Long-term outcomes of en-bloc renal transplantation from paediatric donors into adult recipients.

INTRODUCTION: Transplant units are exploring strategies to increase the availability of donor kidneys. The use of en-bloc kidney transplantation (EBKT) from paediatric donors represents one potential solution. We present our long-term experience with paediatric EBKT among adult recipients. METHODS: Twenty-three paediatric to adult EBKTs were performed by the Irish National Kidney Transplant Service between 1990 and 2016. The primary outcome variable was long-term en-bloc allograft survival rate. Secondary outcome variables were incidence of allograft thrombosis, incidence of delayed graft function, overall patient survival and serum creatinine at most recent follow-up. Outcomes were compared to single kidney transplant recipients from the same time period. RESULTS: Mean donor age was 1.8 ± 0.97 years (range: 7 months to 3 years). Recipient age was 46 ± 12 years. Mean follow-up was 133 ± 64 months (range: 36-264). Overall graft survival was 100%, 91% and 80% after 1, 5 and 10 years respectively, compared to 92%, 79% and 61% in single kidney transplant recipients (p = 0.04). There were 5 cases of allograft failure, 3 due to death from unrelated causes. Median time to graft failure was 108 months (range: 36-172). Mean serum creatinine was 72.6 ± 21.6 µmol/l after the follow-up period. There were no cases of graft thrombosis or delayed graft function. Overall survival was 96.4%, 88.0%, 76.23% and 50.5% at 1, 5, 10 and 20 years respectively. CONCLUSION: En-bloc paediatric kidney transplantation is associated with excellent long-term allograft and patient survival and is a feasible strategy for increasing the transplant donor pool in carefully selected recipients.

Incidence and long-term outcomes of squamous cell bladder cancer after deceased donor renal transplantation.

OBJECTIVE: To review the incidence and long-term outcomes of squamous cell carcinoma (SCC) of the bladder in patients after kidney transplantation. METHODS: Between January 1976 and March 2013, five patients from one center (0.0013%) developed SCC of the bladder after undergoing a deceased donor kidney transplant. Their relevant risk factors included long-term self-intermittent catheterization/indwelling catheter (n = 2), smoking history (n = 2), and a prior history of cyclophosphamide treatment for vasculitis (n = 1). Primary outcome variables were overall patient survival and latency period between transplantation and SCC diagnosis. RESULTS: The duration of long-term follow-up was 94 ± 89 (range: 4-239) months. The latency period between transplantation and bladder SCC was 87 ± 87 (range: 2-228) months, and all five patients were immunosuppressed with tacrolimus, mycophenolate mofetil, and prednisone. Four patients had suspected metastases upon presentation, and one patient presented with organ-confined disease. This patient underwent a radical cystectomy and remains disease free eight months post-operatively. Despite radical treatment, the remaining four patients died from metastatic disease 7 ± 4.4 (range: 2-11) months after their initial diagnosis. CONCLUSION: SCC of the bladder has a poor prognosis particularly in renal transplant patients. Early detection with flexible cystourethroscopy in patients with risk factors for SCC may improve long-term outcomes in this patient cohort.

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.

Increased fusiform area activation in schizophrenia during processing of spatial frequency-degraded faces, as revealed by fMRI.

BACKGROUND: People with schizophrenia demonstrate perceptual organization impairments, and these are thought to contribute to their face processing difficulties. METHOD: We examined the neural substrates of emotionally neutral face processing in schizophrenia by investigating neural activity under three stimulus conditions: faces characterized by the full spectrum of spatial frequencies, faces with low spatial frequency information removed [high spatial frequency (HSF) condition], and faces with high spatial frequency information removed [low spatial frequency (LSF) condition]. Face perception in the HSF condition is more reliant on local feature processing whereas perception in the LSF condition requires greater reliance on global form processing. Past studies of perceptual organization in schizophrenia indicate that patients perform relatively more poorly with degraded stimuli but also that, when global information is absent, patients may perform better than controls because of their relatively increased ability to initially process individual features. Therefore, we hypothesized that people with schizophrenia (n=14) would demonstrate greater face processing difficulties than controls (n=13) in the LSF condition, whereas they would demonstrate a smaller difference or superior performance in the HSF condition. RESULTS: In a gender-discrimination task, behavioral data indicated high levels of accuracy for both groups, with a trend toward an interaction involving higher patient performance in the HSF condition and poorer patient performance in the LSF condition. Patients demonstrated greater activity in the fusiform gyrus compared to controls in both degraded conditions. CONCLUSIONS: These data suggest that impairments in basic integration abilities may be compensated for by relatively increased activity in this region.

Benign prostatic hyperplasia presenting with renal failure--what is the role for transurethral resection of the prostate (TURP)?

The aim of the study was to determine the role of transurethralresection of prostate (TURP) in normalising renal function in men presenting with obstructive renal failure secondary to benign prostatic hyperplasia. We reviewed the cases of 14 men who presented in the last 5 years with renal impairment associated with symptoms of bladder outflow obstruction and radiological evidence of obstructive uropathy. The mean serum creatinine at presentation was 632 ng/mL (range 1299 - 225). The mean age at presentation was 68.2 years (range 50 - 83 years). Duration of symptoms prior to presentation ranged between 1 - 118 months (mean 21.5 months). Following catheter insertion, all patients underwent TURP. Six of the 14 patients required dialysis prior to surgery. Histology of the resected prostate confirmed benign prostatic hypertrophy and/or hyperplasia in all cases. Patients with carcinoma of the prostate were excluded from the study. Following TURP, 2 of the 14 men (14%) failed to void spontaneously following removal of catheter - one patient performs clean self intermittent catheterization (CSIC), the other man has an in-dwelling catheter in situ. One patient died 7 months following TURP due to a myocardial infarction. However, 8 patients, (57%) remained dialysis dependent following TURP. Two of these patients have since undergone successful renal transplantation. Of the remaining 6 patients, only 3 have normal renal function with the other 3 experiencing moderately elevated serum creatinine (range 236 - 344 ng/mL). In patients presenting with renal failure due to bladder outflow obstruction, TURP restores normal voiding pattern in many cases. However renal failure due to bladder outflow obstruction tends to be more refractory and only 3 of 14 patients experienced return to normal renal function post treatment.

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.

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.

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.

Outcomes of adult cadaveric renal transplantation in ireland 1986 to 2001.

BACKGROUND: Since the introduction of renal transplantation in the Republic of Ireland in 1964, the number of transplants performed annually has increased from single figures in the 1960s to the current rate of approximately 130 renal transplants per year. Improvements in graft and patient outcomes have been associated with the introduction of the immunosuppressive agent Cyclosporin (CSA) in the mid 1980s. AIMS: The aim of this study was to examine trends in outcomes and factors that influence outcomes for adult kidney transplantation from 1986 to 2001. METHODS: All adult cadaveric kidney transplantations carried out between 1986 and 2001 were included. We separated the transplanted grafts and patients into four time periods; 1986-1989, 1990-1993, 1994-1997, 1998-2001. Graft and patient survival outcomes were compared for the different periods. RESULTS: The one-year kidney graft survival rate increased from 82% during 1986-1989 to 86% during 1998-2001. Patient survival over the four time periods studied has remained stable at approximately 95% at one year. CONCLUSION: We report a significant improvement in kidney graft outcomes over the past 16 years. Patient survival has remained relatively stable during this period.

Age-related differences and similarities in dual-task interference.

Differences between younger adults (mean age, 20.7 years) and older adults (mean age, 72.7 years) in dual-task performance were examined in 7 experiments in which the overlap between 2 simple tasks was systematically varied. The results were better fit by a task-switching model in which age was assumed to produce generalized slowing than by a shared-capacity model in which age was assumed to reduce processing resources. The functional architecture of task processing appears the same in younger and older adults. There was no evidence for a specific impairment in the ability of older adults to manage simultaneous tasks. There was evidence for both input and output interference, which may be greater in older adults.

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.

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.

Further evidence that negative priming in the Stroop color-word task is equivalent in older and younger adults.

In 2 experiments, possible adult age differences in negative priming were explored using several variants of the Stroop color-word task. Negative priming was at least as high in the older adults as in the younger adults in every variant. Negative priming varied as a function of condition, but the age equivalence was unaffected. This result was true even when the possibility of general slowing was taken into account. Across conditions, interference and negative priming were positively correlated. The results do not permit a clear choice between the 2 major theoretical explanations of negative priming, inhibition and memory retrieval; they do show that negative priming can be systematically manipulated within an experimental paradigm.

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.

Toxoplasmosis after a simultaneous pancreas and kidney transplantation.

We report the case of a simultaneous kidney and pancreas transplant recipient who presented with vague neurologic symptoms 21 months following the surgery. Computed tomography, magnetic resonance imaging, and fundoscopy findings were normal. Serology titers for antitoxoplasmic antibodies were increased. This was an atypical presentation of toxoplasmosis in a simultaneous kidney and pancreas transplant patient.

Treatment of medullary carcinoma of the thyroid by laryngo-pharyngo-oesophagectomy--a case report.

We report the case of a 34 year old man, who presented with advanced medullary carcinoma of the thyroid gland. His initial presentation, with dysphagia, is unusual in this condition. Surgery is the treatment of choice, radiotherapy and chemotherapy being relatively ineffective. Our patient underwent pharyngo-laryngo-oesophagectomy which is rarely performed in these cases, as such extensive disease is not often amenable to surgery.

Outcome of cadaveric renal transplantation in patients with psychiatric disorders.

Psychiatric illness has hitherto been considered a contraindication to solid organ transplantation in many centres. Reasons cited include a perceived lack of compliance with therapeutic drug regimes and the potential psychopharmacological interactions between psychotropic and immunosuppressant medication. We retrospectively examined the outcomes in 24 patients with psychiatric illnesses definable within the confines of the ICD 10 classification who underwent cadaveric renal transplantation between January 1990 and October 1999. The mean age was 31.5 +/- 17.1 years (range 9-68) at the time of transplantation. There were 13 male and 11 female patients. All received cyclosporine, azathioprine and steroid triple immunosuppressive therapy. The 1,3 and 5 year patient and graft survival was 87%, 82% and 65% respectively. The mean follow-up time was 43.67 +/- 38.11 months (range: 1 month-10 years 4 months). Compliance was excellent in all 24 cases. Seven patients died. The causes of graft loss were death with a functioning graft (n=3), vascular thrombosis (n=2), chronic rejection (n=2). The mean serum creatinine of the remaining 17 patients is 129 +/- 45.2mmol/l. Psychiatric illness, in itself, does not preclude the possibility of successful cadaveric renal transplantation.

Renal revascularisation by gastroduodenal-renal bypass as treatment of renal artery stenosis.

We report the case of a 63 year old hypertensive male who presented with acute renal failure following treatment of his hypertension with the ACE antagonist, captopril. He was documented to have bilateral renal artery stenosis, which was treated by left renal artery angioplasty and revascularisation of the right kidney by anastomosis of the right renal artery to the superior gastroduodenal branch of the hepatic artery. Postoperatively, he made an excellent recovery, with restoration of his renal function to normal and improved control of his hypertension.

Thalamic projection fiber integrity in de novo Parkinson disease.

BACKGROUND AND PURPOSE: Postmortem studies of advanced PD have revealed disease-related pathology in the thalamus with an apparent predilection for specific thalamic nuclei. In the present study, we used DTI to investigate in vivo the microstructural integrity of 6 thalamic regions in de novo patients with PD relative to healthy controls. MATERIALS AND METHODS: Forty subjects (20 with early stage untreated PD and 20 age- and sex-matched controls) were studied with a high-resolution DTI protocol at 3T to investigate the integrity of thalamic nuclei projection fibers. Two blinded, independent raters drew ROIs in the following 6 thalamic regions: AN, VA, VL, DM, VPL/VPM, and PU. FA values were then calculated from the projection fibers in each region. RESULTS: FA values were reduced significantly in the fibers projecting from the AN, VA, and DM, but not the VPL/VPM and PU, in the PD group compared with the control group. In addition, there was a reduction in FA values that approached significance in the VL of patients with PD. These findings were consistent across both raters. CONCLUSIONS: The present study provides preliminary in vivo evidence of thalamic projection fiber degeneration in de novo PD and sheds light on the extent of disrupted thalamic circuitry as a result of the disease itself.

A rare case of minimal deviation adenocarcinoma of the uterine cervix in a renal transplant recipient.

INTRODUCTION: We report the first described case of minimal deviation adenocarcinoma of the uterine cervix in the setting of a female renal cadaveric transplant recipient. MATERIALS AND METHODS: A retrospective review of this clinical case was performed. CONCLUSION: This rare cancer represents only about 1% of all cervical adenocarcinoma.