Warm ischemic time during laparoscopic live donor nephrectomy: effects on graft function.

BACKGROUND: Laparoscopic live donor nephrectomy (LDN) has become established as a safe and effective alternative to the open procedure. However, the effect of prolonged warm ischemia time (WIT) during retrieval of the kidney remains unclear. The aim of this study was to analyze the effects of WIT on short-term and long-term graft outcomes after LDN. METHOD: In this retrospective analysis of LDN the effects of WIT on delayed graft function, rate of decline in serum creatinine concentration (SCr) in the first 10 days, changes in SCr at 3 months, acute rejection rate changes in Delta creatinine, biopsy-proved chronic allograft rejection and graft survival were assessed according to duration of WIT. Analysis was made by comparing WIT < or =3 versus >3 minutes and WIT <5, 5-10, and >10 minutes. RESULTS: The WIT, which ranged from 1 to 15 minutes, appeared to be related to the learning curve and to technical difficulties. Prolonged WIT did not appear to have an effect on early graft function or the rate of decline in SCr during the first 3 months posttransplantation, but may be associated with an increased rate of acute rejection. Changes in Delta creatinine over time were not affected by the length of WIT during LDN. CONCLUSION: WIT encountered during LDN has no effect on either short-term or long-term graft outcome.

Routine use of renal-dose dopamine during living donor nephrectomy has no beneficial effect to either donor or recipient.

BACKGROUND: The use of dopamine as a renoprotective agent in kidney transplantation remains unclear. Some reports suggest that dopamine improves initial graft function and survival, while others have failed to demonstrate a beneficial effect. Our live-donor nephrectomy program is serviced by 2 senior anesthetists, one who routinely uses dopamine and the other who considers that current evidence does not support a renoprotective effect of dopamine in laparoscopic donor nephrectomy. PURPOSE: We aimed to study the renoprotective effect on donor and recipient renal function of renal-dose dopamine during laparoscopic live-donor nephrectomy (LDN). METHODS: A retrospective analysis was performed of 59 live donor and recipient pairs between 1999 and 2004. Donors were grouped according to whether they received dopamine infusion during LDN. All donors received Hartmann solution to maintain the central venous pressure at 12 mm Hg. The percentage change in serum creatinine (SCr) in both donors and recipients was compared at day 1, day 7, and week 6. RESULTS: In the donors, dopamine infusion had no effect on the mean percentage rise in SCr at day 1 or the mean percentage decrease in SCr at week 6. At day 7, however, patients who received dopamine had a significantly greater decrease in SCr compared with those who did not. In the recipients, there was no significant difference in the mean percentage decrease in SCr at days 1 or 7 or at week 6. Analysis at 1 year revealed no significant difference in sCr among the groups of donors and recipients. CONCLUSIONS: The intraoperative use of renal-dose dopamine during LDN seems to have no beneficial effect for either donor or recipient.

Impact of cyclosporin on the incidence and prevalence of chronic rejection in renal transplants.

Over a 14-year period, 435 patients underwent renal transplantation. Chronic rejection has occurred in 58 (13%) of all grafts and has accounted for 18% of all graft losses. After the first 6 months following transplantation, chronic rejection was the most common cause of graft failure, accounting for 40% of losses. The median time (interquartile range) from transplantation to graft failure was 3 years (2-5.5 years). Comparison of azathioprine versus cyclosporin treated patients showed no significant difference in the incidence of graft loss (Cox regression score 2.55, P = 0.11). Furthermore, there were significantly more grafts with deteriorating function owing to chronic rejection in cyclosporin-treated patients (n = 16, 11% of surviving grafts) than in azathioprine-treated patients (n = 2, 3% of surviving grafts). These data suggest that cyclosporin does not prevent the development of chronic rejection in renal transplants.

A randomized placebo-controlled study of enalapril in the treatment of erythrocytosis after renal transplantation.

BACKGROUND: Erythrocytosis is a common complication of renal transplantation with an incidence of up to 17%. It is associated with an increased risk of complications due to thromboembolic events and has traditionally been treated by intermittent venesection. More recently, angiotensin-converting enzyme inhibitors have been shown to cause a fall in haematocrit in a number of groups of subjects and some uncontrolled studies have shown these drugs to be of possible therapeutic benefit in post renal transplant erythrocytosis. METHODS: We performed a randomized double-blind placebo-controlled study in 25 patients with post-transplant erythrocytosis. Subjects received either 2.5 mg of enalapril daily or a placebo for 4 months and all patients completed the study period without any serious adverse effects. RESULTS: Haematocrit fell from 52.7 (+/- SEM 0.7) to 47.1 (+/- 1.8) at 1 month and 46.1 (+/- 1.2) after 4 months in patients receiving enalapril, with no change in the placebo group (P = 0.004). We did not demonstrate any change in serum erythropoietin in either group. CONCLUSIONS: Angiotensin-converting enzyme inhibitors are a safe and effective form of treatment for erythrocytosis developing after renal transplantation. The mechanism of action, however, is not mediated by changes in erythropoietin production and remains uncertain.

Traumatic arteriovenous fistula of the superficial temporal vessels: a case for protective headgear when playing squash?

A 35 year old semiprofessional squash player developed the symptoms and signs of an arteriovenous fistula of the left superficial temporal vessels after a squash ball injury. This was sufficiently symptomatic to halt his intensive training programme and required exploration, ligation and excision. Although a rare injury from any cause this would have been prevented by protective headgear.

Renal transplantation: current status, complications and prevention.

Renal transplantation is the ideal mode of renal replacement therapy. One-, 5- and 10-year graft survival rates are currently > 85%, 60-70% and 40-50%, respectively. Graft loss in the first year is predominantly due to vascular complications, acute rejection, and death with a functioning graft. Other significant causes of early graft dysfunction are urological complications, delayed graft function and drug-induced nephrotoxicity. Subsequently, graft loss is due to chronic rejection or death with a functioning graft secondary to cardiovascular disease, malignancy and infection. Renal artery stenosis, chronic cyclosporin nephrotoxicity and recurrent disease also contribute to late graft dysfunction. The immunosuppressed renal transplant recipient is at long term risk of infection and neoplasia.

Cytomegalovirus infection in renal transplantation.

Three case reports of Cytomegalovirus (CMV) disease in seronegative renal transplant recipients of seropositive donor kidneys are presented. Clinicians need to have a high index of suspicion for CMV disease in such patients. Early diagnosis and treatment are essential to decrease morbidity and mortality. Prophylaxis with antiviral and/or CMV-hyperimmunoglobulin may decrease the incidence of serious infection.

Cytomegalovirus infection in renal transplantation

Three case reports of cytomegalovirus (CMV) disease in seronegative renal transplant recipients of seropositive donor kidneys are presented. Clinicians need to have a high index of suspicion for CMV disease in such patients. Early diagnosis and treatment are essential to decrease morbidity and mortalitiy. Prophylaxis with antiviral and/or CMV-hyperimmunoglobulin may decrease the incidence of serious infection (AU)

Cytomegalovirus infection in renal transplantation

Three case reports of cytomegalovirus (CMV) disease in seronegative renal transplant recipients of seropossitive donor kidneys are presented. Clinicians need to have a high index of suspicion for CMV disease in such patients. Early diagnosis and treatment are essential to decrease morbidity and mortalitiy. Prophylaxis with antiviral and/or CMV-hyperimmunoglobulin may decrease the incidence of serious infection

The value of posttransplant monitoring of interleukin (IL)-2, IL-3, IL-4, IL-6, IL-8, and soluble CD23 in the plasma of renal allograft recipients.

Over the past few years, the central role of cytokines in the amplification of the immune response has been reported and several studies have examined the relationship between the plasma level of individual lymphokines during renal allograft rejection. The aim of the present investigation was to study simultaneously IL-2, IL-3, IL-4, IL-6, IL-8, and soluble CD23. Analysis of results has allowed both the prognostic value and any possible interrelationships between the measured cytokines to be determined. We studied 16 renal transplant recipients for the first 14 days after transplantation. Seven patients showed clinical evidence of acute allograft rejection and 5 showed excellent stable graft function with no signs of rejection. Primary nonfunction was seen in 4 patients. The plasma levels of each cytokine were measured by commercially available ELISA and immunoradiometric assay kits. As reported in previous studies, plasma IL-2 levels, whenever found at detectable levels, were predictive of impending graft rejection. Serial monitoring of IL-4 and IL-6 was more reliable for the differential diagnosis of rejection, particularly toward the end of the first week after transplantation. IL-3, IL-8, and soluble CD23 were not diagnostic or predictive of rejection, due to the occurrence of significantly high levels in transplant patients who showed no evidence of clinical rejection. While the value of cytokine monitoring has been shown in this study, it should be remembered that infection, although not seen in these studies, may have a profound affect on the results obtained.

Renal allograft rejection: the temporal relationship and predictive value of plasma TNF (alpha and beta), IFN-gamma and soluble ICAM-1.

Recently, close interactions have been described between the tumour necrosis factors alpha and beta (TNF-alpha and beta), interferon-gamma (INF-gamma) and intercellular adhesion molecule-1 (ICAM-1) in T-cell mediated immune activation. During the process of renal graft rejection, the properties of these cytokines to act as powerful stimulators of macrophages, to upregulate class II MHC expression and to stabilise cell-to-cell binding make them of great potential interest. The aim of the present study was to determine the plasma levels of each cytokine and soluble ICAM-1 in 16 renal allograft recipients. We examined plasmas of patients for the first 2 weeks after transplantation and correlated results with the clinical pattern of rejection. Our data suggest an immunopathologic involvement of TNF-alpha, TNF-beta and slCAM-1 in renal allograft rejection and showed that there was a significant elevation in plasma concentrations of these parameters 2 or 3 days prior to the diagnosis of clinical rejection. Rises in INF-gamma did not appear to be significant with regard to rejection as very high levels were found in patients showing no evidence of clinical rejection.

Characterization of donor-directed antibody class in the post-transplant period using flow cytometry in renal transplantation.

Over the past few years there has been increasing awareness of the importance of humoral mechanisms in the rejection of renal transplants. In this study we have monitored the development of antibodies directed against donor T and B lymphocytes using the sensitive flow cytometric technique. Forty-two cadaveric renal transplants were studied both before and for a maximum of 14 days after transplantation. Donor cells were separated from spleen on the day of transplantation and stored in liquid nitrogen until required. The dual colour flow cytometric assay was used to detect IgG or IgM directed against donor T or B lymphocytes. Using AB sera as controls, results were expressed as relative median fluorescence (RMF) and then correlated with the clinical performance of the grafts. Significant associations were found between the incidence of donor-directed antibodies and the development of clinical rejection. The magnitude of the rise in antibody levels was also related to graft performance. In patients showing severe graft rejection, high levels of antibodies of the IgG class developed before the clinical diagnosis of rejection was made. The routine use of this test allows the prediction of impending severe rejection to be made and may have important implications for immunosuppressive therapy.

Urological complications following renal transplantation. A study of 1016 consecutive transplants from a single centre.

A total of 1016 consecutive renal transplants performed between 1976 and 1990 were analysed retrospectively to determine the incidence of urological complications and possible predisposing factors. Some 189 episodes of ureteric obstruction and/or urinary leak occurred in 143 patients (overall incidence 14.1%). The median annual rate of urinary leak was 5.1%; that of ureteric obstruction was 4.5% pre-1986 and 16.1% post-1986. Sixty-three episodes of urinary leak occurred in 54 patients from 1 day to 3 months post-transplant and 60% involved the distal ureter. Thirty were treated primarily by reconstructive surgery, ten required nephrectomy and three died of associated sepsis. A total of 126 episodes of ureteric obstruction occurred in 104 patients from 1 day to 12 years post-transplant and 86% involved the distal ureter. Prior to 1986, 10/11 patients with ureteric obstruction were treated by reconstructive surgery, but since then 88 (95%) have been treated by percutaneous nephrostomy, with or without stenting, with only one graft lost and no deaths. Children had a significantly increased incidence of ureteric obstruction (P < 0.001) whilst male recipients had an increased incidence of urinary leak (P = 0.04). More patients with ureteric obstruction than those without had two or more episodes of rejection (P = 0.03). No single cause for the increased incidence of ureteric obstruction since 1986 has been identified. Continued attention to technical detail and further study of this trend is warranted.