Gallbladder disease in cardiac transplant patients: a survey study.

HYPOTHESIS: Preemptive cholecystectomy in cardiac transplant patients with radiographic biliary pathology reduces the morbidity and mortality of biliary tract disease following heart transplantation compared with expectant management. DESIGN AND SETTING: Institutional survey at the University of Washington, Seattle. PATIENTS: Cardiac transplant recipients between January 1, 1992, and January 1, 2001. Main Outcome Measure Clinical course of patients who were diagnosed as having biliary tract disease following heart transplantation and were managed expectantly (observed) compared with the course of patients whose conditions were diagnosed and who underwent an operation. RESULTS: Sixty (35.7%) of 168 cardiac transplant patients were evaluated for biliary tract pathologic condition. Of the 71.7% (43 of 60 patients) who had an abnormal radiographic evaluation, 46.5% (20 patients) had surgery on their biliary tract while the other patients were observed. Nine of the 23 patients who were followed up expectantly had cholelithiasis, 7 patients had gallbladder wall thickening, 5 patients had sludge in their gallbladder, and 2 had biliary dilatation. These patients were followed up for a mean +/- SD of 3.7 +/- 1.3 years; none developed biliary tract symptoms during this period. Cholecystectomies were completed for both emergent (7) and elective (14) indications. The mean +/- SD length of stay for patients who had emergent operations was 24.3 +/- 11.2 days, compared with 3.2 +/- 2.8 days for the patients who had elective operations. Seven (33%) of the 21 patients who had an operation had a significant complication and 1 patient died. CONCLUSIONS: These data suggest that the morbidity of an elective cholecystectomy in cardiac transplant patients is significant and equivalent to the morbidity associated with emergent procedures. Expectant management of patients with radiographic evidence of biliary tract pathology discovered after transplantation was safe in this series.

Single-center study of technical graft loss in 714 consecutive renal transplants.

No series has specifically focused on rates of technical failure in the kidney transplantation operation. We retrospectively examined the incidence of technical graft loss in a single kidney transplant program. A total of 714 transplants were performed, with a mean follow-up of 3.4 years (range 2-5 years). Technical graft loss was defined as graft loss within the first 2 weeks, without evidence of allograft rejection. Fourteen patients (2%) demonstrated technical graft loss, none of whom received kidneys with multiple renal arteries (n = 106 with multiple renal arteries). The incidence of technical graft loss was significantly higher in diabetic recipients (4.3% vs. 1.4%, P = 0.03). The mean donor age was significantly higher (46.7 vs. 38.1 years, P = 0.05) in patients with technical graft loss. We observed that arterial thrombosis seemed to be related to the donor (older donor significant risk P = 0.04) and that venous thrombosis seemed to be related to the recipient (four of seven patients with positive hypercoagulable workup).

Fusarium incarnatum/equiseti hemodialysis graft infection.

Hemodialysis graft infections typically occur as a result of contamination by skin flora at the time of insertion or become secondarily infected after high-grade bacteremia. Infection of implanted vascular devices with filamentous fungi is rare. We report a case of infection of an implanted polytetrafluoroethylene dialysis graft with Fusarium incarnatum/equiseti that did not grow in cultures of tissue but was identified by molecular means.

Lung physiology during ECS resuscitation of DCD donors followed by in situ assessment of lung function.

Extracorporeal cardiopulmonary support (ECS) of donors after cardiac death (DCD) has been shown to improve abdominal organs for transplantation. This study assesses whether pulmonary congestion occurs during ECS with the heart arrested and describes an in vivo method to assess if lungs are suitable for transplantation from DCD donors after ECS resuscitation. Cardiac arrest was induced in 30 kg pigs, followed by 10 min of warm ischemia. Cannulae were placed into the right atrium (RA) and iliac artery, and veno-arterial ECS was initiated for 90 min with lungs inflated, group 1 (n = 5) or deflated, group 2 (n = 3). Left atrial pressures were measured as a marker for pulmonary congestion. After 90 min of ECS, lung function was evaluated. Cannulae were placed into the pulmonary artery (PA) and left ventricle (LV). A second pump was included, and ECS was converted to a bi-ventricular (bi-VAD) system. The RVAD drained from the RA and pumped into the PA, and the LVAD drained the LV and pumped into the iliac. This brought the lungs back into circulation for a 1-hr assessment period. The oxygenator was turned off, and ventilation was restarted. Flows, blood gases, PA and left atrial pressures, and compliance were recorded. In both the groups, LA pressure was <15 mm Hg during ECS. During the lung assessment period, PA flows were 1.4-2.2 L/min. PO2 was >300 mm Hg, with normal PCO2. Extracorporeal cardiopulmonary support resuscitation of DCD donors is feasible and allows for assessment of function before procurement. Extracorporeal cardiopulmonary support does not cause pulmonary congestion, and the lungs retain adequate function for transplantation. Compliance correlated with lung function.

Single center review of femoral arteriovenous grafts for hemodialysis.

INTRODUCTION: It is unclear how to manage high risk hemodialysis patients who present with an indwelling catheter. The National Kidney Foundation Practice Guidelines urge prompt removal of the catheter, but the guidelines do not specifically address the problem of patients whose only option is a femoral arteriovenous (AV) graft. METHODS: This study was a retrospective review of all patients who underwent femoral AV graft placement for hemodialysis access between January 1, 1996 and January 1, 2003 at the University of Michigan Health System (UMHS). Graft patency is reported according to the standards developed by the Society of Vascular Surgery and the American Association of Vascular Surgeons. RESULTS: Thirty patients were identified who had undergone femoral AV graft placement. The mean follow-up was 23 months (range 1-75 months). The patients had had significant medical co-morbidities and multiple previous access operations (mean 3; interquartile range 1-5). The 1-year secondary graft patency rate was 41%, the 2-year rate was 26%, and the 3-year rate was 21%. Infection was the cause of final graft loss in eight patients (50% of the grafts losses, 27% of the total grafts placed.) Among those who died (n=14), the mean time from femoral graft placement to death was 31.2+/-27.5 months. The patient survival was quite low: at 1 year 81%, at 2 years 68%, and at 3 years 54%. CONCLUSIONS: These complex patients who have exhausted their upper extremity hemodialysis options do poorly following femoral AV graft placement. Consideration should be given to long-term catheter-based access in some of these patients.

Ex vivo ureteroscopic treatment of calculi in donor kidneys at renal transplantation.

PURPOSE: We evaluated the safety and efficacy of ex vivo ureteroscopy (ExURS) as a means of rendering the donated kidney stone-free at live donor renal transplantation. MATERIALS AND METHODS: A total of 10 suitable kidney donors with small, unilateral nonobstructive calculi underwent live donor nephrectomy (8 open flank, 2 hand assisted transperitoneal). Immediately after cold perfusion, ExURS was performed in an iced saline solution. Access to the collecting system was via the ureteral stump. Calculi were either removed with endoscopic baskets and/or completely fragmented with Holmium laser lithotripsy. RESULTS: Access to the renal collecting system was technically successful in all cases. A total of 10 stones, ranging in largest diameter from 1 to 8 mm (average 5.2) were visualized. Of the kidneys 6 had solitary stones, 2 had 2 stones and 1 had no stone. Of 10 stones 9 were successfully removed and/or fragmented with an average procedure time of 6.5 minutes (range 3 to 28). Indwelling ureteral stents were placed at transplantation in 5 of 10 kidneys. There were no intra-operative or postoperative ureteral complications. At 1 month after transplant serum creatinine ranged from 0.9 to 2.7 mg/dl (average 1.5). At a mean followup of 33.2 months new stones have not formed in any recipients and at mean 36.4-month followup no new calculi have formed in the remaining kidney of any donors. CONCLUSIONS: ExURS is a technically feasible means of rendering a stone bearing kidney stone-free without compromising ureteral integrity or renal allograft function.