transplanted in the Eurotransplant region between 2004 and 2013. RESULTS: A total of 13 914 recipients were included. Median donor nephrectomy time was 51 (i.q.r. 39-65) min. Kidneys donated after circulatory death had longer nephrectomy times than those from brain-dead donors: median 57 (43-78) versus 50 (39-64) min respectively (P < 0·001). Donor nephrectomy time was independently associated with graft loss when kidneys were donated after circulatory death: adjusted hazard ratio (HR) 1·05 (95 per cent c.i. 1·01 to 1·09) per 10-min increase (P = 0·026). The magnitude of this effect was comparable to the effect of each hour of additional cold ischaemia: HR 1·04 (1·01 to 1·07) per h (P = 0·004). For kidneys donated after brain death, there was no effect of nephrectomy time on graft survival: adjusted HR 1·01 (0·98 to 1·04) per 10 min (P = 0·464). CONCLUSION: Prolonged donor nephrectomy time impairs graft outcome in kidneys donated after circulatory death. Keeping this short, together with efficient cooling during nephrectomy, might improve outcome.

ANTECEDENTES: La lesión por isquemia empieza en el momento que cesa la irrigación sanguínea del órgano donante. Para reducir el metabolismo celular y la lesión isquémica se reduce la temperatura de los riñones. Este enfriamiento es lento y los riñones se mantienen tibios durante la nefrectomía. Estudios unicéntricos con muestras pequeñas han demostrado que el tiempo de la nefrectomía del donante disminuye la función precoz del injerto renal, pero nunca se ha analizado su repercusión a largo plazo en grandes estudios multicéntricos. MÉTODOS: Se analizó la relación entre la duración de la nefrectomía del donante y la supervivencia del injerto en 13.914 adultos receptores de un primer riñón procedente de donante cadavérico adulto en la región de Eurotransplant entre los años 2004 y 2013. RESULTADOS: La mediana de duración de la nefrectomía del donante fue de 51 minutos (rango intercuartílico 39-65). En los riñones obtenidos en donantes a corazón parado la duración de la nefrectomía fue más prolongada que en los donantes en muerte cerebral (mediana 57 min (43-78 min) versus 50 min (39-64 min), P < 0,001). La duración de la nefrectomía en el donante se asoció de forma independiente con la pérdida del injerto (cociente de riesgos instantáneos, hazard ratio, HR, ajustado 1,05 por cada incremento de 10 minutos, i.c. del 95%: 1,01 a 1,09; P = 0,026) cuando los riñones se obtuvieron en donantes en parada cardíaca. La magnitud de este efecto fue comparable al efecto de cada hora adicional de isquemia fría (1,04, i.c. 95% 1,01-1,07, P = 0,004). En los riñones obtenidos de donantes en muerte cerebral, la duración de la nefrectomía no influyó en la supervivencia del injerto (HR ajustada 1,01 por aumento de 10 min, i.c. del 95%: 0,98 a 1,04). CONCLUSIÓN: La duración de la nefrectomía en donantes a corazón parado afecta la función de los injertos trasplantados. Reducir esta duración y disponer de un sistema de enfriamiento eficiente durante la nefrectomía podría mejorar los resultados.

The Frequency and Risk Factors of Delayed Graft Function in living Donor Kidney Transplantation and Its Clinical Impact on Graft and Patient Survival in Part of Middle East.

Delayed graft function (DGF) is a form of acute renal failure which results in increased post-transplantation allograft immunogenicity and risk of acute rejection episodes in addition to decreased long-term survival. Its incidence and risk factors have been extensively studied, especially after deceased donation. Until now, only few data has been  published on DGF in living donor kidney transplant recipients. The present study was performed to investigate the frequency and risk factors of DGF among living- kidney transplant recipients. In this retrospective study, data had been collected from existing local hospital registries in three countries (Iran, Kingdom of Saudi Arabia (KSA) , and Kuwait ).

Posttransplant Outcomes for cPRA-100% Recipients Under the New Kidney Allocation System.

BACKGROUND: There is concern in the transplant community that outcomes for the most highly sensitized recipients might be poor under Kidney Allocation System (KAS) high prioritization. METHODS: To study this, we compared posttransplant outcomes of 525 pre-KAS (December 4, 2009, to December 3, 2014) calculated panel-reactive antibodies (cPRA)-100% recipients to 3026 post-KAS (December 4, 2014, to December 3, 2017) cPRA-100% recipients using SRTR data. We compared mortality and death-censored graft survival using Cox regression, acute rejection, and delayed graft function (DGF) using logistic regression, and length of stay (LOS) using negative binomial regression. RESULTS: Compared with pre-KAS recipients, post-KAS recipients were allocated kidneys with lower Kidney Donor Profile Index (median 30% versus 35%, P < 0.001) but longer cold ischemic time (CIT) (median 21.0 h versus 18.6 h, P < 0.001). Compared with pre-KAS cPRA-100% recipients, those post-KAS had higher 3-year patient survival (93.6% versus 91.4%, P = 0.04) and 3-year death-censored graft survival (93.7% versus 90.6%, P = 0.005). The incidence of DGF (29.3% versus 29.2%, P = 0.9), acute rejection (11.2% versus 11.7%, P = 0.8), and median LOS (5 d versus 5d, P = 0.2) were similar between pre-KAS and post-KAS recipients. After accounting for secular trends and adjusting for recipient characteristics, post-KAS recipients had no difference in mortality (adjusted hazard ratio [aHR]: 0.861.623.06, P = 0.1), death-censored graft failure (aHR: 0.521.001.91, P > 0.9), DGF (adjusted odds ratio [aOR]: 0.580.861.27, P = 0.4), acute rejection (aOR: 0.610.941.43, P = 0.8), and LOS (adjusted LOS ratio: 0.981.161.36, P = 0.08). CONCLUSIONS: We did not find any statistically significant worsening of outcomes for cPRA-100% recipients under KAS, although longer-term monitoring of posttransplant mortality is warranted.

The "oldest and coldest" shipped living donor kidneys transplanted through kidney paired donation.

To date, thousands of living donor kidneys have been shipped through kidney paired donation (KPD). To expand on this growing segment of living donor transplantation, we evaluated the effect of advanced age donation ("oldest kidneys") and prolonged cold ischemia time ("coldest kidneys") on graft function and survival using the National Kidney Registry database from February 2008 to May 2018. Donors were stratified by age at time of donation (<65 or ≥65 years) and kidneys were stratified by cold ischemia time (<16 or ≥16 hours). We evaluated delayed graft function and death-censored graft failure (DCGF) for up to seven posttransplant years. Of the 2363 shipped living donor kidney transplants, 4.1% of donors were ≥65 years and 6.0% of transplanted kidneys had cold ischemia times ≥16 hours. Delayed graft function and DCGF occurred in 5.2% and 4.7% of cases. There were no significant associations between delayed graft function and donor age (P = .947) or cold ischemia (P = .532). Donor age and cold ischemia time were not predictive of delayed graft function (OR = 0.86,1.20; P = .8, .6) or DCGF (HR = 1.38,0.35, P = .5, .1). These findings may alleviate concerns surrounding the utilization of kidneys from older donors or those originating from distant transplant centers.

Heterogeneity of Human Pancreatic Islet Isolation Around Europe: Results of a Survey Study.

BACKGROUND: Europe is currently the most active region in the field of pancreatic islet transplantation, and many of the leading groups are actually achieving similar good outcomes. Further collaborative advances in the field require the standardization of islet cell product isolation processes, and this work aimed to identify differences in the human pancreatic islet isolation processes within European countries. METHODS: A web-based questionnaire about critical steps, including donor selection, pancreas processing, pancreas perfusion and digestion, islet counting and culture, islet quality evaluation, microbiological evaluation, and release criteria of the product, was completed by isolation facilities participating at the Ninth International European Pancreas and Islet Transplant Association (EPITA) Workshop on Islet-Beta Cell Replacement in Milan. RESULTS: Eleven islet isolation facilities completed the questionnaire. The facilities reported 445 and 53 islet isolations per year over the last 3 years from deceased organ donors and pancreatectomized patients, respectively. This activity resulted in 120 and 40 infusions per year in allograft and autograft recipients, respectively. Differences among facilities emerged in donor selection (age, cold ischemia time, intensive care unit length, amylase concentration), pancreas procurement, isolation procedures (brand and concentration of collagenase, additive, maximum acceptable digestion time), quality evaluation, and release criteria for transplantation (glucose-stimulated insulin secretion tests, islet numbers, and purity). Moreover, even when a high concordance about the relevance of one parameter was evident, thresholds for the acceptance were different among facilities. CONCLUSIONS: The result highlighted the presence of a heterogeneity in the islet cell product process and product release criteria.

Logistic Coordination in Pediatric Liver Transplantation: Criteria for Optimization.

INTRODUCTION: Logistic organization of the transplantation coordination process aims to synchronize the recovery and recipient team and to reduce to a minimum the graft's cold ischemia time (CIT), which, in turn, is known, to have deleterious effects on the graft and recipient, if prolonged. To determine whether variables influencing the different steps in the coordination process might allow for reducing CIT, this study aimed to analyze these variables. PATIENTS AND METHODS: Retrospective analysis of 61 pediatric liver transplantations from 2006 to 2015 in the Geneva University Hospitals. RESULTS: Length of donor hepatectomy was increased for split grafts (P < .0001). Length of recipient hepatectomy was longer in the case of previous surgery (P = .06). The recipient team waiting time for the graft was longer for split grafts (P = .01). The graft waiting time at the recipient site was longer for whole grafts (P = .0005) and increased recipient weight (P = .03). The graft waiting time at the donor site was doubled in the case of recovery of organs after the liver by the same team (P = .007). The graft waiting time at the donor and recipient site not surprisingly increased the CIT (P = .007 and < .0001, respectively). CONCLUSION: CIT depends on waiting times during the entire coordination process, which largely depends on the estimation of hepatectomy lengths. A more accurate estimation, considering graft type and recipient's previous surgery and weight, might allow for decreasing CIT and consequently improve outcomes after pediatric liver transplantation.

Implementing local cooling to increase skin tolerance to ischemia during normal seating in people with spinal cord injury.

The purpose of this study was to investigate the effectiveness of local cooling in reducing reactive hyperemia after ischemia at the ischial tuberosities for people with spinal cord injury (SCI) during normal seating. The degree of the reactive hyperemic response is indicative of the extent of cellular stress caused by the ischemia. We hypothesized that reactive hyperemic skin blood flow (SBF) responses will be lower when local cooling is implemented by the wheelchair seat cushion. This study used a repeated measures design, and each subject underwent two conditions: normal seating with temperature control 'on' (cooling) and 'off' (non-cooling) for 30 min. Twenty-three participants with traumatic SCI were recruited. SBF and skin temperature were collected before, during and after seating. SBF signals were processed with short-time Fourier analyses to examine the underlying vascular control mechanisms, including the following (corresponding frequency bands): metabolic (0.0095-0.02 Hz), neurogenic (0.02-0.05 Hz), and myogenic (0.05-0.15 Hz) spectral densities. Our results showed that with cooling, skin temperature decreased (range -0.4 ~ -3.1 °C, p = 0.002), and reactive hyperemia parameters (normalized peak SBF and perfusion area) were reduced (p = 0.02, p = 0.033, respectively). In addition, changes in normalized peak SBF (non-cooling - cooling) was moderately correlated with changes in normalized metabolic and neurogenic spectral densities. Our findings suggested that local cooling has a positive effect on reducing the cellular stress caused by ischemia during normal seating. Metabolic and neurogenic SBF control mechanisms may play a minor role. Further exploration of the effect of temperature control on pressure injury prevention is warranted.

Introducing Robot-Assisted Laparoscopic Donor Nephrectomy after Experience in Hand-Assisted Retroperitoneoscopic Approach.

BACKGROUND: Robot-assisted laparoscopic donor nephrectomy (RALDN) can help to improve donor safety by enabling enhanced precision, flexibility, control, and vision. We are presenting our initial series during the introduction of RALDN by comparing our adopted surgical technique, hand-assisted retroperitoneoscopic donor nephrectomy (HARPDN), performed at the same time interval. METHODS: We performed 12 RALDN and 27 HARPDN with Pfannenstiel incision between March 2018 and July 2018. We evaluated the demographics, operation duration, warm/cold ischemia time, estimated blood loss, length of hospital stay, postoperative complications, and donor and recipient serum creatinine levels retrospectively. RESULTS: Demographics including sex, mean of age, and body mass index of the 2 groups were similar. Five cases were right sided nephrectomy in the HARPDN group. We performed only left sided donor nephrectomy in the RALDN group. The duration of operation and warm ischemia time was significantly longer in the robot-assisted group (P < .001). Postoperative major complications were not detected in any of the donors. The function of the transplanted kidneys in both groups was good on the fifth day and 1 month postoperatively. CONCLUSION: We introduced the robot-assisted approach for donor candidates who are not suitable candidates for HARPDN in our center. The operation time and warm ischemia time was longer in the RALDN group, but it did not have any impact on outcome. The robot-assisted donor nephrectomy technique can be introduced safely in centers experienced in the hand-assisted approach.

Modifiable Risk Factors for Delayed Graft Function After Deceased Donor Kidney Transplantation.

PURPOSE: Delayed graft function is a major complication after kidney transplantation affecting patients' long-term outcome. The aim of this study was to identify modifiable risk factors for delayed graft function after deceased donor kidney transplantation. METHODS: This is a single-center retrospective cohort study of a university transplantation center. Univariate and multivariate step-wise logistic regression analysis of patient-specific and procedural risk factors were conducted. RESULTS: We analyzed 380 deceased donor kidney transplantation patients between October 30, 2008 and December 30, 2017. The incidence of delayed graft function was 15% (58/380). Among the patient-specific risk factors recipient diabetes (2.8 [1.4-5.9] odds ratio [OR] [95% confidence interval [CI]]), American Society of Anesthesiologist score of 4 (2.7 [1.2-6.5] OR [95% CI]), cold ischemic time >13 hours (2.8 [1.5-5.3] OR [95% CI]) and donor age >55 years (1.9 [1.01-3.6] OR [95% CI]) revealed significance. The significant intraoperative, procedural risk factors included the use of colloids (3.9 [1.4-11.3] OR [95% CI]), albumin (3.0 [1.2-7.5] OR [95% CI]), crystalloids >3000 mL (3.1 [1.2-7.5] OR [95% CI]) and mean arterial pressure <80 mm Hg at the time of reperfusion (2.4 [1.2-4.8] OR [95% CI]). CONCLUSION: Patients undergoing deceased donor kidney transplantation with a mean arterial pressure >80 mm Hg at the time of transplant reperfusion without requiring excessive fluid therapy in terms of colloids, albumin or crystalloids >3000 mL are less likely to develop delayed graft function.

Renal allograft loss due to renal vascular thrombosis in the US pediatric renal transplantation.

BACKGROUND: Renal vascular thrombosis (RVT) is a major cause of early allograft loss in the first year following pediatric kidney transplantation. We examined recent trends in allograft loss due to RVT and identified associated risk factors. METHODS: We identified 14,640 kidney-only transplants performed between 1995 and 2014 with follow-up until June 30, 2016, in 13,758 pediatric patients aged < 19 years from the US Renal Data System. We examined the 1-year incidence of allograft loss due to RVT by year of transplant, and plotted the trend over time. Cox proportional hazards models were used to investigate the relationship between year of transplant as well as recipient, donor, and transplant characteristics with allograft loss due to RVT. RESULTS: The incidence of allograft loss due to RVT consistently declined among pediatric kidney transplant performed between 1995 and 2014. Among transplants performed between 1995 and 2004, 128/7542 (1.7%) allografts were lost due to RVT compared to 53/7098 (0.8%) among transplants performed between 2005 and 2014; average 1-year cumulative incidence was 1.5% (95% CI, 1.3-1.9%) and 0.6% (95% CI, 0.5-0.8%), respectively. Increased risk for allograft loss due to RVT was associated with en bloc kidney transplantation (HR, 3.42; 95% CI 1.38-8.43) and cold ischemia time ≥ 12 h (HR, 1.78; 95% CI, 1.15-2.76). Interestingly, these risk factors were more prevalent in the latter decade. CONCLUSIONS: The incidence of allograft loss due to RVT significantly and continuously declined among pediatric kidney transplants performed between 1995 and 2014. The causes for this improvement are unclear in the present analysis.