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PubMed2004

Donation after cardiac death: the University of Wisconsin experience.

OBJECTIVES: The objective of this analysis was to compare the results of transplantation of livers, pancreases, kidneys, and lungs from donation after cardiac death (DCD) donors to organs transplanted from donation after brain death (DBD) donors. METHODS: From January 1984 through July 2000, outcomes of 382 DCD kidneys were compared to 1,089 kidneys (SPK) transplants and 36 liver transplants from DCD donors were compared to 455 SPK and 510 liver transplants from DBD donors. Likewise, 31 simultaneous pancreas-kidneys transplants from DBD donors. RESULTS: The rate of delayed graft function (DGF) was higher in kidneys transplanted from DCD donors (27.5% versus 21.3%, p=0.01). Likewise, discharge creatinines were higher in recipients of DCD kidneys (1.9 mg/dL versus 1.7 mg/dL, p=0.001). There was no difference in 10-year graft survival between DCD and DBD recipients (45.0% versus 48.0%, p=0.054). No difference in 5-year pancreatic and renal allograft survival was seen after SPK from DCD or DBD donors. After liver transplantation, biliary strictures were higher in recipients of DCD livers (13.9% versus 8.0%, p=0.03). Likewise, 3-year patient and graft survivals were lower for recipients of DCD livers (65.8% versus 84.9%, p=0.01; and 58.6% versus 76.9%, p=0.006). CONCLUSIONS: This large experience with transplantation from DCD donors demonstrates that similar patient and graft survivals can be expected when compared to recipients of organs from DBD donors.

Brain Death↗
PubMed2004

Excellent outcome of renal transplantation using single old kidneys in old recipients.

Aim of this monocentric study is to compare the outcome of 101 renal transplants performed in patients older than 55 years with single kidney retrieved from donors older than 50 years, with 263 transplants performed in patients younger than 55 years transplanted with young kidneys. Delayed graft function (DGF) had similar incidence (24 vs 23%). Acute rejections (AR) were fewer in younger recipients without statistical significance. A 6-month serum creatinine < 130 mmol/L was less frequent in older recipients (RR 1.20; p=0.004). 5-year patient survival rate was lower in older patients (80.6% vs 92.6%; p=0.009). Crude 5-year graft survival rate was lower in older recipients (68.5% vs 84.5%; p=0.004). Adjusting for death with functioning kidney 5-year graft survival was still, but not significantly, lower in older recipients (82.8% vs 90%; p=NS). This data outline that graft survival rate must be always adjusted for death with functioning grafts and that excellent outcomes with a 5-year graft survival, higher that 80% can be obtained in old patients using single cadaveric kidneys.

Aging↗
PubMed2004

Weight increase during machine perfusion may be an indicator of organ and in particular, vascular damage.

OBJECTIVES: Hypothermic machine perfusion preservation has been shown to improve the outcome of renal grafts from non-heartbeating donors. We have noticed that organs gain a variable amount of weight during perfusion. METHODS: All grafts, whether used or discarded, were assessed with respect to their weight gain. Primary outcome measures were the results of viability testing. Secondary outcomes were early transplant variables including incidence and duration of delayed graft function and histological examination of protocol graft biopsies. RESULTS: Weight increase data was available on 97 grafts. There were no significant differences in weight gain between kidneys used and discarded (17% vs 20%). 14 patients received grafts which gained over 30% of their initial retrieval weight. There were no significant differences in secondary outcome measures between this group of recipients and patients who had received less "waterlogged" kidneys. Histological changes including endothelial inflammation and oedema were observed. CONCLUSIONS: Kidney grafts which have gained over 30% of weight on hypothermic machine perfusion preservation can be transplanted successfully. Complex interactions between the period of warm ischaemia, in situ flushing, perfusion pressures and perfusate probably lead to the phenomenon of excessive graft weight gain.

Blood Vessels↗
PubMed2004

[Living donor nephrectomy for kidney transplantation. Experience in the first two years].

OBJECTIVES: Laparoscopic surgery offers potential advantages in terms of diminishment of postoperative pain, shorter hospital stay, faster convalescence, and better cosmetic results. These advantages may increase kidney donation, making donation be accepted by more candidates. We report our first 2 years' experience with laparoscopic donor nephrectomy METHODS: Between March 2002 and February 2004 we performed 38 laparoscopic living donor nephrectomies for kidney transplantation. The technique of choice was the transperitoneal laparoscopic approach with four trocars, usually three of them from the start of the procedure--two 10-12 mm and one 5 mm--, and a 6.5 cm perumbilical midline incision for kidney retrieval at the end of the procedure. RESULTS: Receptor and donor survivals were 100%. Graft survival was 97.6%. There was not any case of delayed graft function. Donor: Mean operative time was 161 minutes (115-260). Mean estimated blood loss was 270 ml (100-1200). Three patients required blood transfusions, 2 units of packed red blood cells each. Mean hospital stay was 5.1 days (3-11). Mean warm ischemia time was 3.2 min. (2-10). Conversion to open surgery was necessary in four cases. Receptor: there have been three significant complications requiring surgical repair: one case of low arterial flow, one vesico ureteral leak, and one midurethra stenosis. Initial renal function: mean serum creatinine at one month was 147mmol/l, with a trend to improve to 126 mmol/l at one year, which is considered optimum. First postoperative day mean serum creatinine was 192mmol/l and the nadir was on second postoperative day with a value of 152mmol/l. CONCLUSIONS: We believe laparoscopic living donor nephrectomy is a real alternative to open surgery because it offers better recovery to the donor with the same capacity to preserve renal function in the receptor.

Humans↗
PubMed2005

Hand-assisted laparoscopic versus open nephrectomies in living donors.

UNLABELLED: Shortages of cadaveric kidneys for transplant into rising numbers of patients with end-stage renal failure have increased the demand for kidneys from live donors. The morbidity associated with traditional open donor nephrectomies (ODN) may discourage many candidates. The newer laparoscopic technique has been promoted as having less morbidity. OBJECTIVES: To evaluate outcomes of hand-assisted laparoscopic nephrectomies (HALN) and prospectively compare HALN and ODN. METHODS: After retrospectively reviewing donor and recipient outcomes in 33 HALN (December through August, 2000), we prospectively compared another 47 with 30 ODN performed from September 2000 through April 2001. RESULTS: All 80 HALN were successful, with no requirement to convert to an open procedure. Four donors experienced surgery-related complications: wound infection, retroperitoneal hematoma, prolonged ileus and early small-bowel obstruction, respectively. Two recipients had ureteral complications (1 stricture, 1 leak); 5 experienced delayed graft function, 2 requiring dialysis; and 2 kidneys were lost from infarction. The prospective comparison showed the operative time for HALN (mean 184 min, standard deviation [SD] 39 min) was significantly longer (143 [SD 27] min, p < 0.01), but resulted in less blood loss (p < 0.05). Lengths of time to warm ischemia/early graft function, resumption of oral intake/first bowel movement, and hospital discharge were similar. The abdominal-wall laxity and loss of cutaneous sensation from the flank incision experienced by many ODN patients after was uncommon in the HALN group. Three months after nephrectomy, donor complaints of incisional pain were less common after HALN (p < 0.01). CONCLUSIONS: HALN had good outcomes for donors and recipients, with quicker, more complete recoveries 3 months afterward.

Adult↗
PubMed2005

[Application of Danshen injection on early stage of renal transplantation].

OBJECTIVE: To investigate the effect of Danshen injection (DSI) on early stage of renal transplantation. METHODS: One hundred and twelve patients in early stage after renal transplantation were allocated in the treated group, they were treated by conventional treatment with DSI 60 ml given additionally once a day for 10 days. And 109 patients who received conventional treatment alone after renal transplantation at the corresponding period were allocated in the control group. Indexes in the two groups, including volume of urine, serum creatinine (SCr), endogenous creatinine clearance rate, incidence of delayed graft function and acute rejection reaction, blood viscosity (BV), platelet aggregation rate (PAR) as well as the blood flow resistance in graft measured by color Doppler ultrasonography. RESULTS: The urinary volume and endogenous creatinine clearance rate in the treated group were significantly higher, but levels of SCr, incidence of renal function recovery retardation, BV, PAR and blood flow resistance in graft were significantly lower than those in the control group (P < 0.05). The difference of incidence of acute rejection reaction between the two groups was insignificant (P > 0.05). CONCLUSION: DSI can improve blood microcirculation, decrease the incidence of renal function recovery retardation, these effects are helpful for recovery of renal function after renal transplantation.

Adolescent↗
PubMed2005

[Outcomes of transplantation from living renal donor].

Living donors represent 30% of our kidneys for renal transplantation. Laparoscopic nephrectomy is the best surgical procedure to obtain them due to its clear advantages such as low morbidity, less blood supply and donor time in hospital. From March 2002 to August 2004 we performed 50 laparoscopic nephrectomies for renal transplantation. Kidneys were transplanted to recipients receiving tacrolimus 0.1 mg/kg/bid, mycophenolate mofetil 1 g/bid and prednisone 0.5-1 mg/kg/day p.o 48 hours before transplantation. Mean time for surgery was 170 minutes (120-260), warm ischaemia time 3.1 minutes (1.5-10) and cold ischaemia time 1.27 hours (0.85-4). Mean bleeding was 270 cc (100-900) and donor time in hospital 5.5 days (3-9). Four cases required conversion of the laparoscopic procedure to open surgery because of bleeding. 72 hours post-transplant mean plasmatic creatinine was 170 micromol/l. None of the patients suffered delayed graft function. 18% presented acute rejection. Survival of donor and recipient was 100% at 1 year and graft survival was 94% at 1 year (kidney losses were due to acute rejection, severe acute pancreatitis and surgical problem).

Anti-Inflammatory Agents↗
PubMed2005

[Early urinary tract infection in kidney transplantation. Risk factors and impact on graft survival].

The early urinary tract infection (EUTI) in kidney transplant recipients is an infection develop during the first 3 months post transplant surgery. The effect of EUTI on graft survival and risk factors have been scarcely studied. Our objetives were the evaluation of risk factors to EUTI, the assessment of the causal agent and graft survival impact. A retrospective analysis of kidney transplantation, period 1997-2000 in Hospital Privado-Centro Médico de Córdoba was carried out. There were two groups of patients with (EUTI group) and without EUTI (control group). Cox model was used to analyze risk factors and Kaplan-Meier method for graft survival. A total of 226 consecutive patients received kidney transplantation. In 55 patients (24.3%) EUTI was detected. Risk factors for EUTI were: invasive urological maneuvers (RR = 4.34, CI 95% 1.42-13.21), diabetes mellitus (RR = 3.79, CI 95% 1.42-10.14), cytomegalovirus infection (RR = 2.9, CI 95% 1.02-8.24) and previous transplants (RR = 2.83, CI 95% 1.08-7.45). Delayed graft function was associated with lower incidence of EUTI (RR = 0.38, CI 95% 0.15-0.94). The causal agents were: Klebsiella pneumoniae (36%), Pseudomonas aeruginosa (24%) and Escherichia coli (9%). Graft survival at 2 years was similar in EUTI (87.2%) and control group (81.2%, p = 0.32). This series shows that invasive urological maneuvers were the main risk factors for EUTI. Graft survival was similar. High prevalence of non coli bacteria need further evaluation.

Adult↗
PubMed2006

[Renal transplantation with positive crossmatch].

INTRODUCTION: Lymphocytotoxic antibodies reduce the expectancy of renal transplantation due to the increased risk of a positive crossmatch. MATERIAL AND METHODS: We analyzed the evolution of eight kidney transplants performed in our unit in presence of a positive crossmatch with historical T and/or B lymphocyte positive crossmatches. RESULTS: Mean panel reactivity was 76,6 +/- 25,7% (r: 22-100%), been higher than 75% in six patients. Six patients were recipients of a second or third transplant. Immunosuppression consisted of quadruple therapy including induction with thymoglobuline. Five patients had delayed graft function, and one had primary non-function of the graft. One patient lost her graft due to chronic allograft nephropathy in the second year postransplantation. Six patients maintained a good renal function (serum creatinine 1,2 +/- 0,5 mg/dl, proteinuria 0,20 +/- 0,34 g/day). CONCLUSION: Renal transplantation in presence of a positive cross-match with historical serum and T lymphocytes and/or B lymphocytes, was followed by a satisfactory graft survival.

Adult↗
PubMed2006

Chronic allograft nephropathy--immunologic and nonimmunologic factors.

Chronic Allograft Nephropathy (CAN) is one of the most common cause of kidney transplant loss. CAN may be caused by immunologic as well as nonimmunologic factors which may interfere and increase response. Immunologic factors include acute rejection, degree of HLA mismatch, inadequate immunosuppression. Nonimmunologic factors contain delayed graft function, ischemia-reperfusion injury, nephrotoxicity of calcineurin inhibitors, hyperfiltration, hypertension and hyperlipidemia. The histopatological description of CAN may indicate two phases of injury. An initial phase by one year include tubulointerstitial infiltration in the late phase of CAN arteriolar hyalinosis and glomerulosclerosis were revealed. Modification of the immunosuppressive treatment with reduction or withdrawal of calcineurin inhibitors may prevent graft loss, while addition of nonnephrotoxic agents such as mycophenolate mofetil or sirolimus should be considered by the risk of acute rejection. Additionally effective management by hypertension and hyperlipidemia is essential.

Chronic Disease↗
PubMed1991

Sensitization in renal transplantation.

1. The 1-year graft survival rate for 2,615 broadly sensitized patients of first cadaver-donor transplants between 1985 and 1990 was 72%, 7% lower than 15,615 nonsensitized patients and 6% lower than 4,824 moderately sensitized patients. For retransplants, 1,752 broadly sensitized patients had 61% 1-year graft survival rates, 12% lower than 1,299 nonsensitized patients and 8% lower than 1,104 moderately sensitized patients. 2. Rejection of a previous transplant, pretransplant blood transfusions, sex, and a history of pregnancies were the dominant causes of sensitization. 3. The percentage of nontransfused recipients of first cadaver transplants has increased yearly from 10% in 1985 to more than 40% in 1990 in both the UCLA and UNOS Registries. Over the same period, the percentage of broadly sensitized recipients has declined from 15% to 8%. 4. The beneficial effect of pretransplant transfusions (a 4% improvement at 1 year) was limited in first transplants to males and nonsensitized females. No difference in survival rates of sensitized patients comparing transfused and nontransfused was observed. Patients retransplanted without ever being transfused had very poor outcomes. 5. Delayed graft function (DGF) occurred in approximately 20% of nonsensitized, 28% of moderately (1-50% peak PRA), and 37% of broadly sensitized first transplant recipients. Among retransplanted patients, 28% of nonsensitized, 37% of moderately, and 48% of broadly sensitized patients had DGF. 6. HLA-A,B, and DR matching overcame the deleterious effect of sensitization on graft survival. Sensitization had no effect on the outcome of transplants from HLA-identical siblings, but survival decreased by 7-10% in sensitized recipients of mismatched transplants from relatives. Sensitized first cadaver transplant recipients matched for HLA-A,B, or HLA-DR antigens had 1-year survival rates comparable to those of mismatched nonsensitized recipients. 7. First transplant recipients who were nonsensitized using their current serum but had been broadly sensitized in an historical sample had 73% 1-year graft survival, the same as that of patients who were broadly sensitized in their current serum and 6% less than patients who were never sensitized (p less than 0.001). 8. Assuming a random distribution of sensitized patients at UNOS transplant centers using different methods to measure preformed antibody, the antihuman globulin (AHG) method was more sensitive than the NIH or 1-Wash tests. With AHG, 31% of first and 58% of retransplanted patients were broadly sensitized, whereas with the NIH and 1-Wash methods, the corresponding figures were 18-21% and 41-44%.(ABSTRACT TRUNCATED AT 400 WORDS)

Blood Transfusion↗
PubMed1991

Case management of the anemic patient. Epoetin alfa: focus on renal transplantation.

Candidates for kidney transplant are susceptible to a variety of problems related to blood transfusions, including sensitization and infection. Because of delayed graft function or rejection, these problems often persist after transplantation. Epoetin alfa therapy offers a method of maintaining the red cell count while avoiding the risks of transfusion.

Adult↗
PubMed1990

Kidney transplantation at UCLA.

1. Six hundred twenty kidney transplants have been performed at UCLA since 1984. Rather than 1 rigid immune suppression protocol for all patients, an individualized approach has been taken since the advent of OKT3 in 1987. Since then, the 1-year cadaver graft and patient survival rates have been 87% and 97%, respectively, for both primary and repeat transplants, including various categories of high-risk recipients. 2. Delayed graft function, HLA matching, and percent prior sensitization were major determinants of graft survival. Race, age, and diabetes were not significant determinants of graft outcome. 3. Small children had a 94% 1-year graft survival rate following cadaver transplantation. Sequential immune suppression, the use of large kidneys, and careful perioperative fluid management to prevent graft thrombosis may be responsible for the graft survival rate. 4. Long-term (1 year) results continue to show deterioration in graft survival. Many patients are hypertensive and hypercholesterolemic. Many children are noncompliant with medications.

Adult↗
PubMed1990

In situ dissection of cadaver kidneys.

Major anatomic injuries occurred in 18 of 151 (12%) en bloc kidneys. No injuries occurred among the in situ kidneys. The rates of delayed graft function were equal. All the kidneys removed by the in situ method were removed by one surgeon (ALH). The results are good enough to recommend the technique even without a randomized study.

Brain Death↗
PubMed1989

The impact of purposeful sharing by HLA matching in the South Eastern Organ Procurement Foundation (SEOPF).

A voluntary system was created to foster early sharing of well-matched organs between like-minded renal transplantation programs. In the two historic periods 1982-85 and 1985-86, sharing programs (Category I & II) and nonsharing programs (Category III) had similar graft survival. In the study period 1986-88, graft survival improved in Category I and II programs and was unchanged in Category III programs. Highly sensitized recipients in sharing programs had an incremental gain of 15.0%, patients receiving multiple grafts 12.6%. Grafts derived from local donors and transplants in less sensitized patients also were improved but for less obvious reasons. The implementation of this study was followed by a slight decrement in delayed graft function. It is our conclusion that early graft sharing can result in improved overall early graft survival.

Graft Survival↗
PubMed1986

Anesthetic protocol in human renal transplantation: twenty-two years of experience.

This paper reviews the experience of 22 years of transplantation. From June 1963 to December 1984, 1362 human renal grafts were performed in our center. Throughout this period, advances in surgical techniques, kidney preservation methods and immunosuppressive regimen have improved patient and graft survival. Simultaneously, progress in anesthetic monitoring and techniques (particularly the use of new muscle relaxants and isoflurane) led to better and safer surgical conditions. A protocol of maximal intraoperative hydration using pulmonary arterial pressure monitoring was progressively developed. This protocol has allowed to reduce significantly the incidence of delayed graft function.

Adult↗
PubMed1995

Evaluation by histology, immunohistology and PCR of protocollized renal biopsies 1 week post-transplant in relation to subsequent rejection episodes.

Renal biopsies were performed 1 week following renal transplantation at a time without clinical evidence of rejection in 43 patients (13 females, mean age 48 years range 18-60 and 30 males, mean age 43 years range 17-59 years). Thirty-six biopsies were available for histological or immunohistochemical analysis. Immunohistochemical analyses were performed with monoclonal antibodies against leukocytes (CD45), monocytes (WT14), complement factor 3 (C3), T-cells (Leu4), T-cell receptor alpha beta and gamma delta, tumour necrosis factor alpha (TNF alpha), IL-2 receptor (IL2-R, TAC), intercellular adhesion molecule-1 (ICAM1) and HLA-DR. The slides were scored semiquantitatively with the observers having no knowledge of clinical or patient data. TNF alpha and IL-2R were also measured by quantative PCR. None of the studied parameters correlated to delayed graft function or graft loss. Histological analysis showed that both focal interstitial infiltrate (18/35) and tubular basement membrane disruption (11/35) were followed by a higher incidence of subsequent rejection (P = 0.03 and 0.02 respectively). Also positivity for WT14 around tubuli (P = 0.02) was associated with subsequent occurrence of rejection. The intensity of staining of ICAM-1 on PTC as well as TAC on proximal tubular cells was associated with the number of subsequent rejection episodes. The association between the IL-2 receptor and subsequent rejection was also found applying PCR to the tissue specimens. We conclude that the presence of focal interstitial infiltrates and tubulitis in 1-week biopsies from well-functioning grafts carries an increased risk of subsequent rejection.(ABSTRACT TRUNCATED AT 250 WORDS)

2-Isopropylmalate Synthase↗
PubMed1995

Outcome of transplantation of non-heart-beating donor kidneys.

To reduce the shortage of kidneys for transplantation, we started a non-heart-beating (NHB) donor programme, and compared the short-term and long-term outcomes of kidneys from NHB donors with those of a matched group of kidneys from heart-beating (HB) donors. 57 NHB kidneys were procured at the University Hospital in Maastricht and at three regional hospitals in the Netherlands, and were transplanted in 21 transplant centres within the Eurotransplant exchange organisation. 114 matched controls from HB donors were selected from Eurotransplant files. Mean follow-up was 85 months. At 5 years, graft survival was 54% for NHB kidneys and 55% for HB kidneys; patient survival was 75% and 77%. Kidneys from NHB donors had a significantly higher rate of delayed graft function (60% vs 35%), resulting in a longer hospital stay. Primary non-function of the graft was seen as frequently in the NHB donor-kidney group as in the HB group (14% vs 8%, p = 0.3). We conclude that NHB donors are a valuable source of kidneys for transplantation.

Death↗