Single-center experience with perioperative antibiotic prophylaxis and surgical site infections in kidney transplant recipients.

BACKGROUND: Infections in kidney transplant recipients are particularly challenging owing to the immunosuppressive treatment, usually long history of chronic illness, comorbidities and prior exposures to antibiotics. Among the most common complications early after surgery are surgical site infections. The aim of this study was to identify risk factors and evaluate epidemiological data regarding surgical site infections. Moreover, we were able to compare the current results with historical data from our institution when different perioperative antibiotic prophylaxis was practiced. METHODS: We conducted a retrospective case-control study in a group of 254 deceased donor renal graft recipients transplanted in a single Central European institution. We evaluated epidemiological findings and resistance patterns of pathogens causing surgical site infections. We used multivariable logistic regression to determine risk factors for surgical site infections. RESULTS: We revealed no differences in baseline characteristics between patients with and without surgical site infections. Ten surgical site infections (3.9%) were diagnosed (six superficial incisional, two deep incisional, and two organ/space). Eight species (19 strains) were identified, most of which were multi-drug resistant (63%). The most common was extended-spectrum ß-lactamase producing Klebsiella pneumoniae (26%). We showed that statistically significant differences were present between reoperated and non-reoperated patients (adjusted odds ratio: 6.963, 95% confidence interval 1.523-31.842, P = .012). CONCLUSIONS: Reoperation is an individual risk factor for surgical site infection after kidney transplantation. According to our experience, cefazolin-based prophylaxis can be safe and is associated with relatively low prevalence of surgical site infections.

Early Postoperative Complications and Outcomes of Kidney Transplantation in Moderately Obese Patients.

BACKGROUND: Obese renal transplant recipients (body mass index [BMI] ≥30 kg/m2) are at risk of delayed graft function and postoperative complications, such as infections or delayed wound healing. There is also a tendency to exclude extremely obese patients from transplantation (KTx). Nonetheless, no association between obesity and increased mortality has been reported. The aim of this study is to evaluate the effect of BMI on the most common surgical and infectious complications after KTx. MATERIALS AND METHODS: An observational study in 872 patients transplanted from 2010-2017 was conducted. Median BMI was 24.6 (13.9-34.3), and 8.3% of the group was obese. Patient records were searched for early postoperative complications: lymphocele or hematoma (>33 mL), urinary leakage, or urinary tract infection (UTI). Mann-Whitney U and χ2 or Fisher exact tests were used. P < .05 was considered statistically significant. The study complies with the Helsinki Congress and the Istanbul Declaration. RESULTS: Renal primary nonfunction was observed in 1.4% (12/872) of patients. Surgical or infectious complications occurred in 52.7% (453/860) of patients. No correlation between BMI and complication rate was noted. Complications were observed in 56.9% (41/72) of obese vs 52.3% (412/788) of nonobese patients (P = .448), including lymphocele in 15.3% vs 16.4% (P = .810), hematoma in 22.2% vs 19.2% (P = .530), urinary leakage in 1.4% vs 4.6% (P = .203), and UTI in 31.9% vs 32.9% (P = .873), respectively. CONCLUSIONS: Recipient's BMI has no significant association with the most common surgical complications after KTx. There is no need to delay KTx in moderately obese patients.

Reoperation in Early Kidney Post-transplant Period as a Strong Risk Factor of Surgical Site Infection Occurrence.

BACKGROUND: One of the most common infective complications after kidney transplant (KTx) is surgical site infection (SSI). Providing indications of improvement of perioperative antibiotic prophylaxis (PAP) and allowing the characterization of risk factors are critical to reduce SSI. The purpose of this study was to evaluate the SSI risk factors and impact of reoperation in the early post-transplant period on SSI occurrence and assess if standard PAP in those cases is a best consideration. METHODS: Between April 2014 and October 2015, a total of 236 KTxs were performed in our center. Deceased donor data, recipient data, and data related to surgical procedures were collected. RESULTS: Surgical site infections were reported in 5.6% (12/214) of patients. Seven patients were diagnosed as having superficial SSI (7/12; 58.3%), 2 with deep SSI (2/12; 16.6%), and 4 with organ-specific SSI (4/12; 33.3%). Extended criteria donor-related transplant, cold ischemia time > 22 hours, dialysis period > 30 months, recipient age older than 45 years, recipient body mass index > 27, induction therapy prior to transplant, diabetes prior to transplant, and ≥ 1 reoperation during 30 days of observation were independent risk factors of SSI occurrence. A total of 19 reoperations were performed in 17 patients. In 8 of all 12 patients with SSI diagnosis, the reoperation was performed (66.7%). In 202 patients of non-SSI patients, only 9 reoperations were performed (4.5%). CONCLUSIONS: Early reoperation after Ktx is a strong risk factor of SSI occurrence. There is a probability that > 4 SSI risk factors and reoperation in the early post-transplant period could require different and more aggressive proceeding, as standard PAP in those cases is insufficient.

Should Immunosuppression After Kidney Transplant Be Adjusted Based on Renal Resistance During Pretransplant Hypothermic Machine Perfusion?

BACKGROUND: The hypothermic machine perfusion reduces delayed graft function after kidney transplant and allows, to some extent, predicting early graft function. However, it is difficult to identify exact perfusion criteria with which to exclude kidneys from transplant or modify post-transplant care. The aim of this study was to analyze whether renal resistance during the fourth hour of hypothermic machine perfusion is useful in the prediction of graft survival and acute rejection. PATIENTS AND METHODS: Data on pretransplant hypothermic machine perfusion parameters of 407 transplanted kidneys were available. Receiver operating characteristic curve analysis was performed to find an optimal cutoff value of ratio for predicting a higher risk class of considered group of patients. According to this, patients were divided into 2 groups: those who received kidneys with renal resistance lower than 0.19 mm Hg/mL/min (R1; n = 187) and those who received kidneys with renal resistance equal to or higher than 0.19 mm Hg/mL/min (R2; n = 220). Within R2, we additionally analyzed 2 subgroups: patients who received induction therapy (R2-Ind+; n = 124) and those who did not received induction therapy (R2-Ind-; n = 96). RESULTS: Acute rejection in R1 within 1 month post transplant was 2-fold lower compared with R2 and was 6.4% vs 13.1% (P = .03), respectively. One-year graft survival was higher in R1 compared with R2 and was 94.6% vs 88.5% (P = .03), respectively. Acute rejection in the R2-Ind+ subgroup within 1 month post transplant was 2.46-fold lower compared with the R2-Ind- subgroup and was 8% vs 19.7% (P = .01), respectively. CONCLUSION: Immunosuppression treatment after transplant should be adjusted to perfusion parameters.

Do We Need Insulin Independence After Islet Transplantation?

INTRODUCTION: Most life-threatening diabetes-related complications involve the kidneys, eyes, cardiovascular system, and autonomic nervous system. Clinical islet transplantation (CITx) may be a therapeutic option for some patients. In this study, we analyzed the progression of diabetic complications after CITx and in patients waiting for islet transplantation. METHODS: From 2008 to 2015, 67 patients were listed for pancreatic or islet transplantation. We compared beta scores, islet scores, and secondary complications between patients who underwent islet allotransplantation (CITx group, n = 6) and the patients awaiting islet transplantation (wait group, n = 19) at baseline and during the 1-year follow-up. RESULTS: In the CITx group, good islet function was observed in 80% of patients 1 month post-transplantation and 40% of patients 1 year post-transplantation; however, no patient achieved insulin independence. One patient who underwent simultaneous islet-kidney transplantation died on day 8 because of severe bleeding in the retroperitoneal space. In 1 case, islet primary nonfunction was observed. Mean islet score in the CITx group 1 year post-transplantation was significantly higher than the pretransplant score and wait group scores at enrollment and 1 year later (P < .01). Increased albuminuria was observed in 3 of 11 (27%) patients in the wait group and 0 patients in the CITx group (P = .08). One patient (9%) in the wait group developed chronic renal failure requiring hemodialysis. Ophthalmologic procedures were required by 47% of patients in the wait group and 0 patients in the CITx group in the first year after transplantation (P < .01). CONCLUSION: Successful islet transplantation slows the progression of diabetic complications.

Time of Cold Storage Prior to Start of Hypothermic Machine Perfusion and Its Influence on Graft Survival.

BACKGROUND: Hypothermic machine perfusion (HMP) has become a standard method of preservation for kidneys procured from expanded-criteria donors and donors after cardiac death. There are different systems and approaches to the HMP preservation period, with cold storage prior to HMP sometimes taking several hours. This study evaluated whether the time at which kidneys receive HMP had any influence on the outcomes of kidney transplantation. METHODS: In this analysis, patient and graft survival were evaluated over a 1-year post-transplantation period. Patients who received HMP kidneys (n = 379) were divided into 2 groups: those who received kidneys with a cold ischemia time (CIT) prior to HMP <295 minutes (group G1; n = 254) and those who received kidneys with CIT prior to HMP >295 minutes (group G2; n = 125). RESULTS: Delayed graft function was observed in 31.8% (81/254) of patients in group G1 vs 46.4% (58/125) of patients in group G2 (P = .007). One-year graft survival was statistically higher in the group G1 (93.2%; 233/254) vs group G2 (86.5%; 105/125, P = .029). Mean 1-year estimated glomerular filtration rate was significantly better in the group G1. CONCLUSIONS: In conclusion, introduction of HMP up to 295 minutes from procurement led to better early and 1-year graft results. Kidneys should receive HMP as soon as possible after retrieval, preferably during procurement.

Islet Autotransplantation in Diabetic Patients.

INTRODUCTION: Painful chronic pancreatitis (CP) is the main indication for analgesic pancreatectomy with simultaneous islet autotransplantation to prevent postoperative diabetes mellitus (DM). However, advanced CP may lead to insulin secretion disorders and DM. There are doubts as to whether islet autotransplantation in such cases is an appropriate procedure. The aim of this study was to analyze the results of islet autotransplantation in patients with CP with already diagnosed with DM. METHOD: Between 2008 and 2015, at the Department of General and Transplantation Surgery, patients with CP and unsatisfying pain treatment with positive fasting C-peptide ( > 0.3 ng/mL) level were qualified for simultaneous pancreatectomy and islet autotransplantation. Eight procedures were performed. In 5 cases patients had DM diagnosed prior to the procedure (DM group n = 5). Three patients without DM diagnosed prior to surgery were the control group (n = 3). RESULT: There were no cases of procedure-related deaths in either group. Pain relief without analgesics was reported by all patients. Good islet function was observed in 80% (4/5) of the DM group vs 100% (3/3) in the control group (P = ns). Brittle diabetes was diagnosed in 1 patient in the DM group as a result of islet primary non-function. CONCLUSION: Patients with CP-related severe pain and DM patients with positive C-peptides should be considered for pancreatectomy and islet autotransplantation.

Successful transplantation of kidneys from deceased donors with terminal acute kidney injury.

BACKGROUND: There are many doubts with regards to accepting deceased kidneys with acute kidney injury (AKI) for transplantation. PURPOSE: The aim of this study was to present the 5-years outcome of kidney transplantation cases where deceased donors developed AKI before organ procurement. METHODS: Two hundred twenty-six deceased renal transplants were analyzed. Data regarding donors and recipients were collected. Terminal AKI was defined as terminal serum creatinine concentration higher than 1.99 mg/dL and 66 such cases were diagnosed. All kidney transplant recipients were followed for 60 months. RESULTS: AKI group presented more episodes of delayed graft function (DGF) compared to the non-AKI group (56% vs 35%, p < .05). No differences were observed between the groups in the rate of acute rejection episodes, kidney function as well as patient and graft survival. CONCLUSIONS: Transplants with AKI present more often DGF and comparable graft survival to transplants without AKI. Kidneys with AKI can be a valuable source of organs provided attentive selection and appropriate care of deceased donors.

Killer Immunoglobulin-Like Receptor 2DS2 (KIR2DS2), KIR2DL2-HLA-C1, and KIR2DL3 as Genetic Markers for Stratifying the Risk of Cytomegalovirus Infection in Kidney Transplant Recipients.

Infection with cytomegalovirus (CMV) remains a major problem in kidney transplant recipients, resulting in serious infectious complications and occasionally mortality. Accumulating evidence indicates that natural killer cell immunoglobulin-like receptors (KIRs) and their ligands affect the susceptibility to various diseases, including viral infections (e.g., CMV infection). We investigated whether KIR genes and their ligands affect the occurrence of CMV infection in a group of 138 kidney transplant recipients who were observed for 720 days posttransplantation. We typed the recipients for the presence of KIR genes (human leukocyte antigen C1 [HLA-C1], HLA-C2, HLA-A, HLA-B, and HLA-DR1) by polymerase chain reaction with sequence-specific primers. The multivariate analysis revealed that the lack of KIR2DS2 (p = 0.035), the presence of KIR2DL3 (p = 0.075), and the presence of KIR2DL2⁻HLA-C1 (p = 0.044) were risk factors for posttransplant CMV infection. We also found that a lower estimated glomerular filtration rate (p = 0.036), an earlier time of antiviral prophylaxis initiation (p = 0.025), lymphocytopenia (p = 0.012), and pretransplant serostatus (donor-positive/recipient-negative; p = 0.042) were independent risk factors for posttransplant CMV infection. In conclusion, our findings confirm that the KIR/HLA genotype plays a significant role in anti-CMV immunity and suggest the contribution of both environmental and genetic factors to the incidence of CMV infection after kidney transplantation.

Surgical site infections after kidney transplantation--where do we stand now?

BACKGROUND: Kidney transplantation (KTx) is a widely accepted method of renal function replacement therapy. Surgical site infections (SSIs), along with urinary tract infections, are among the most common infective complications after KTx. The purpose of this study was to assess the incidence of SSI in patients after KTx, identify risk factors for SSI, and classify patients in which standard antibiotic prophylaxis could be avoided. METHODS: Between January 2010 and December 2011, 262 KTxs were performed in our center. Deceased donors', recipients' data, and data related to surgical procedures were collected. SSIs were diagnosed in accordance with the guidelines published by the U.S. Centers for Disease Control and Prevention. RESULTS: SSIs were diagnosed in 7.25% (19/262) of patients. Of nineteen SSI patients, two (10.5%) were diagnosed with organ-specific SSIs, which eventually led to graft loss; six (31.5%) developed deep incisional SSIs; and eleven (58%) developed superficial incisional SSIs. Through analysis of this extensive data set, we determined the following risk factors for the development of SSI: kidney from extended criteria donors, a cold ischemia time of more than 30 hr, time of surgical procedure longer than 200 min, confirmed diabetes in the recipients, a recipient body mass index higher than 27 kg/m, and occurrence of delayed graft function. CONCLUSIONS: It may be possible to reduce standard antibiotic prophylaxis to a single dose in patients without known risk factors for SSI. Any opportunity to reduce antibiotic use is crucial in preventing the development of multi-drug-resistant pathogens.