Urinary Tract Infections in the First 6 Months after Renal Transplantation.

PURPOSE: Urinary tract infections (UTIs) are common in the first 6 months after renal transplantation, and there are only limited data about UTIs after transplantation in Saudi Arabia in general. METHODS: A retrospective study from January 2017 to May 2020 with 6-month follow-up. RESULTS: 279 renal transplant recipients were included. Mean age was 43.4 ± 16.0 years, and114 (40.9%) were women. Urinary stents were inserted routinely during transplantation and were removed 35.3 ± 28 days postoperatively. Ninety-seven patients (35%) developed urinary tract infections (UTIs) in the first six months after renal transplantation. Of those who developed the first episode of UTI, the recurrence rates were 57%, 27%, and 14% for having one, two, or three recurrences, respectively. Late urinary stent removals, defined as more than 21 days postoperatively, tended to have more UTIs (OR: 1.43, P: 0.259, CI: 0.76-2.66). Age >40, female gender, history of neurogenic bladder, and transplantation abroad were statistically significant factors associated with UTIs and recurrence. Diabetes, level of immunosuppression, deceased donor renal transplantation, pretransplant residual urine volume, or history of vesicoureteral reflux (VUR) was not associated with a higher incidence of UTIs. UTIs were asymptomatic in 60% but complicated with bacteremia in 6% of the cases. Multidrug resistant organisms (MDROs) were the causative organisms in 42% of cases, and in-hospital treatment was required in about 50% of cases. Norfloxacin + Bactrim DD (160/800 mg) every other day was not associated with the lower risk of developing UTIs compared to the standard prophylaxis daily Bactrim SS (80/400 mg). CONCLUSION: UTIs and recurrence are common in the first 6 months after renal transplantation. Age >40, female gender, neurogenic bladder, and transplantation abroad are associated with the increased risk of UTIs and recurrence. MDROs are common causative organisms, and hospitalization is frequently required. Dual prophylactic antibiotics did not seem to be advantageous over the standard daily Bactrim.

The Impact of Timing of Stent Removal on the Incidence of UTI, Recurrence, Symptomatology, Resistance, and Hospitalization in Renal Transplant Recipients.

PURPOSE: To evaluate the impact of early (<3 weeks) versus late (>3 weeks) urinary stent removal on urinary tract infections (UTIs) post renal transplantation. METHODS: A retrospective study was performed including all adult renal transplants who were transplanted between January 2017 and May 2020 with a minimum of 6-month follow-up at King Abdulaziz Medical City, Riyadh, Saudi Arabia. RESULTS: A total of 279 kidney recipients included in the study were stratified into 114 in the early stent removal group (ESR) and 165 in the late stent removal group (LSR). Mean age was 43.4 ± 15.8; women: n: 114, 40.90%; and deceased donor transplant: n: 55, 19.70%. Mean stent removal time was 35.3 ± 28.0 days posttransplant (14.1 ± 4.6 days in the ESR versus 49.9 ± 28.1 days in LSR, p < 0.001). Seventy-four UTIs were diagnosed while the stents were in vivo or up to two weeks after the stent removal "UTIs related to the stent" (n = 20, 17.5% in ESR versus n = 54, 32.7% in LSR; p=0.006). By six months after transplantation, there were 97 UTIs (n = 36, 31.6% UTIs in ESR versus n = 61, 37% in LSR; p=0.373). Compared with UTIs diagnosed after stent removal, UTIs diagnosed while the stent was still in vivo tended to be complicated (17.9% versus 4.9%, p: 0.019), recurrent (66.1% versus 46.3%; p: 0.063), associated with bacteremia (10.7% versus 0%; p: 0.019), and requiring hospitalization (61% versus 24%, p: 0.024). Early stent removal decreased the need for expedited stent removal due to UTI reasons (rate of UTIs before stent removal) (n = 11, 9% in the early group versus n = 45, 27% in the late group; p=0.001). The effect on the rate of multidrug-resistant organisms (MDRO) was less clear (33% versus 47%, p: 0.205). Early stent removal was associated with a statistically significant reduction in the incidence of UTIs related to the stent (HR = 0.505, 95% CI: 0.302-0.844, p=0.009) without increasing the incidence of urological complications. Removing the stent before 21 days posttransplantation decreased UTIs related to stent (aOR: 0.403, CI: 0.218-0.744). Removing the stent before 14 days may even further decrease the risk of UTIs (aOR: 0.311, CI: 0.035- 2.726). CONCLUSION: Early ureteric stent removal defined as less than 21 days post renal transplantation reduced the incidence of UTIs related to stent without increasing the incidence of urological complications. UTIs occurring while the ureteric stent still in vivo were notably associated with bacteremia and hospitalization. A randomized trial will be required to further determine the best timing for stent removal.

Corrigendum: Analysis of donor motivations in living donor liver transplantation.

[This corrects the article DOI: 10.3389/fsurg.2014.00025.].

Incidence, Characteristics, and Prognosis of Incidentally Discovered Hepatocellular Carcinoma after Liver Transplantation.

Background. We aimed to assess incidentally discovered hepatocellular carcinoma (iHCC) over time and to compare outcome to preoperatively diagnosed hepatocellular carcinoma (pdHCC) and nontumor liver transplants. Methods. We studied adults transplanted with a follow-up of at least one year. Patients were divided into 3 groups according to diagnosis of hepatocellular carcinoma. Results. Between 1990 and 2010, 887 adults were transplanted. Among them, 121 patients (13.6%) had pdHCC and 32 patients (3.6%) had iHCC; frequency of iHCC decreased markedly over years, in parallel with significant increase in pdHCC. Between 1990 and 1995, 120 patients had liver transplants, 4 (3.3%) of them had iHCC, and only 3 (2.5%) had pdHCC, while in the last 5 years, 263 patients were transplanted, 7 (0.03%) of them had iHCC, and 66 (25.1%) had pdHCC (P < 0.001). There was no significant difference between groups regarding patient survival; 5-year survival was 74%, 75.5%, and 77.3% in iHCC, pdHCC, and non-HCC groups, respectively (P = 0.702). Patients with iHCC had no recurrences after transplant, while pdHCC patients experienced 17 recurrences (15.3%) (P = 0.016). Conclusions. iHCC has significantly decreased despite steady increase in number of transplants for hepatocellular carcinoma. Patients with iHCC had excellent outcomes with no tumor recurrence and survival comparable to pdHCC.

Long-term outcome after liver transplantation for hepatic schistosomiasis: a single-center experience over 15 years.

Our objective was to study the long-term outcomes of patients who had undergone liver transplantation because of schistosomiasis at our institute over the last 15 years. Four hundred forty-one patients underwent liver transplantation at our institute, and 14 did so for schistosomiasis. The survival of patients who underwent transplantation for schistosomiasis was compared with that of patients who underwent transplantation for other liver diseases. Survival curves were drawn via the Kaplan-Meier method and were compared with the log-rank test. P < 0.05 was considered significant. All 14 patients were male, and the average age was 56.8 ± 8.4 years. The average Model for End-Stage Liver Disease score was 18.2 ± 5.6, and the average Child-Pugh score was 10.6 ± 1.2. All patients had splenomegaly; pretransplant variceal bleeding occurred in 7 patients (50%), and portal vein thrombosis was diagnosed in 5 patients (36%). Patient survival was 75% 1 year after transplantation and 75% at the end of follow-up because no patients were lost after the first year. Patients who underwent transplantation for other causes achieved survival rates of 86% and 76% 1 and 10 years after transplantation, respectively. There was no significant survival difference between the 2 groups (P = 0.66). All patients who survived the early posttransplant period had functioning liver grafts with no reported diagnoses of schistosomiasis in the new grafts. In conclusion, liver transplantation for patients with schistosomiasis has a favorable outcome with no risk of reactivation.

Three-dimensional tumor volume and serum alpha-fetoprotein are predictors of hepatocellular carcinoma recurrence after liver transplantation: refined selection criteria.

Total tumor volume (TTV), as a better predictor of hepatocellular carcinoma (HCC) recurrence after liver transplant, has been explored by our center. Some tumors are not typically spherical but rather ellipsoid or spheroid, and calculating their TTV based on one dimension only may overestimate their volume and exclude them from candidacy for transplantation. Our aim was to study the actual tumor volume (ATV) calculated using the ellipsoid formula and assess its impact on recurrence. HCC patients transplanted between 1990 and 2010 at University of Alberta Hospital were analyzed. Tumor volumes were calculated using both formulas: [(4/3) πr(3)] (r = max. radius) and [(4/3) πabc] (a, b, c = the 3 radiuses). A total of 115 patients were included with a mean follow-up of 4.99 ± 4.23 yr. Five-yr recurrence-free survival was 79.8%. Univariate analysis for predictors of recurrence included: maximum tumor diameter, ATV, TTV, and alpha-fetoprotein (AFP) ≥ 400 ng/mL. Multivariate analysis showed that ATV and AFP ≥ 400 ng/mL were the only predictors of recurrence. Combining both variables provides better predication of recurrence with accuracy that exceeds 80%. Three-dimensional calculation of tumor volume is of critical importance for the group of patients with ellipsoid tumors where volumes are overestimated with the spherical formula and could lead to inappropriate exclusion from transplant.

Analysis of donor motivations in living donor liver transplantation.

OBJECTIVES: The introduction of the living donor liver transplantation (LDLT) in Egypt as in elsewhere, has raised important psychological conflicts and ethical questions. The objective of this study was to get better understanding of the potential donors' motives toward LDLT. METHODS: This study was conducted on consecutive 193 living-liver donors who underwent partial hepatectomy as donors for LDLT during the period between April 2003 and January 2013, at the National Liver Institute Menoufeyia University, Egypt. Potential donors were thoroughly evaluated preoperatively through a screening questionnaire and interviews as regard their demographic data, relationship to the potential recipient, and motives toward proceeding to surgery. They were assured that the information shared between them and the transplant center is confidential. RESULTS: The donors' mean age was 25.53 ± 6.39 years with a range of 18-45 years. Males represented 64.7% and females were 35.3%. The most common donors (32.1%, n = 62) were sons and daughters to their parents (sons: n = 43, daughters: n = 19) while parents to their offsprings represent 15% (mothers: n = 21, fathers: n = 8). Brothers and sisters represent 16.5% (brothers: n = 22, sisters: n = 10). Nephews and nieces giving their uncles or aunts were 14%. The number of wives donating to their husbands was 11 (5.7%). Interestingly, there was no single husband who donated his wife. Among the remaining donors, there were 11 cousins and 1 uncle. Unrelated donors were 20 (10.4%). Several factors seemed to contribute to motivation for donation: the seriousness of the potential recipient condition, the relationship and personal history of the donor to the potential recipient, the religious beliefs, the trust in the health care system, and family dynamics and obligations. CONCLUSION: Absolute absence of coercion on the living-liver donor's motives may not be realistic because of the serious condition of the potential recipient. It is mandatory that the donor is truly willing to donate.

Moral and ethical issues in living-donor liver transplant in Egypt.

OBJECTIVES: Since brain-death criteria are not accepted in Egypt, only organs acquired from living donors can be used for transplant. Our objective was to highlight the ethical issues raised by living-donor liver transplant. MATERIALS AND METHODS: The study was conducted by reviewing publications from centers performing living-donor liver transplant in Egypt and by consulting with a group of experts in the fields of liver transplantation, clinical ethics, and religious scholarship. RESULTS: The first successful living-donor liver transplant in Egypt was performed at the National Liver Institute in 1991; however, this program did not continue because of poor early results. In August 2002, transplants began at Dar-Al-Foaud Hospital; since then, almost 500 cases of living-donor liver transplant have been performed at 9 centers. Although the donor risk is estimated to be low, 2 donors died (0.4%). The ethical principle that best applies to living-donor liver transplant is primum non nocere (first, not to harm), as the donor derives emotional benefit fromdonation and the opportunity to save a life. It is important to stress that the alternative to living-donor liver transplant in Egypt is not deceased-donor liver transplant. There are no doubts that this is a beneficial procedure for the recipient with acceptable risks to the donor. CONCLUSIONS: It is ethically appropriate to perform liver transplant using living donors.