Transplantation of liver and kidney from donors with malignancy at the time of donation: an experience from a single centre.

Transplantation of organs from donors with malignancy poses clinical and ethical questions regarding outcome, informed consent, immunosuppression and follow-up. We review our experience of kidney and liver transplantation from such donors. Our database was complemented by data from National Health Service Blood and Transplant. All patients who received a renal or liver transplant in our institution between April 2003 and January 2014 were included. About 2546 liver and kidney transplants were performed: 71 recipients received 53 kidney and 18 liver transplants. These included 51 (36 kidney, 15 liver) CNS malignancy, and six kidneys, three ipsilateral and three contralateral with RCC. One kidney recipient developed donor-transmitted lung cancer in the transplant kidney, and one liver transplant recipient developed donor-transmitted lymphoma; both subsequently died. Seven recipients developed donor-unrelated cancer. No recipient developed cancer, whereas the donor had a CNS or RCC. The 1-, 3- and 5-year patient survival was 96%, 93.3% and 75%, respectively, for kidneys and 83.3%, 75% and 50%, respectively, for liver. Where donor malignancy was known and assessed before transplantation, judicious use of kidney and liver for transplant achieved satisfactory outcome. The risk of transmission from donors with CNS and low-grade renal malignancy remains extremely low.

Impact of the new fast track kidney allocation scheme for declined kidneys in the United Kingdom.

INTRODUCTION: A "new" fast track kidney allocation scheme (FTKAS) was implemented in the UK in 2012 for offering of previously declined kidneys. We evaluated the impact of the FTKAS in utilization of declined kidneys and outcome. METHODS: Adult renal transplant centers were surveyed. Overall utilization was evaluated using National Health Service Blood and Transplant (NHSBT) data. Outcome of FTKAS kidneys in our center was analyzed. RESULTS: Centers cited graft, patient outcome concerns, and inadequate logistical support for their non-FTKAS participation. In the first year of the scheme, 266 kidneys were offered through the FTKAS, 158 were transplanted in 10 centers (59%). In comparison, 166 kidneys were offered through previous system over five yr (2006-2011), and 65 were utilized in 59 transplants (39%). In our center, 42 kidneys were transplanted in 39 recipients. One-yr graft and patient survival were both 95%. Results were comparable to a matched group of kidney transplants during the same periods allocated via the standard scheme. CONCLUSIONS: The FTKAS has led to effective utilization of the declined kidneys with outcome comparable to kidneys allocated through the standard scheme. Non-participation based on outcome concerns is mostly subjective while logistical issues need to be addressed.

Ureteric reconstruction for the management of transplant ureteric stricture: a decade of experience from a single centre.

This study was conducted to review the outcomes of patients who had undergone surgical repair of a ureteric stricture following renal transplantation. All patients who developed a ureteric stricture and underwent ureteric reconstruction following renal transplantation, between December 2003 and November 2013, were reviewed. One thousand five hundred and sixty renal transplants were performed during the study period. Forty patients required surgical repair of a ureteric stricture (2.5%, 25 male, median age 48 [14-78]). The median time to stricture was 3 [1-149] months. 19 patients were reconstructed by reimplantation to the bladder, 18 utilized a Boari flap, two were a pre-existing ileal conduit and one was an anastomosis to a native ureter. In one patient, reconstruction was impossible and consequently an extra-anatomic stent was used. Two patients required re-operation for restricture and kinking. Median serum creatinine at 12 months following surgery was 148 [84-508] µmol/l. There was no 90-day mortality. Eleven grafts were lost at the time of this study, a median time of 11 [1-103] months after reconstruction. The incidence of ureteric stricture following renal transplant is low. Surgical reconstruction of the transplant ureter is the optimal treatment and is successful in the majority of patients.

Transplantation of solid organs procured from influenza A H1N1 infected donors.

Following the influenza A H1N1 (swine flu) pandemic, there remains little evidence informing the safety of transplanting organs from donors suspected or diagnosed with H1N1. Limited guidelines from the major transplant societies leave the use of such organs at the discretion of individual transplant centres, and practice varies considerably both nationally and internationally. We present the largest published series of outcome following transplantation of organs from H1N1 positive donors and demonstrate that these organs can be transplanted safely and with good short-term outcome. We discuss our local policy for treatment of recipients with Oseltamivir.

The Prevailing Preference for Left Nephrectomy in Living Donor Transplantation Does Not Adversely Affect Long-Term Donor and Recipient Outcomes.

BACKGROUND: In living donor renal transplantation, surgeons traditionally prefer the left kidney for donation. The aim of this study was to assess the effects of the choice of laterality of donor nephrectomy on donor and recipient outcomes. METHODS: The data was obtained from the UK National Health Service Blood and Transplant (NHSBT). During the study period, 7919 donor nephrectomy and transplantation were carried out in 24 transplant centers. Of these procedures, 6407 (80.9%) were left and 1512 (19.1%) were right kidney donors. RESULTS: Right kidney donation was associated with higher incidence of surgical site infection in the donor. Recipient outcome was superior for left-sided kidneys in terms of immediate graft function, delayed graft function, graft loss within 30 days, and graft survival at 3 years, but not at 1 and 5 years. Open donor nephrectomy (n = 2396, 30.2%) was associated with higher rates of pneumothorax and hemorrhage, longer hospital stay, and inferior graft survival at 3 and 5 years compared with laparoscopic donor nephrectomy (n = 5523, 69.8%). CONCLUSIONS: A right donor nephrectomy is associated with higher rate of wound infection in the donor and similar long-term graft outcomes in the recipients. Laparoscopic donor nephrectomy offers lower rate of major complications in the donor and a better overall graft survival.

Complete Absence of Iliac Arteries in the Left Hemipelvis in a Case of Deceased Donor Renal Transplantation.

Renal transplantation is an established method of treating end-stage renal failure. Whilst the majority of procedures follow a standard technique, vascular anomalies may pose intraoperative challenges and, therefore, careful preoperative assessment is warranted. We present a unique, complex case compounded by complete absence of iliac arteries in the left hemipelvis in association with double inferior vena cava in a young recipient.

Renal Transplantation From Pediatric Donors in the United Kingdom.

BACKGROUND: Significant disparity exists in the United Kingdom between the need for organ transplant and supply of deceased donor organs. In the recent years, efforts to increase donation has improved the rate of mainly deceased donors after circulatory death and from older donors. The rate of donation from pediatric population has remained low and those younger than 2 years including neonatal donation has remained largely unexplored. METHODS: A retrospective review of the outcome of renal transplantation from pediatric donor (<18 years) kidneys in the United Kingdom. RESULTS: Our results show a poor referral and conversion rate, and high discard rate (43%) of kidneys procured from donors younger than 2 years. During the 15-year study period (1997-2011), 47 donors younger than 2 years were referred (3 per year). Of these, 26 proceeded to donation resulting in 17 transplants (65% utilization). The referral rate for donors 2 years or older to younger than 5 years also remains low (76 in 15 years), but the conversion (88%) and utilization rates (73%) are better in this group. There was better utilization in donors aged 5 years or older to younger than 18 years. Overall graft and patient survival remains excellent in all 3 groups; with comparable survival of 82%, 85%, and 77% (P = 0.29) with mean follow-up periods of 9, 12.5, and 11.8 years, respectively. CONCLUSIONS: Despite excellent outcome, the referral, donation, and utilization of kidneys from donors younger than 5 years and particularly those younger than 2 years remain low. We suggest implementing improved strategies to increase donation from this group of population.

A pathophysiologic study of the kidney tubule to optimize organ preservation solutions.

BACKGROUND: Tissue damage at the time of organ transplantation has a negative impact on the subsequent success of the procedure, both in the immediate and longer term. Hypothermia is the principal element used to prolong organ viability ex vivo, but paradoxically also induces cellular edema through inhibition of energy-dependent adenosine triphosphatases (ATPases). This induces an electrolyte imbalance that leads to fluid influx and cell swelling. It is important, therefore, that improvements are made in the preservation of ischemic organs to reduce this injury. METHODS: This study has applied a novel in vitro system to model cold and warm ischemic-induced renal tubule swelling that characterizes tissue damage in ischemia/reperfusion injury. Biochemical blockade of ATPases in this system using strophanthidin modeled the effects of energy depletion and induced cell swelling. By measuring such tubule swelling and changes to tubular cell volume in isolated rabbit renal proximal tubules, an analysis was made that defined the basis on which an optimal preservation solution may be developed. RESULTS: The data show that our model could reproduce ischemically induced cell swelling and characterized the response at the cellular level of tubules to different components of preservation solutions. The data indicate that an isosmolar, phosphate-buffered, sucrose solution prevented tubule swelling more effectively than Euro-Collins, hyperosmolar citrate, or University of Wisconsin solutions that are in routine clinical use. CONCLUSION: Future developments in organ preservation may significantly improve transplant outcomes. Our novel analysis forms the basis of future whole-organ studies that ultimately may allow us to propose an optimum platform for improved preservation solutions.