Use of preoperative embolization prior to Transplant nephrectomy.

INTRODUCTION: After a failed transplant, management of a non-functional graft with pain or recurrent infections can be challenging. Transplant nephrectomy (TN) can be a morbid procedure with the potential for significant blood loss. Embolization of the renal artery alone has been proposed as a method of reducing complications from an in vivo failed kidney transplant. While this does yield less morbidity, it may not address an infected graft or refractory hematuria or rejection. We elected to begin preoperative embolization to assess if this would help decrease the blood loss and transfusion rate associated with TN. MATERIALS AND METHODS: We performed a retrospective analysis of all patients who underwent non-emergent TN at our institution. Patients who had functioning grafts that later failed were included in analysis. TN was performed for recurrent infections, pain or hematuria. We evaluated for blood loss (EBL) during TN, transfusion rate and length of hospital stay. RESULTS: A total of 16 patients were identified. Nine had preoperative embolization or no blood flow to the graft prior to TN. The remaining 7 did not have preoperative embolization. The shortest time from transplant to TN was 8 months and the longest 18 years with an average of 6.3 years. Average EBL for the embolized patients (ETN) was 143.9cc compared to 621.4cc in the non-embolized (NETN) group (p=0.041). Average number of units of blood transfused was 0.44 in the ETN with only 3/9 patients requiring transfusion. The NETN patients had average of 1.29 units transfused with 5/7 requiring transfusion. The length of stay was longer for the ETN (5.4 days) compared to 3.9 in the NETN. No intraoperative complications were seen in either group and only one patient had a postoperative ileus in the NETN. CONCLUSION: Embolization prior to TN significantly decreases the EBL but does not significantly decrease transfusion rate. However, patients do require a significantly longer hospitalization with embolization due to the time needed for embolization. Larger studies are needed to determine if embolization before transplant nephrectomy reduces the transfusion rates and overall complications.

Laparoscopic donor nephrectomy - safety in a small-volume transplant center.

INTRODUCTION: Laparoscopy is a standard surgical option for live donor nephrectomy (LDN) at the majority of transplant centers. Equivalent graft survival with shorter convalescence has been reported by several large volume centers. With the arrival of an experienced laparoscopic surgeon in 2002, we began to offer laparoscopic LDN at our institution. We report our experience as a large volume laparoscopic surgery program but a low volume transplant center. METHODS: A retrospective review of the previous 34 LDN (17 open, 17 laparoscopic) performed at the University of Missouri were included. A single laparoscopic surgeon performed all laparoscopic procedures. Hand assisted laparoscopy was performed in 15 and standard laparoscopy with a pfannenstiel incision in two. Open procedures were performed through anterior subcostal or flank incision. A single surgeon performed all open procedures. RESULTS: There was no statistical difference in age, body mass index or American Society of Anesthesiologies Score between the two groups. Mean operative time, estimated blood loss and hospital stay were 229 minutes, 324 cc and 2.2 days respectively in the laparoscopic group compared to 202 minutes, 440 cc and five days for the open group. Average warm ischemia time was 179 seconds. Recipient creatinine for the two groups at one week, one month and one year was not statistically significantly different. Each group had one graft loss due to medication noncompliance. CONCLUSION: For small transplant centers with an advanced laparoscopic program, laparoscopic LDN is a safe procedure with comparable outcomes to major transplant centers.

Intrasubject medication adherence patterns.

The purpose of this prospective descriptive study was to explore the patterns of intrasubject (between medication) adherence of two similarly timed, twice-daily medications using the Medication Event Management System electronic monitoring cap. Medication adherence was measured for 6 months using electronic monitoring in 25 adult renal-transplant recipients. Data were available from 7,119 electronic medication events. Results indicated that two twice-daily medications scheduled to be taken simultaneously were taken within 5 min of each other 77% of the time and within 10 min, 92% of the time. When only the first scheduled dose of the day was examined, the results are 79% and 95%, respectively. These findings are important to researchers and clinicians who must evaluate medication adherence in transplant recipients while balancing cost and subject burden. This study provides empirical support for monitoring a single immunosuppressive medication electronically to estimate medication adherence with double or triple immunosuppressive drug therapy.

Medication adherence patterns in adult renal transplant recipients.

Patient adherence to immunosuppressive medications adherence is crucial to survival of the patient and a transplanted kidney, yet adherence is variable. Using a prospective, descriptive design, immunosuppressive medication adherence of 44 renal transplant recipients was followed for 6 months at a Midwestern transplant center using electronic monitoring. Four medication adherence patterns emerged from a hierarchical cluster analysis: those who took medications on time, those who took medications on time with late/missed doses, those who rarely took medications on time and who were late with morning and/or evening doses, and those who missed doses. This study is a step toward developing and implementing interventions targeted to specific patterns of poor adherence.

A perspective on the safety of cosmetic products: a position paper of the American Council on Science and Health.

Over the years, some activist groups have targeted cosmetics as possible human health threats, claiming that cosmetic ingredients are not adequately tested for safety and may pose risks to consumers. The groups allege that industry practices related to safety testing are flawed, that there is little government oversight, and that cosmetics contain cancer-causing chemicals and other toxicants. A critical review of the scientific data related to these claims indicates the following: (1) Industry has the primary responsibility to ensure that all ingredients, preservatives, and coformulants used in products are safe for their intended uses. (2) The U.S. Food and Drug Administration (FDA) has regulatory oversight of the cosmetic industry. Its authority includes the banning or restriction of ingredients for safety reasons. (3) The Cosmetic Ingredient Review (CIR), an independent, scientific review board, critically evaluates chemical ingredients used in cosmetics and publishes the results of its findings in the peer-reviewed literature. (4) Health-related allegations about cosmetic ingredients are generally based on the results of high-dose laboratory testing in animals and have little relevance for humans. As true now as when Paracelsus said it in the 16th century, "It is the dose that makes the poison." (5) The health-related allegations involving specific chemicals (e.g., phthalates, parabens, and 1,3-butadiene) fail to consider important scientific studies and recent regulatory conclusions about these chemicals, which have found that they are not hazardous. (6) Animal and human physiology differ in crucial ways, further invalidating simplistic attempts to extrapolate rodent testing to human health risks. The cosmetic industry should be encouraged to publish more of its toxicity studies and safety evaluations, which would aid in dispelling the uncertainty that some consumers have about cosmetic safety.

Improving access to kidney transplantation without decreasing graft survival: long-term outcomes of blood group A2/A2B deceased donor kidneys in B recipients.

BACKGROUND: The transplantation of blood group A2/A2B deceased donor kidneys into B recipients could improve access to transplantation for blood group B recipients. However, this practice is controversial, and long-term data are lacking. This study analyzed the long-term outcomes of A2/A2B deceased donor kidneys transplanted into selected B recipients. METHODS: We retrospectively assessed the outcomes (graft survival, transplant rates, and acute rejection) of deceased-donor kidneys using an allocation system that transplanted A2/A2B donors into B recipients with low anti-A blood group antibody titers between 1994 and 2003. Patients received conventional immunosuppression without any specific antibody reduction procedures. We further assessed the impact this system had on access to transplantation by blood group. RESULTS: Of 1,400 kidney transplants, 56 (4.0%) were A2/A2B to B recipients. The system reduced waiting time for all B recipients, even shorter than for blood group A recipients (median waiting times of A2/A2B to B transplants=182 days vs. B to B transplants=297 days; and A to A=307 days). Although there was a trend toward increased acute rejection in A2/A2B to B transplants, the actuarial 7-year death censored graft survival was 72% for B recipients regardless of donor type. CONCLUSIONS: Transplanting A2/A2B deceased donor kidneys into B recipients leads to an equalization of waiting time between blood groups with similar patient and graft survival using conventional immunosuppression. This protocol could lead to more equal access to kidney transplantation in blood group B recipients.

The public health implications of polychlorinated biphenyls (PCBs) in the environment.

Polychlorinated biphenyls (PCBs) were widely used in various industrial applications. Research confirmed that some PCB congeners degrade slowly in the environment and can build up in the food chain. Poisoning episodes in Asia were initially attributed to PCB-contaminated oil, although subsequent analysis suggested that thermal degradation products of PCBs were responsible for the observed toxicity. Commercial production of PCBs in the United States was banned in 1979. Several agencies have categorized PCBs as animal carcinogens; however, studies of workers exposed to high doses of PCBs have not demonstrated an increased cancer risk. Health effects attributable to PCBs include skin and eye irritation. There is no reliable evidence that PCBs in the environment result in either "endocrine disruption" or intellectual deterioration in children exposed in utero. Because PCB exposures from environmental sources do not pose a significant health risk, little benefit to public health can result from continued remediation of PCB sources.

Transplantation of A2 and A2B kidneys from deceased donors into B waiting list candidates increases their transplantation rate.

Transplant centers in the Midwest Transplant Network began transplanting kidneys from A2 or A2B donors into blood group B and O patients in 1986. Since 1991, an OPTN/UNOS variance has permitted us to allocate these kidneys preferentially into B and O waiting list patients. With more than 10 years of experience we have noted the following: 1. Thirty-one percent more blood group B patients were transplanted by allocating them A2 or A2B kidneys from our deceased donors. 2. Ten-year graft survival for B recipients of an A2 or A2B kidney (72%) was equivalent to that for B recipients of a B kidney (69%). 3. Type B recipients of simultaneous pancreas-kidney transplants (n=4) also did well with A2 or A2B organs. 4. Non-A recipients were transplanted only when their anti-A IgG titer history was consistently low (< or =4). 5. Most (90%) blood group B patients had a low anti-A IgG titer history; whereas, only one-third of blood group O patients had a low titer history. 6. Neither ethnicity nor HLA class I sensitization level influenced the anti-A IgG titer history. 7. In an OPO with mostly (87%) white donors, nearly 20% of blood group A donors were A2. 8. Waiting time until transplantation was lower for B patients who received an A2 or A2B kidney than for those who received a B or O kidney. 9. Our OPO blood group B waiting list was reduced from 25 low PRA (<40%) B candidates in 1994 to 4 in July, 2004. 10. Blood group A candidates received 6.4% fewer transplants with our A2/A2B--> B allocation algorithm. 11. Minority patients were transplanted at the same rate when using the A2/A2B--> B allocation algorithm as when using the standard UNOS algorithm for allocating B and O kidneys--> B patients.

Arsenic, drinking water, and health: a position paper of the American Council on Science and Health.

The purpose of this American Council on Science and Health report is to review issues and sources of uncertainty affecting assessment of potential health risks related to drinking water in the United States. Some background is included on how these issues arose, as is a review of the 1999 National Research Council report (with references to an updated version), to formulate a position based on the current science concerning how much of a risk of adverse health effects actually exists from arsenic in drinking water in the United States. ACSH concludes that there is clear evidence that chronic exposure to inorganic arsenic at concentrations of at least several hundred micrograms per liter may cause: (1) cancer of skin, bladder, lung (and possibly several other internal organs, including kidney, liver, and prostate), and (2) noncancer effects, including classic cutaneous manifestations that are distinctive and characteristic of chronic arsenic poisoning (diffuse or spotted hyperpigmentation and palmar-plantar hyperkeratoses). Noncancer effects may be multisystemic, with some evidence of peripheral vascular, cardiovascular, and cerebrovascular disease, diabetes, and adverse reproductive outcomes. Further study is needed to know if beneficial effects of arsenic in animal studies apply to humans. ACSH concludes that there is little, if any, evidence of a detrimental health effect in humans from inorganic arsenic in drinking water at the current maximum contaminant level (MCL) of 50 microg/L or below, either in the United States or elsewhere. As noted in the 1999 NRC report, "No human studies of sufficient statistical power or scope have examined whether consumption of arsenic in drinking water at the current MCL results in an increased incidence of cancer or noncancer effects" (NRC, 1999, p. 7). Based on our review, described in this article, ACSH finds that the limitations of the epidemiological data available and the state-of-the-science on the mode-of-action of arsenic toxicity, including can cer, are inadequate to support the conclusion that there are adverse health effects in the United States from arsenic in drinking water at or below the limit of 50 microg/L.