Do we need a different organ allocation system for kidney transplants using donors after circulatory death?

BACKGROUND: There is no national policy for allocation of kidneys from Donation after circulatory death (DCD) donors in the UK. Allocation is geographical and based on individual/regional centre policies. We have evaluated the short term outcomes of paired kidneys from DCD donors subject to this allocation policy. METHODS: Retrospective analysis of paired renal transplants from DCD's from 2002 to 2010 in London. Cold ischemia time (CIT), recipient risk factors, delayed graft function (DGF), 3 and 12 month creatinine) were compared. RESULTS: Complete data was available on 129 paired kidneys.115 pairs were transplanted in the same centre and 14 pairs transplanted in different centres. There was a significant increase in CIT in kidneys transplanted second when both kidneys were accepted by the same centre (15.5 ± 4.1 vs 20.5 ± 5.8 hrs p<0.0001 and at different centres (15.8 ± 5.3 vs. 25.2 ± 5.5 hrs p=0.0008). DGF rates were increased in the second implant following sequential transplantation (p=0.05). CONCLUSIONS: Paired study sequential transplantation of kidneys from DCD donors results in a significant increase in CIT for the second kidney, with an increased risk of DGF. Sequential transplantation from a DCD donor should be avoided either by the availability of resources to undertake simultaneous procedures or the allocation of kidneys to 2 separate centres.

Test of long-term uterine survival after allogeneic transplantation in rabbits.

AIM: To see if: (i) a large vessel aortocaval vascular patch technique may bring about long-term graft survival after allogeneic uterine transplantation (UTn) in a rabbit model; and (ii) fertility can be achieved following natural mating post-allogeneic UTn. METHODS: Allogeneic uterine cross transplantations were performed in New Zealand white rabbits using an aortocaval macrovascular patch harvested as part of the uterine allograft. Five rabbit recipients received a uterine graft from five unrelated donor rabbits. All female rabbits were unrelated and were of proven fertility with at least one previous litter each. Tacrolimus was administrated for immunosuppression post-transplant. Natural mating was attempted if long-term survival had been achieved. The main outcome measures were: (i) long-term recipient survival; (ii) long-term adequate uterine perfusion; and (iii) successful pregnancy post-UTn. RESULTS: All five recipient animals survived the surgery with satisfactory immediate postoperative recovery. Recipients 1, 2 and 4 died within the first 4 postoperative days. Both long-term survivors failed to conceive following introduction of a proven male breeder despite evidence of mating. Necropsy at 9 and 11 months showed a lack of patency of uterine cornua at the point of anastomosis, albeit a small uterus in recipient 3 and a reddish brown amorphous material at the site of the transplanted uterus in recipient 5. CONCLUSION: We have demonstrated the feasibility of uterine allotransplantation using a macrovascular patch technique, but could not demonstrate conception because of blocked cornua. To address this, we propose using embryo transfer techniques in order to achieve conception.

Incentives for organ donation: proposed standards for an internationally acceptable system.

Incentives for organ donation, currently prohibited in most countries, may increase donation and save lives. Discussion of incentives has focused on two areas: (1) whether or not there are ethical principles that justify the current prohibition and (2) whether incentives would do more good than harm. We herein address the second concern and propose for discussion standards and guidelines for an acceptable system of incentives for donation. We believe that if systems based on these guidelines were developed, harms would be no greater than those to today's conventional donors. Ultimately, until there are trials of incentives, the question of benefits and harms cannot be satisfactorily answered.

Pediatric Kidney Transplantation in Africa: A Case Report.

This case report shows the vital importance of vigilant observation of patients after transplant. In centers where ultrasonographs are not available, exploration of the patient may be necessary to salvage a precious kidney. In the patient reported here, who received a kidney transplant at St. Nicholas Hospital in Lagos (Nigeria, Africa), reexploration resulted in an increased area for the kidney, with both improved urine output and graft function.

Laparoscopic Versus Finger-Assisted Open Donor Nephrectomy Technique: A Possible Safe Alternative.

OBJECTIVES: Despite the present use ofthe laparoscopic technique for living-donor kidney nephrectomy, a search for alternative techniques continues.The aim of this study was to compare finger-assisted open donor nephrectomy versus laparoscopic donor nephrectomy. MATERIALS AND METHODS: This study included retrospective data of 95 consecutive donors in a transplant center who were under going donor nephrectomy RESULTS: Donor demographics and clinical characteristics were generally similar between treatment groups. There were fewer female donors in the finger-assisted open donor nephrectomy treatment group (70.5% vs 29.5%; P = .003), but median body mass index was similar between groups (28 vs 26 kg/m²; P = .032). Patients who received laparoscopic donor nephrectomy had longer operative duration (3.5 vs 1.2 h; P < .001), longer combined length of incision (6 vs 5 cm; P = .001), andshorter median hospital length of stay (3 vs 4 days; P < .001). A left nephrectomy was preferred in both groups. Minor postoperative complications occurred less often in the finger-assisted open donor nephrectomy group (14.7% vs 31.6%; P = .0094). Donors who received laparoscopic nephrectomy had lower glomerular filtration rate at 1 year after donation (60 vs 89 mL/min/1.73 m²; P < .001) than donors who received finger-assisted nephrectomy. However, recipients of donors of both procedures had similar glomerular filtration rate at 1 year after transplant (65 vs 69 mL/min/1.73 m²; P = .5). CONCLUSIONS: Our study demonstrated that finger-assisted open donor nephrectomy is a successful and safe alternative versus laparoscopic donor nephrectomy, providing favorable results for patients in terms of complications and outcomes.

In transition: current health challenges and priorities in Sudan.

A recent symposium and workshop in Khartoum, the capital of the Republic of Sudan, brought together broad expertise from three universities to address the current burden of communicable and non-communicable diseases facing the Sudanese healthcare system. These meetings identified common challenges that impact the burden of diseases in the country, most notably gaps in data and infrastructure which are essential to inform and deliver effective interventions. Non-communicable diseases, including obesity, type 2 diabetes, renal disease and cancer are increasing dramatically, contributing to multimorbidity. At the same time, progress against communicable diseases has been slow, and the burden of chronic and endemic infections remains considerable, with parasitic diseases (such as malaria, leishmaniasis and schistosomiasis) causing substantial morbidity and mortality. Antimicrobial resistance has become a major threat throughout the healthcare system, with an emerging impact on maternal, neonatal and paediatric populations. Meanwhile, malnutrition, micronutrient deficiency and poor perinatal outcomes remain common and contribute to a lifelong burden of disease. These challenges echo the United Nations (UN) sustainable development goals and concentrating on them in a unified strategy will be necessary to address the national burden of disease. At a time when the country is going through societal and political transition, we draw focus on the country and the need for resolution of its healthcare needs.

Anaemia and congestive heart failure early post-renal transplantation.

BACKGROUND: Anaemia is common following renal transplantation and is associated with the development of congestive heart failure (CHF). However the prevalence of anaemia in the first year following transplantation and the association between anaemia occurring early and the development of CHF have been understudied. METHODS: In this study, 132 incident patients undergoing tacrolimus and mycophenolate mofetil-based renal transplantation were studied for the prevalence of, and risk factors for, anaemia and CHF in the early period post transplantation. RESULTS: Anaemia occurred in 94.5% and 53.1% of patients at 1 week and 12 months, respectively, and was associated with allograft dysfunction, hypoalbuminaemia, higher mycophenolic acid (MPA) levels, bacterial infection and hypoalbuminaemia. The association with hypoalbuminaemia may reflect the presence of chronic inflammation post-transplantation. Of patients displaying haemoglobin <11 g/dl, 41.1% and 29.4% were treated with erythropoiesis stimulating agents (ESAs) at 1 and 12 months respectively. CHF developed in 26 patients beyond 1 month post-transplantation, with echocardiographic left ventricular systolic function preserved in all but one. CHF was associated with anaemia and lower haemoglobin, allograft dysfunction, duration of dialysis and left ventricular hypertrophy on echocardiography prior to transplantation, suggesting the aetiology of CHF may involve the interplay of diastolic cardiac dysfunction, pre-load mismatch and after-load mismatch. CONCLUSIONS: Modification of risk factors may improve anaemia management post transplantation. Reducing the prevalence of anaemia may in turn reduce the incidence of CHF-these observations support the need for clinical trials to determine how anaemia management may impact CHF incidence.

Distal transplant pancreatectomy during SPK: successful clinical outcome.

Simultaneous pancreas and kidney transplantation (SPK) is considered an extremely effective and well-established therapeutic option for selected patients with end-stage renal disease (ESRD), secondary to type 1 diabetes. Vascular complications in pancreas transplantation are more common than in any other solid organ transplant. Thrombosis is the most frequently observed surgical complication of pancreatic transplantation. We report a case of a successful management regarding the thrombosed distal pancreatic segment during SPK transplantation.

Autogenous brachio-cephalic arterio-venousautogenous brachio-cephalic arterio-venous fistulae: effect of age, diabetes,fistulae: effect of age, diabetes, atherosclerosis, and anticoagulation on theatherosclerosis, and anticoagulation on the long-term outcomelong-term outcome.

Age, diabetes, and generalized atherosclerosis are thought to be limiting factors forAge, diabetes, and generalized atherosclerosis are thought to be limiting factors for creating an autogenous arterio-venous fistula (AVF) unlike the use of anticoagulants. Wecreating an autogenous arterio-venous fistula (AVF) unlike the use of anticoagulants. We retrospectively assessed the effect of these factors on the outcome of 75 autogenousretrospectively assessed the effect of these factors on the outcome of 75 autogenous brachio-cephalic AVFs created between January 1, 2002 and August 31, 2005. Differentbrachio-cephalic AVFs created between January 1, 2002 and August 31, 2005. Different groups of patients were compared and the longevity of the AVFs was calculated. Fifty-twogroups of patients were compared and the longevity of the AVFs was calculated. Fifty-two percent of the patients were >65 years old, 41.3% werepercent of the patients were >65 years old, 41.3% were diabetic, 48% were arteriopaths,diabetic, 48% were arteriopaths, and 41.3% were not using anticoagulants. The maximum follow-up was 35 months (mean,and 41.3% were not using anticoagulants. The maximum follow-up was 35 months (mean, 11.2 +/- 10.3 months; median, 7 months). The success rate of the operation was 93.3% (mean 11.2 +/- 10.3 months; median, 7 months). The success rate of the operation was 93.3% (70 patent AVFs); 79.3% of the AVFs were functioning at 35 months. Age >65 years old,patent AVFs); 79.3% of the AVFs were functioning at 35 months. Age >65 years old, diabetes, generalized atherosclerosis, and the lack of use of anticoagulants were notdiabetes, generalized atherosclerosis, and the lack of use of anticoagulants were not associated with an increased rate of technical failures or a decreased long-term patencyassociated with an increased rate of technical failures or a decreased long-term patency rate of the AVFs.rate of the AVFs.

Esophageal squamous cell carcinomas and expression of p53, Bcl-2, and Bcl-X(L).

p53 protein promotes apoptosis, whereas Bcl-2 family proteins have an antiapoptotic function. This study determines the predictive value of selected clinical and histopathological factors in correlation with the expression of p53, Bcl-2, and Bcl-X(L) proteins in esophageal squamous cell carcinomas (SCCs). Paraffin-embedded sections from 19 surgically resected primary esophageal SCCs were examined by immunohistochemistry. p53 expression was related to degree of tumor differentiation (P = 0.044). Bcl-2 expression was associated with regional lymph node metastasis (P = 0.053), whereas Bcl-X(L) expression was correlated with distant metastasis (P = 0.060) and with the expression of Bcl-2 protein (P = 0.068). p53 and Bcl-2 family proteins may help to estimate the properties of esophageal SCCs and provide useful information to the oncologist for the selection of patients for intensive combined therapy modalities with curative intention or for palliative therapy.

Uterine allotranspiantation in the rabbit model using a macrovascular patch technique.

The uterus and its blood supply en bloc were successfully harvested with an aortic-caval macrovascular patch in animal and human cadaveric models. The objective of this study was to assess the technical feasibility of uterine allotransplantation in the rabbit. Six uterine allotransplants were performed. This involved harvesting the uterine allograft with an aortic-caval vascular patch en bloc in the donor. After 1 hour of cold ischemic storage, the uterine allograft was transplanted to the recipient using an aortic-aortal cava-caval end to side anastomosis. Our 6 rabbit recipients surgically survived the procedure. After postmortem and histological analyses in the short term, all of the uteri appeared viable with no evidence of graft vessel thromboses. Postoperative complications included limb paraplegia, pulmonary emboli, and intraperitoneal hemorrhage. The feasibility of uterine allotransplantation using a macrovascular patch, in anatomical and surgical terms, has been proven. Further research will lead to a successful program of fertility restoration.

Relationship between vessel size and vascular access patency based on preoperatively ultrasound Doppler.

Vascular access is a critical issue in the management of patients with end-stage renal failure and is the leading cause of hospitalization in this group of patients. The object of this study was to find out whether it would be possible to predict vascular access patency rates based on preoperative Doppler assessment of vessel size. Furthermore, this study sought to define the relationship between access flow rate and access patency. This was a prospective cohort conducted at St. Mary Hospital, London, between 2002 and 2005, where a group of 83 patients who underwent venous and arterial Doppler prior to creation of arteriovenous access underwent regular postoperative assessment at 3-month intervals of their access using flow rate and usability of the access as outcome measures. The collected data showed a positive correlation between vein size and access patency rate. Preoperative vein diameters of 1.5-3.9 mm showed a patency rate of 71.08% at follow-up at 13.8 months (range, 12-42 months). Although large-sized vessels are correlated with long-term patency, smaller vein diameters (1.5-2 mm) were found to have an acceptable patency rate at 20% over 12 months. Furthermore, data indicated a positive correlation between access flow rate and access patency, with flow rates of above 700 ml/min being associated with a patency rate of 70% at 12-month follow-up.

Apoptosis and adenocarcinoma of the cardia: expression of p53, Bcl-2, Bcl-XL, WAF1, and fas proteins and association with characteristics of the tumors.

Our knowledge regarding the biology of the gastroesophageal junction adenocarcinomas is still incomplete. Paraffin-embedded sections from 31 surgically resected primary cardia adenocarcinomas were examined by immunohistochemistry. Statistical analysis showed that Bcl-2 expression was significantly correlated with the age of the patients (P = 0.043), whereas Bcl-X(L) expression was inversely correlated with Bcl-2 expression (P = 0.021). An inverse correlation of high statistical significance was also found between p53 and Bcl-2 expression (P = 0.000). Fas expression was highly correlated with tumor stage (P = 0.006), degree of differentiation (P = 0.044), and the stage of the disease (P = 0.029). A significant correlation was also observed between the expression levels of WAF1 and Fas (P = 0.037), Fas and Bcl-X(L) (P = 0.018), and WAF1 and p53 (P = 0.018). These proteins may contribute to the estimation of the properties of adenocarcinomas of the gastroesophageal junction, facilitating prognosis of cancer patients treated by multimode therapy.

End-stage vascular access: direct intra-atrial insertion of a dialysis catheter.

Central venous occlusions are a frequent problem in hemodialysis patients. We describe the case of a patient with end-stage vascular access in whom we successfully inserted a direct intra-atrial dialysis line during coronary artery bypass grafting. This technique could be a significant contribution to patients in whom alternative vascular access options are exhausted.

Justifying a third pancreas transplant: a case report.

Early pancreas graft failure after simultaneous pancreas-kidney transplant can occur in up to 20% of recipients. Results after pancreas retransplant continue to improve, with results comparable to primary pancreas transplants. We describe an unusual case of a third pancreas transplant in which a remnant of a previous arterial Y-graft was used for the arterial anastomosis, and we discuss the factors used to justify the decision to do a third pancreas transplant.

Salvage of Pancreas Transplant After Successful Splenic Artery Thrombectomy.

Primary nonfunction due to thrombosis after pancreas transplant is still the leading cause of nonimmunologic graft failure. Early identification of pancreatic graft arterial thrombus and prompt surgical intervention are effective for rescue of graft perfusion and its associated complications. Here, we report a case of successful surgical thrombectomy of the splenic artery, with particular emphasis on clinical presentation, diagnosis, and surgical technique.

Vascular access in lipoprotein apheresis: a retrospective analysis from the UK's largest lipoprotein apheresis centre.

INTRODUCTION: Lipoprotein apheresis (LA) has proven to be an effective, safe and life-saving therapy. Vascular access is needed to facilitate this treatment but has recognised complications. Despite consistency in treatment indication and duration there are no guidelines in place. The aim of this study is to characterise vascular access practice at the UK's largest LA centre and forward suggestions for future approaches. METHODS: A retrospective analysis of vascular access strategies was undertaken in all patients who received LA treatment in the low-density lipoprotein (LDL) Apheresis Unit at Harefield Hospital (Middlesex, UK) from November 2000 to March 2016. RESULTS: Fifty-three former and current patients underwent 4260 LA treatments. Peripheral vein cannulation represented 79% of initial vascular access strategies with arteriovenous (AV) fistula use accounting for 15%. Last used method of vascular access was peripheral vein cannulation in 57% versus AV fistula in 32%. Total AV fistula failure rate was 37%. CONCLUSIONS: Peripheral vein cannulation remains the most common method to facilitate LA. Practice trends indicate a move towards AV fistula creation; the favoured approach receiving support from the expert body in this area. AV fistula failure rate is high and of great concern, therefore we suggest the implementation of upper limb ultrasound vascular mapping in all patients who meet treatment eligibility criteria. We encourage close ties between apheresis units and specialist surgical centres to facilitate patient counselling and monitoring. Further prospective data regarding fistula failure is needed in this expanding treatment field.

Five years of steroid sparing in renal transplantation with tacrolimus and mycophenolate mofetil.

Steroid sparing with tacrolimus and mycophenolate mofetil (MMF) is associated with good short-term renal transplant outcomes. However, late allograft dysfunction and failure remain concerns. In this study, 101 consecutive patients underwent renal transplantation with tacrolimus, MMF, and 7 days of corticosteroids only. After a median follow-up of 51 months (range 36-62), overall patient survival is 97%, and overall survival with graft function is 91%. The acute rejection rate at 12 months was 19%. Late rejection was uncommon, with only three further episodes beyond 12 months. Graft function was stable during the study, with a mean creatinine of 140 micromol/L and mean estimated creatinine clearance of 57 ml/min at the end of follow-up. Six patients developed posttransplant diabetes mellitus (three cases beyond 12 months). This steroid avoidance regimen is associated with excellent medium-term patient and graft outcomes, and a low incidence of side effects.

Graft pancreatitis: literature review.

Graft pancreatitis is an inflammatory disease leading to autodigestion of the gland. The failure of the pancreatic graft can be attributed to immunological or nonimmunological causes. It consists of a premature activation of pancreatic proenzymes. When complications such as bleeding or leaks have already occurred, surgical correction should be considered. The aim of this review is to draw the attention of surgeons to the complications that can easily be avoided.