RESUMO
OBJECTIVES: To report our long-term clinical results with the use of endoureterotomy in patients undergoing renal transplant with a minimum follow-up of 23 months. METHODS: Six renal transplant patients developed persistent ureteral obstruction demonstrated by elevated serum creatinine levels, renal ultrasound, and antegrade pyelography. Stent placement and balloon dilation were performed as the initial therapy in all patients. Persistent ureteral obstruction was managed with balloon cautery endoureterotomy. Ureteral stents were removed cystoscopically 6 weeks after the procedure. RESULTS: Four men and 2 women, mean age 45 years (range 38 to 54), underwent eight procedures: six by way of an antegrade percutaneous approach and two in an endoscopic retrograde fashion. The sites of ureteral stricture were ureterovesical junction (n = 4), ureteropelvic junction (n = 1), and midureteroureteral (n = 1). Two patients required a second endoureterotomy 3 months after the first attempt. Patients were followed up for a mean of 27 months (range 23 to 34). The mean serum creatinine level for all patients at follow-up was 2.6 mg/dL (range 1.6 to 3.9), including a mean serum creatinine level of 1.8 mg/dL (range 1.6 to 1.9) for nonrejected kidneys and a mean of 3.4 mg/dL (range 2.5 to 3.9) in those found to have concurrent rejection. Overall, five (63%) of eight procedures were successful in 5 (83%) of 6 patients. No intraoperative complications occurred and no blood transfusions were required. CONCLUSIONS: Balloon cautery endoureterotomy was successful in this select group of renal transplant patients with persistent ureteral strictures after initial balloon dilation and stenting failed. This modality proved durable to 27 months of follow-up without significant complications.
Assuntos
Transplante de Rim/efeitos adversos , Obstrução Ureteral/terapia , Adulto , Cateterismo , Constrição Patológica/etiologia , Constrição Patológica/terapia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Stents , Resultado do Tratamento , Obstrução Ureteral/etiologiaRESUMO
PURPOSE: We report our long-term experience with a preexisting native cutaneous ureterostomy via an ipsilateral transplant ureteral native ureterostomy for transplant drainage without native nephrectomy. MATERIALS AND METHODS: Between 1993 and 1998, 5 patients without a usable bladder had undergone previously urinary diversion via cutaneous ureterostomy. All patients had a well functioning cutaneous ureterostomy for a mean plus or minus standard deviation of 18+/-12 years before renal transplantation. No patient had a history of stomal stenosis, recent urinary tract infection or pyelonephritis. RESULTS: All 5 patients continued to have a functioning renal transplant at last mean followup of 36+/-6.6 months. Complications included stomal retraction due to postoperative weight gain requiring revision in 2 cases and ureteroureteral anastomotic stenosis treated with endopyelotomy in 1. Mean serum creatinine at last followup was 1.5+/-0.6 mg./dl. CONCLUSIONS: Of the complications that we present only 1 may be attributed to the singularity of our procedure. Our experience suggests that a preexisting native cutaneous ureterostomy may serve as a receptacle for transplant ureteral drainage in select patients with excellent long-term function.
Assuntos
Drenagem/métodos , Transplante de Rim , Ureterostomia/métodos , Adulto , Feminino , Seguimentos , Humanos , Masculino , Fatores de Tempo , Derivação UrináriaRESUMO
PURPOSE: Urological complications in renal transplant recipients will become more common with increasing numbers of transplantations as well as increased graft survival secondary to improvements in immunosuppression. Urinary stone disease may be one of those complications. We determine the current incidence of urinary stone disease in renal transplant patients based on contemporary immunosuppressive regimens. MATERIALS AND METHODS: We reviewed the records of 1,730 renal and 83 pancreas/renal transplantations performed during the cyclosporine era and identified 8 recipients (0.4%) with urinary stone disease, including 3 with renal pelvic stones, 1 with multiple ureteral stones and 4 with bladder calculi. RESULTS: Treatment ranged from conservative observation to open pyelolithotomy, and included percutaneous nephrolithotomy and extracorporeal shock wave lithotripsy. The ureteral stones were removed with antegrade and retrograde ureteroscopy. The 4 bladder stones were treated with cystolithalopaxy. No case had significant permanent graft damage. Mean followup was 68.6 months. Mean serum creatinine was 1.5 mg./dl. (normal 0.5 to 1.3) at baseline and 2.38 after followup. CONCLUSIONS: While the incidence of upper tract urinary stone disease in renal (0.23%) and pancreas/renal (1.2%) transplant recipients is not statistically significant (p <0.45), the latter have significantly higher rates of bladder stones (4.8 versus 0%, p <0.001). The diagnosis of urinary stone disease in transplant recipients can be challenging because of the lack of symptoms but the treatment approach is the same as in the normal population.
Assuntos
Transplante de Rim/efeitos adversos , Transplante de Pâncreas/efeitos adversos , Cálculos Urinários/etiologia , Adulto , Ciclosporina/uso terapêutico , Feminino , Humanos , Imunossupressores/uso terapêutico , Incidência , Masculino , Pessoa de Meia-Idade , Cálculos Urinários/diagnóstico , Cálculos Urinários/epidemiologia , Cálculos Urinários/terapiaRESUMO
PURPOSE: To assess the efficacy of magnetic resonance (MR) imaging in the evaluation of complex abnormalities of renal allografts. MATERIALS AND METHODS: Clinical and radiologic findings were retrospectively reviewed in 24 patients who underwent MR imaging of a renal allograft because ultrasonographic (US) findings were inconclusive or discordant with clinical findings. The final diagnoses were established with histopathologic analysis (n = 16) or clinical and imaging follow-up (n = 8). RESULTS: MR imaging diagnoses were correct in 16 patients (67%), whereas US diagnoses were correct in six patients (25%) (P < .05). Five cases of allograft involvement by posttransplantation lymphoproliferative disorder (PTLD) were found at histopathologic analysis; at MR imaging, PTLD appeared as hypointense masses on T1-and T2-weighted images with minimal enhancement. In four of the five cases of PTLD, the masses occurred at the renal hilum and encased hilar vessels. Normal morphology was correctly diagnosed with MR imaging in five patients in whom a mass was suspected at US. CONCLUSION: MR imaging results are often diagnostic in cases of complex abnormalities of renal allografts. Renal allograft involvement by PTLD appears to have a relatively characteristic MR imaging appearance. Normal MR imaging findings in cases of suspected masses at US may obviate biopsy.
Assuntos
Rejeição de Enxerto/diagnóstico , Transplante de Rim/patologia , Transtornos Linfoproliferativos/diagnóstico , Imageamento por Ressonância Magnética , Complicações Pós-Operatórias/diagnóstico , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Transplante HomólogoAssuntos
Sobrevivência de Enxerto/fisiologia , Transplante de Rim/fisiologia , Rim/irrigação sanguínea , Preservação de Órgãos/métodos , Animais , Creatinina/sangue , Diltiazem/farmacologia , Transplante de Rim/métodos , Masculino , Monitorização Intraoperatória , Ratos , Ratos Sprague-Dawley , Fluxo Sanguíneo Regional , Circulação Renal/efeitos dos fármacos , ReperfusãoRESUMO
This article provides a complete review of current renal reconstructive techniques. The techniques described include partial nephrectomy, intrasinusal surgery, anatrophic nephrolithotomy, nonvascular bench procedures with autotransplantation, and allograft partial nephrectomy in renal transplantation. A detailed discussion on renovascular and collecting system anatomy and current indications for these procedures is presented.
Assuntos
Rim/cirurgia , Procedimentos de Cirurgia Plástica/métodos , Humanos , Cálculos Renais/cirurgia , Neoplasias Renais/cirurgia , Transplante de Rim/métodos , Masculino , Pessoa de Meia-Idade , Nefrectomia/métodos , Transplante AutólogoRESUMO
PURPOSE: To analyze the outcome of percutaneous antegrade ureteral stent placement for treatment of ureteral stenoses and leaks after renal transplantation. MATERIALS AND METHODS: Antegrade pyelography and percutaneous ureteral stent placement were performed in 45 patients with ureteral obstruction (n = 40), leak (n = 3), or both (n = 2). Obstructions were graded as mild, moderate, or complete, and as early (< or = 3 months after transplantation) or late (> 3 months). RESULTS: The outcome of stent placement was successful in 25 (57%) patients (average follow-up, 30 months). The ureteroneocystostomy (UNC) was the most common site of obstructions (22 of 41), leaks (four of five), and successful outcomes (16 of 22). Moderate obstructions were most common (29 of 41) and responded best to treatment (17 of 29). Eighteen (69%) of 26 early obstructions and five (33%) of 15 late obstructions were successfully managed percutaneously. All complications (12 of 45 patients) were minor, with infections the most common (n = 7). No mortality or allograft loss was attributable to stent placement. CONCLUSION: Ureteral stents are safe and effective for the treatment of obstructions and leaks and are particularly effective for early and UNC obstructions. These stents may also be useful for temporary drainage.
Assuntos
Transplante de Rim , Complicações Pós-Operatórias/terapia , Stents , Doenças Ureterais/terapia , Obstrução Ureteral/terapia , Adolescente , Adulto , Idoso , Criança , Pré-Escolar , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/classificação , Complicações Pós-Operatórias/diagnóstico por imagem , Radiografia Intervencionista , Estudos Retrospectivos , Stents/efeitos adversos , Stents/estatística & dados numéricos , Resultado do Tratamento , Ureter/diagnóstico por imagem , Doenças Ureterais/classificação , Doenças Ureterais/diagnóstico por imagem , Obstrução Ureteral/classificação , Obstrução Ureteral/diagnóstico por imagem , UrografiaRESUMO
PURPOSE: We investigated a possible relationship between levels of the vasoconstrictive peptide endothelin and renal transplant reperfusion injury, and modified a technique for measuring renal blood flow with an ultrasonic perivascular transit time flow probe. MATERIALS AND METHODS: Renal grafts in a swine transplant model were cold flushed with either Collins-2 or University of Wisconsin solution. Renal blood flow and renal vein endothelin levels after reperfusion of transplanted grafts, as well as histological parameters within the transplanted kidney were measured. The 5-minute post-reperfusion renal blood flow was used as the baseline allograft flow. The definition of reperfusion injury was a decrease in flow from baseline with no recovery within 1 hour of reperfusion. In 9 human recipients reperfusion injury was further verified by monitoring subsequent serum creatinine, urine output, graft survival and rejection episodes. RESULTS: In the swine model and human transplant recipients no evidence of post-reperfusion ischemia was noted by histological examination, supporting that moderate to mild reperfusion injury or ischemic injury cannot be clinically determined with this method. In the swine model the decrease flow from baseline in allograft post-reperfusion renal blood flow was significantly greater in kidneys preserved in Collins'-2 than in University of Wisconsin solution (41.75 +/- 5.69 versus 11.18 +/- 13.99 ml. per minute, p = 0.005), supporting that this technique can assess mild to moderate reperfusion injury. The increase in serum endothelin in the allografts from the swine model and in humans was not significantly different from baseline. Clinically, post-reperfusion renal blood flow changes correlated well with subsequent function. The 4 patients with renal transplant reperfusion injury had significantly higher serum creatinine values and lower urine output 1 week postoperatively than 5 patients with no evidence of injury (serum creatinine: 6.75 +/- 3.03 versus 2.08 +/- 1.28 mg./dl., p = 0.015). Reperfusion injury patients had more rejections (2 versus 1) and less graft survival (75% versus 100%) at 1-year followup compared to the nonreperfusion injury patients. CONCLUSIONS: Vasoactive factors other than endothelin most likely contribute to reperfusion injury. Furthermore, the ultrasonic transit time flow probe accurately measures post-reperfusion renal blood flow and offers a practical method for assessing acute reperfusion injury, which may help to optimize immunosuppressive strategies to decrease allograft loss associated with delayed graft function.
Assuntos
Endotelinas/sangue , Transplante de Rim , Preservação de Órgãos/efeitos adversos , Circulação Renal , Traumatismo por Reperfusão/diagnóstico , Animais , Humanos , Período Intraoperatório , Traumatismo por Reperfusão/sangue , Traumatismo por Reperfusão/etiologia , SuínosRESUMO
PURPOSE: We developed a technical and immunological protocol to increase survival of renal transplants from pediatric donors. MATERIALS AND METHODS: En bloc kidneys (22) were procured from donors weighing 2 to 14 kg. (1 to 60 months old) and transplanted into adult recipients. In group 1 (12 patients) sequential therapy was used for kidneys with more than 35 hours of cold storage and immediate triple therapy (cyclosporine, azathioprine and prednisone) was used for those with less than 35 hours of cold storage. In group 2 (10 patients) OKT3 induction therapy was used. Mean followup was 4.7 years. RESULTS: Mean blood pressure at 1 and 4 years was not significantly different between the groups. Mean serum creatinine was not significantly different between the groups at 1 year but it was significantly less in group 2 at 4 years (1.9 +/- 1.0 versus 1.2 +/- 0.24 mg./dl., p <0.05). At 1 year of followup the complication rate was 75% in 9 of 12 patients in group 1, including 4 infections or leaks (2 lost), 6 rejections (3 lost) and 3 cases of thrombosis or hemorrhage, and 20% (p <0.01) in group 2 (1 patient had the hemolytic uremic syndrome leading to graft loss). Graft survival was significantly greater in group 2 at all 4 years of followup (p = 0.05). CONCLUSIONS: The success of pediatric en bloc renal transplantation can be enhanced by induction therapy in healthy recipients.
Assuntos
Sobrevivência de Enxerto , Transplante de Rim/métodos , Pré-Escolar , Seguimentos , Humanos , Lactente , Doadores de TecidosRESUMO
Renal transplantation using infant donors is associated with significantly less graft survival (GS) and increased morbidity, especially from very young and small donors. We report our results using specific strategies to determine which age and size donor require en bloc renal transplant reconstruction and associated immunologic protocols for optimization of subsequent GS. Forty cadaveric pediatric en bloc renal transplants were performed. Mean donor age was 23.6+/-18.4 months with subgroups: 2-12 months, n=14; 13-24 months, n=19; and 25-60 months, n=7. Mean donor weight was 14.4+/-4.5 kg. All kidneys were placed in primary, nonsensitized (peak PRA = 7.9+/-5.6%) adult (41.6+/-16 years) recipients. Low weight was preferred (62.4+/-12.8 kg). Mean cold ischemia time was 26.9+/-8.6 hr. Immunosuppression consisted of quadruple immunosuppression (QI) with OKT3 induction. All patients had ureteral stents placed intraoperatively. Mean follow-up was 16.9 months. Actuarial GS at 12, 24, and 33 months were 100% (n=13), 85% (n=20), and 71% (n=7), respectively. Total GS was 35/40=88%. All grafts functioned immediately and there were no technical losses. Biopsy proven rejections occurred in 12 (30%) patients, developing at 16-167 days postoperatively (mean = 50.3 days). Mean serum creatinine at one week and 1, 6, 12, and 18 months were 2.1+/-2.0, 1.5+/-0.8, 1.3+/-0.5, 1.1+/-0.4, and 0.9+/-0.4 mg/dl, respectively. Functional isotopic renography, as well as sonographic monitoring reflected rapid initial and continued growth in these kidneys. Mean BP at 12 and 24 months postoperatively were 145/83+/-18/13 and 122/76+/-20/10 mmHg, respectively, with no significant proteinuria noted. Excellent results with minimal complications utilizing very small and young infant donors can be achieved with QI immunosuppression, and selection of low immune reactive and noncomplicated adult recipients. Additionally, maximal renal dosing by minimizing recipient weight may prevent future hyperfiltration damage.
Assuntos
Peso Corporal , Sobrevivência de Enxerto , Transplante de Rim/fisiologia , Seleção de Pacientes , Doadores de Tecidos , Análise Atuarial , Adulto , Pressão Sanguínea , Pré-Escolar , Creatinina/sangue , Quimioterapia Combinada , Feminino , Seguimentos , Humanos , Terapia de Imunossupressão/métodos , Imunossupressores/uso terapêutico , Lactente , Transplante de Rim/imunologia , Masculino , Muromonab-CD3/uso terapêutico , Fatores de TempoAssuntos
Sobrevivência de Enxerto , Transplante de Rim/fisiologia , Rim , Doadores de Tecidos , Adolescente , Adulto , Fatores Etários , Peso Corporal , Pré-Escolar , Seguimentos , Humanos , Imunossupressores/uso terapêutico , Lactente , Pessoa de Meia-Idade , Seleção de Pacientes , Fatores de TempoAssuntos
Endotelina-1/sangue , Transplante de Rim/fisiologia , Rim , Traumatismo por Reperfusão , Animais , Biópsia por Agulha , Humanos , Técnicas In Vitro , Rim/fisiologia , Transplante de Rim/patologia , Preservação de Órgãos/efeitos adversos , Fluxo Sanguíneo Regional , Circulação Renal , Veias Renais/fisiologia , SuínosRESUMO
Donor-recipient histocompatibility, as evaluated by the HLA matching results, plays an important role in the outcome of renal transplants, although much controversy surrounds the benefit of kidney allocation based on HLA typing. In this report HLA matching and survival data on 1,342 transplants performed at the University of California at San Francisco between 1984 and 1992 and treated uniformly by quadruple immunosuppression were analyzed in relation to the recipient's age. With respect to the influence of the increasing number of mismatches from 0 to 6, the analysis revealed decreasing 3-year graft survival rates as follows: 85.4%; 87.3%; 71.3%; 78.2%; 75.8%; 70.9% and 67.5%. Whereas the impact of cold ischemia time and histocompatibility was equally important during the 3-year postoperative period, the essential positive influence of good HLA matching on the long-term graft survival was demonstrated. The children aged between 5 and 18 years were identified as a high-risk group by the analysis, HLA-A incompatibility being attributed to poor graft survival in this age group. With respect to the effect of HLA-A histoincompatibility, the data provide evidence that HLA-A matching results seem to play an important role in graft survival in children, whereas transplants well matched in terms of HLA-B did well in adult recipients. No age difference in the impact of HLA-DR could be detected. In conclusion, HLA matching is still essential. It seems that there are differences in the impact of HLA loci in relation to the recipient's age.
Assuntos
Teste de Histocompatibilidade , Transplante de Rim/fisiologia , Sobrevivência de Tecidos/genética , Adolescente , Adulto , Fatores Etários , Cadáver , Criança , Pré-Escolar , Feminino , Humanos , Terapia de Imunossupressão , Lactente , Masculino , Pessoa de Meia-Idade , Fatores de RiscoRESUMO
The risk for renal allograft failure in pediatric renal transplantation (donor age below 3 years) is still high, although it has been reduced by the use of potent immunosuppressive therapies. In this study we report on experience with 80 kidneys of donors below 3 years of age (PD) transplanted at the University of California at San Francisco Hospital in accordance with the policy of minimizing donor-recipient size differences. The graft survival rates were comparable with the results for adult donors, 18-50 years of age (AD, n = 891): at 1 year PD 74.1% vs AD 85.5%, at 2 years PD 70.5% vs AD 80.2%, at 3 years PD 63.5% vs AD 76%; there were no significant differences. The policy of minimizing donor-recipient size differences seems to improve graft survival rates, avoiding the tendency for hyperfiltration phenomena and possibly being responsible for this salutary effect. We conclude that the use of pediatric donor kidneys can yield excellent long-term results independent of primary disease if the donor-recipient size difference is minimized and a potent immunosuppressive regimen is employed.
Assuntos
Antropometria , Rejeição de Enxerto/prevenção & controle , Transplante de Rim/métodos , Complicações Pós-Operatórias/prevenção & controle , Doadores de Tecidos , Sobrevivência de Tecidos/fisiologia , Adolescente , Adulto , Fatores Etários , Criança , Pré-Escolar , Feminino , Seguimentos , Rejeição de Enxerto/patologia , Teste de Histocompatibilidade/métodos , Humanos , Terapia de Imunossupressão/métodos , Lactente , Transplante de Rim/patologia , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/patologiaRESUMO
PURPOSE: We assessed the long-term efficacy of renal transplantation in patients with posterior urethral valves. MATERIALS AND METHODS: We reviewed the outcome in 23 patients with posterior urethral valves who underwent renal transplantation since 1979. RESULTS: Graft survival was 69% at 5 years and 63% at 10 years. Seven patients with followup of 7 years or longer had a mean serum creatinine level of 1.5 mg/dl. Three patients (13%) demonstrated significant bladder dysfunction postoperatively. CONCLUSIONS: Renal transplantation into a valve bladder is not associated with an abnormally high rate of failure. Deterioration of graft function secondary to lower urinary tract dysfunction is uncommon, with the majority of patients able to use the unmodified native bladder as a receptacle for the transplanted kidney.
Assuntos
Transplante de Rim , Uretra/anormalidades , Adolescente , Pré-Escolar , Creatinina/sangue , Seguimentos , Sobrevivência de Enxerto , Humanos , Complicações Pós-Operatórias , Resultado do Tratamento , Obstrução Uretral/cirurgiaRESUMO
Liver allografts from HBcAb(+), IgM(-), HBsAg(-) donors can transmit HBV to uninfected recipients. We currently no longer accept these livers for transplantation while continuing to accept the kidneys. The purpose of this study is to determine the risk of donor-transmitted HBV infections from HBcAb(+), HBIgM(-), HBsAg(-) organ donors and determine if the risk of donor-transmitted HBV infections and their severity is dependent on the organ being transplanted. This study consists of a retrospective review of the posttransplant course of recipients of HBcAb(+), HBIgM(-), HBsAg(-) donors accepted at UCSF from 6/85 to 12/93. Transmitted HBV infection was defined as one in which the recipient changed from HBsAg(-) prior to transplantation to HBsAg(+) posttransplant, with no other source. There were 25 of 1190 donors who were HBcAb(+), HBIgM(-), HBsAg(-); 1/42 kidney, 3/6 liver, and 0/7 heart HBsAg(-) transplant recipients of organs from these donors became HBsAg(+) after transplantation. This difference in infection rate (liver vs. kidney and heart) is statistically significant. The clinical course of the liver recipients was also more severe. All of the patients who became infected were HBsAb(-) and HBcAb(-) prior to transplant. We conclude that (1) HBV can be transmitted from HBcAb(+), HBIgM(-), HBsAg(-) organ donors, (2) the rate of transmission is highest and severity of infection is worst in the liver recipients; and (3) we will continue to transplant kidneys from these donors, preferably into immunized recipients.
Assuntos
Transplante de Coração/efeitos adversos , Antígenos do Núcleo do Vírus da Hepatite B/sangue , Antígenos de Superfície da Hepatite B/sangue , Hepatite B/transmissão , Imunoglobulina M/sangue , Transplante de Rim/efeitos adversos , Transplante de Fígado/efeitos adversos , Doadores de Tecidos , Adolescente , Hepatite B/sangue , Hepatite B/imunologia , Humanos , Estudos Retrospectivos , Fatores de RiscoRESUMO
We report a new technique for the management of ureterovesical junction stenosis in a renal transplant recipient. Endoscopic retrograde resection of a bladder window permitted direct retroperitoneal vision and longitudinal incision of the distal ureter. Ureteral and bladder mucosa were in close proximity and were stabilized with a double-J catheter. This alternative transmural transvesical ureteroneocystostomy had minimal morbidity and may be an alternative to traditional open surgical repair of these lesions.