Organ donation following the circulatory determination of death (DCD): an audit of donation and outcomes following renal transplantation.

Organ Donation following the Circulatory determination of Death was introduced in Beaumont Hospital during 2011. The Intensive Care Society of Ireland formally endorsed a national DCD clinical practice guideline in 2012. This retrospective audit covers a 2-year period during which eleven patients were considered suitable for DCD and where consent was obtained. Nine patients died within the ninety-minute period following the withdrawal of life sustaining therapies and subsequently donated organs (82%). Eighteen kidneys were recovered and seventeen patients received renal transplants--one patient received a nephron-dosing dual renal transplant. Lungs were recovered on two occasions and one patient received a lung transplant. Heart valves were recovered on one occasion. To date sixteen of seventeen recipient patients have functioning renal transplants (94%). In conclusion, this model of deceased donation has proven acceptable to families, nursing and medical staff and the outcomes reported are consistent with international best practice.

Autotransplantation of a single functioning kidney following rupture of renal artery aneurysm.

Renal artery aneurysms (RAA) are the second most common visceral artery aneurysm. In cases of rupture they pose a significant and emergent surgical challenge. Extracorporeal arterial reconstruction and autotransplantation is often necessary in certain complex cases that are not amenable to aneurysm repair in vivo. We report a case of a 35 year old female with a RAA in a solitary functioning kidney, requiring ex vivo reconstruction and autotransplantation to the iliac vessels.

A review of inpatient urology consultations in an Irish tertiary referral centre.

INTRODUCTION: Our institution is a 680-bed tertiary referral centre with broad medical and surgical subspecialty services. We retrospectively audited the pattern of inpatient consultations from all specialities within our institution to the urology department over a 1-year period. METHODS: All consultations to the urology service were identified from our computerised inpatient consultation system from July 2010 to June 2011. Follow up data on investigations, interventions and subsequent outpatient appointments were also identified by review of individual patient discharge letters. RESULTS: Seven hundred and twenty five inpatient consultations were received over the period. The male to female ratio was 7:3. Mean age of patients was 66 (15-96) years. Seventy three percent of referrals were from medical sub-specialities, most commonly nephrology (17%), gastroenterology (11%) and respiratory medicine (9%). The remainder were from general surgery (16%) and other surgical sub specialities (11%). Interns (66%) and senior house officers (SHO) (28%) communicated the majority of consults. Male lower urinary tract/benign prostate related issues resulted in 25% of all consultations. Less than half of consults (47%) resulted in interventions initiated by urology, most commonly of which were catheter insertions (48%) and endoscopic procedures (35%). Only 43% of consultations were followed up in the outpatients setting. CONCLUSIONS: Inpatient consultations constitute a significant workload for urology services. The majority of these referrals did not require any urological intervention and could have been seen routinely in the outpatient setting. Providing structured referral guidelines and achieving better communication with referring teams may help to optimise this service.

Higher tacrolimus trough levels on days 2-5 post-renal transplant are associated with reduced rates of acute rejection.

We analyzed the association between whole-blood trough tacrolimus (TAC) levels in the first days post-kidney transplant and acute cellular rejection (ACR) rates. Four hundred and sixty-four consecutive, deceased-donor kidney transplant recipients were included. All were treated with a combination of TAC, mycophenolate mofetil and prednisolone. Patients were analyzed in four groups based on quartiles of the mean TAC on days 2 and 5 post-transplant: Group 1: median TAC 11 ng/mL (n = 122, range 2-13.5 ng/mL), Group 2: median 17 ng/mL (n = 123, range 14-20 ng/mL), Group 3: median 24 ng/mL (n = 108, range 20.5-27 ng/mL) and Group 4: median 33.5 ng/mL (n = 116, range 27.5-77.5 ng/mL). A graded reduction in the rates of ACR was observed for each incremental days 2-5 TAC. The one-yr ACR rate was 24.03% (95% CI 17.26-32.88), 22.20% (95% CI 15.78-30.70), 13.41% (95% CI 8.15-21.63) and 8.69% (95% CI 4.77-15.55) for Groups 1-4, respectively (p = 0.003). This study suggests that higher early TACs are associated with reduced rates of ACR at one yr.

Complications of renal transplantation in patients with amyloidosis.

OBJECTIVE: Renal transplantation in patients with end-stage renal failure (ESRF) secondary to amyloidosis carries a high risk of postoperative complications. Preoperative investigations are crucial for a successful perioperative course. There are limited data studying the outcome of patients with amyloid nephropathy who undergo renal transplantation. Therefore, we undertook this retrospective review of our experience to highlight the difficulties. MATERIALS AND METHODS: Thirteen patients with AA amyloid-induced ESRF underwent cadaveric renal transplantation from 1985 to 2001 in the Irish transplant population. The perioperative course of these patients was compared to an age-matched control group of 142 nonamyloid patients who had cadaveric renal transplantation during the same time period. Both groups were followed annually for 5 years. RESULTS: The 1- and 5-year patient survival rates were 69% and 69% in the amyloid as compared with 97% and 87% for the control group. In the amyloid group, early death was primarily due to cardiac causes followed by complications of sepsis. Graft survival at 1 and 5 years was 56% and 56% in the amyloid group as compared with 87% and 59% in the control group (P = .0027). Four deaths with a functioning graft contributed to the early graft losses. CONCLUSION: Increased complications, especially cardiac, are noted post-renal transplantation among patients with renal amyloidosis. However, appropriate guideline, for the perioperative management of these patients has yet to be established.

Survival and progression in high grade tumour subset of G2 and G3 pT1 bladder transitional cell carcinoma.

AIMS: The newer 1998 WHO/ISUP grading system for bladder transitional cell carcinoma combined grade 3 (G3) and high grade tumour subset of grade 2 (G2) of the older 1973 WHO grading system into one homogenous high grade group. We evaluated for possible differences in survival and progression between these 2 grades in pT1 bladder tumours. METHODS: From Jan 1(st) 1991-Dec 31(st) 2003, 105 (61 G2 and 44 G3) pT1 bladder tumours fulfilled the 1998 WHO/ISUP high grade criteria. Survival and progression of these tumours were assessed. RESULTS: Of the 44 patients with G3 tumours, 20 are alive versus 22 of the 61 patients with high grade tumour subset of G2 (P=0.04). Of the 44 patients with G3 tumours, 13 progressed versus 12 of the 61 patients with high grade tumour subset of G2 (P=0.02). In multivariate analysis, G3 was a significant predictor of tumour progression (P=0.05) and marginally non-significant predictor of poor patient survival (P=0.056). CONCLUSIONS: A notable difference in survival and progression between high grade tumour subset of G2 and G3 is observed.

Renal artery aneurysm treated with ex vivo repair and autotransplantation.

Renal artery aneurysms are being encountered more frequently due to a wider use of angiography. As the risk of rupture is unclear, the indications for surgery remain controversial. Despite advances in treatment, complex aneurysms often require nephrectomy for adequate excision. We report a case of an incidentally diagnosed renal artery aneurysm successfully treated with extracorporeal repair and autotransplantation. Ex vivo repair and renal autotransplantation is a safe and effective treatment for the management of complex renal artery aneurysms

Single centre experience of hypothermic machine perfusion of kidneys from extended criteria deceased heart-beating donors: a comparative study.

INTRODUCTION: Kidneys from extended criteria donors are associated with higher rates of delayed graft function (DGF). Hypothermic machine perfusion (MP) for storage is associated with more favourable outcomes. METHODS: A retrospective analysis was performed in 93 patients where the kidney was stored using hypothermic MP (LifePort(®)) and compared to an age-matched control group where the kidney was stored in cold static storage (CSS) using University of Wisconsin solution. RESULTS: Median age was similar in both groups (59.2 years in MP vs 59.9 years in CSS, p = 0.5598). Mean cold storage time was 15.6 h in MP vs 17.9 h in CSS. Post transplant mean serum creatinine was as follows; MP group-144.7 µmol/L at 1 month; 138.3 µmol/L at 3 months and 129.5 µmol/L at 12 months. In the CSS group-163 µmol/L at 1 month; 154.9 µmol/L at 3 months and 140.2 µmol/L at 12 months. There was a statistically significant difference at 1 month (p = 0.0096) and 3 months (p = 0.0236). DGF was defined as the need for haemodialysis within 7 days post transplant. In the MP group, DGF occurred in 17.2 % patients with mean of 6 days (range 1-18). In the CSS group, 25.8 % patients with mean of 8.1 days (range 3-25). One-year graft survival rate was better in the MP group (97.85 vs 96.77 %). CONCLUSION: Our experience to date recommends the use of hypothermic MP for storage of kidneys from extended criteria deceased heart-beating donors.

Cadaveric kidney transplantation in children < or =20 kg in weight: long-term single-center experience.

BACKGROUND: We report long-term follow-up data on cadaveric kidney transplantation in children < or =20 kg in weight. METHODS: Between January 1990 and October 2003, we performed 19 cadaveric renal transplants in 19 children < or =20 kg in weight. Mean age at transplantation was 4.7 years (range 18 months to 9 years). Mean weight at transplantation was 14.4 kg (range 9 to 20 kg). Nine patients had preemptive kidney transplantation, whereas 10 were maintained on renal replacement therapy before the transplant operation. RESULTS: Actuarial 1-, 3-, 5-, and 10-year patient survival rates were 89.5%, 89.5%, 89.5%, and 82%, respectively. Actuarial 1-, 3-, 5-, and 10-year graft survival rates were 79%, 73%, 73%, 65%, respectively. Three patients died. Eight grafts failed. Cause of graft failure was death with a functioning graft in 3 patients, chronic rejection in 1, acute cellular rejection in 1, vascular rejection in 1, hemolytic-uremic syndrome in 1, and unknown in 1. CONCLUSIONS: Our results indicate the success of cadaveric kidney transplantation in the very small child with results comparable to living related donor transplantation.

Long-term outcome of cadaveric pediatric en bloc transplantation--a 15-year experience.

Pediatric en bloc transplantation of infant organs into adult recipients is a recognized technique to expand the number of kidneys available for transplantation. We reviewed our experience with this technique over a 15-year period to determine the long-term outcomes. Twelve patients underwent pediatric en bloc transplantation from donors aged <4 years. All transplants functioned immediately with no graft thrombosis. Two patients died 12 and 10 years posttransplant with functioning grafts. The remaining 10 recipients experienced excellent graft function with a mean follow-up time of 73.8 months (range, 10 to 169 months) with no evidence of hyperfiltration injury. We conclude that pediatric en bloc transplantations achieve excellent long-term allograft function in selected recipients.

Treatment limitations in nursing homes in northwest Ohio.

Eighty-eight nursing homes in northwest Ohio were surveyed by telephone regarding the acceptance of "do not resuscitate" (DNR) and "do not hospitalize" (DNH) orders. Written protocols addressing these issues were requested, if available. Eighty-three of the 88 homes participated in the survey. Seventy-five percent of nursing homes accept DNR orders, while 35% accept DNH orders. The most common qualifying condition for a DNR/DNH order was the approval of the family. Although 32 homes stated that they have written protocols, only eight were made available for review. The authors concluded that DNR orders are widely accepted in nursing homes in northwestern Ohio. However, DNH orders are less likely to be accepted in northwest Ohio long-term facilities and the use of written protocols is even more limited.

Multi organ transplantation: a review of the Irish experience.

As the criteria for organ transplantation have broadened, multi organ transplantation has become more common. Calcineurin inhibitor induced end stage renal failure is a common indication for kidney transplantation. We present our experience of 12 kidney transplants, in 11 patients, over a period of 9 years all in the setting of multi-organ transplantation. Kaplan-Meier survival estimates were applied. Estimated patient survival at 1, 3 and 5 years post transplant was 100%, 83% and 66% respectively. Estimated graft survival at 1, 3 and 5 years was 90%, 79% and 63% respectively. The estimated median renal graft survival was 6.2 years. Calcineurin inhibitor toxicity was the most common cause of end stage renal failure in this series of patients. There is a very fine balance between ideal immunosuppression for kidney and other organ transplants. Patients who avoid morbidity such as sepsis or graft rejection enjoy good graft function at 5 years post transplant.

Donor sepsis is not a contraindication to cadaveric organ donation.

Systemic donor infection is regarded as being an absolute contraindication to cadaveric organ donation for transplantation. This is largely due to fear of transmitting pathogenic organisms to the immunosuppressed recipient. However, due to the current shortage of organs available for transplantation, clinicians are faced with the option of using organs from 'non-ideal' donors, such as those patients with documented evidence of infection. We report the successful outcome of six orthotopic liver transplants, 11 renal transplants, one combined heart lung transplant and one simultaneous kidney and pancreas transplant with organs from eight donors in whom bacterial meningitis (n = 7) and acute bacterial epiglottitis (n = 1) were the antecedent causes of death.

Comparison of single agent cisplatin and cisplatin containing combinations in treatment of murine bladder cancer.

Using the FANFT-induced tumors MBT-2 and MBT-683 we compared the response rate and survival using cisplatin alone and in various combinations with doxorubicin hydrochloride (Adriamycin), mitomycin C, methotrexate, and vinblastine. Sixty C3H/He female mice received 7.5 x 10(4) MBT-2 cells in the right hind limb. The animals were randomly divided into a control group and four treatment groups as follows: cisplatin, 6.0 mg/kg; cisplatin, 2.0 mg/kg, vinblastine, and methotrexate; cisplatin, 2.0 mg/kg, vinblastine, methotrexate, and doxorubicin hydrochloride; and cisplatin, 2.0 mg/kg, vinblastine, methotrexate, and mitomycin C. The drugs were given intraperitoneally on days 7, 14, and 21. The study was repeated using MBT-683. Drug effect on tumor diameter and survival were compared. Cisplatin alone was as effective in MBT-2 and more effective in MBT-683 in reducing tumor volume and increasing survival than the various combinations. The higher tolerable dose of cisplatin used as a single agent probably accounts for these results and suggests that cisplatin is the most effective agent in these combination therapy regimens.

Loin pain-hematuria syndrome: how effective is renal autotransplantation in its treatment?

OBJECTIVES: To evaluate our experience with renal autotransplantation in the management of loin pain-hematuria (LPH) syndrome after relatively long follow-up (30 to 35 months). METHODS: Four patients with LPH syndrome of 3 to 18 years' duration underwent technically successful autotransplantation. All patients preoperatively had normal radiologic investigations, including renal arteriography and biopsy. All required narcotic analgesia for pain control. Patients were followed for 30 to 35 months. RESULTS: All 4 patients were pain and narcotic free for 6 months postoperatively. At 18 months after surgery, 3 of the 4 had recurrence of the pain and at 30 months, 2 required nephrectomy. Only 1 patient of 4 had sustained pain relief at 35 months. CONCLUSIONS: Renal autotransplantation certainly offers temporary relief from LPH syndrome, but in our experience this was not durable in the majority of our patients.

Retrograde transurethral balloon dilation of prostate: innovative management of abacterial chronic prostatitis and prostatodynia.

Retrograde transurethral balloon dilatation (RTBD) of the prostate recently has been suggested as alternative therapy for patients with benign prostatic hyperplasia (BPH). Seven patients with documented functional urinary outlet obstruction at the level of the bladder neck or prostatic urethra underwent RTBD of prostate. Each patient had a classic diagnosis of abacterial chronic prostatitis or prostatodynia based on history, physical examination, and localization cultures. Prior to RTBD of prostate, patients underwent cystoscopy, voiding cystourethrogram, urodynamic and uroflow studies. RTBD of prostate was done as an outpatient procedure requiring intravenous sedation or general anesthesia. Dilation was performed with a 25-mm urethroplasty balloon catheter inflated at 3.5 atm of pressure for twenty minutes. Improvement in voiding symptomatology was noted in all patients and graded numerically (0-10 scale), with ten indicating normal voiding. Follow-up to date ranges from one to five months. This technique may have promise as a treatment option in patients with abacterial chronic prostatitis and prostatodynia.

Transrectal ultrasound for staging prior to radical prostatectomy.

Transrectal ultrasound (TRUS) was used to predict tumor stage in 43 patients prior to radical prostatectomy. For assessing extracapsular extension, the sensitivity was 54 percent, specificity 58 percent, and accuracy 56 percent. For detecting seminal vesicle involvement, the sensitivity was 60 percent, specificity 89 percent, and accuracy 82 percent. The predominant tumor echo pattern was isoechoic in 37 percent of cases, mixed (hyper-, iso-, and hypoechoic) in 47 percent, and hypoechoic in 16 percent. An anterior-posterior to transverse dimension ratio of greater than 0.8 suggested diffuse involvement of the prostate with an increased chance of extracapsular spread.

Renal transplantation in patients with spina bifida.

OBJECTIVES: Renal transplantation in patients with spina bifida is not commonly performed, although these patients have a high incidence of end-stage renal disease. METHODS: Between February 1989 and December 1991, we performed 5 cadaveric renal transplants in 4 patients with spina bifida. There were 3 male patients and 1 female patient with a mean age of 22.5 years (range, 10 to 36 years). All patients had lumbar myelomeningoceles repaired shortly after birth. Three patients were wheelchair-bound due to their neurologic deficit. Prior to renal transplantation, management of neuropathic bladder dysfunction consisted of ileal conduit (1 patient), "clam" cystoplasty with clean intermittent self-catheterization (CISC; 1 patient), and CISC alone (2 patients). RESULTS: In this series, 1 patient died of fungal septicemia 6 weeks postoperatively. One patient underwent transplantation again following primary nonfunction of his original allograft. Serum creatinine levels were 56, 91, and 120 mmol/L, respectively, after 18 months' follow-up. CONCLUSIONS: This article demonstrates the feasibility of cadaveric renal transplantation in selected patients with end-stage renal failure and spina bifida. We currently recommend that these patients not be excluded from gaining the benefits of renal transplantation.

Renal cell carcinoma presenting as a pseudo-carcinoid tumour.

A 38-year-old woman presented with hypertension and a renal cell carcinoma. Raised urinary 5-hydroxyindoleacetic acid values >300 micromol/l, predictive of carcinoid tumour, were found during the perioperative period. The values returned towards normal 2 weeks post-surgery. Immunohistochemical examination of the renal cell carcinoma with neuroendocrine markers was negative. Despite a diligent search, no carcinoid tumour could be identified and the patient was well 4 years later. There was no dietary or drug explanation for this pseudocarcinoid.

Urological evaluation prior to renal transplantation.

Renal transplantation is the best available therapy for patients with end-stage renal failure. Urologists are often consulted regarding pretransplant evaluation and treatment of potential renal transplant recipients. Frequently the urologist is the primary surgeon in the transplant unit. This review highlights the importance of performing a comprehensive urological assessment before renal transplantation. A retrospective review of the urological and transplant literature using Medline was performed from 1976 to 2002, searching for renal transplantation and its association with urological cancers and urinary tract malformations. The pretransplant urological assessment aims to diagnose, treat, and optimize any preexisting urological disease. On occasion, certain urological diseases may not be obvious or may not have contributed to the progression to end-stage renal failure such as occult urinary tract neoplasms, urinary calculus disease, or benign prostatic hyperplasia. A thorough evaluation of the urinary tract prior to renal transplantation is mandatory to avoid unforeseen problems occurring posttransplant. If this assessment is consistently adhered to, only in very rare circumstances does a potential recipient have to be denied the opportunity of receiving an allograft based on a preexisting urological disease.