Kidney graft and patient survival with and without a simultaneous pancreas utilizing contralateral kidneys from the same donor.
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Adult↗
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Results for “Delayed Graft Function”
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[The usefulness of ultrasonography and Doppler ultrasound in renal transplantation].
OBJECTIVES: The aim of the study is to analyze the usefulness of ultrasound and Doppler ultrasound for the evaluation of transplant donors and recipients, for renal transplant follow-up and for the resolution of surgical complications after renal transplant. METHODS: Abdominal ultrasound was performed in donors and recipients of renal grafts. In the recipients with vascular risk factors a Doppler ultrasound of the iliac and lower limb arteries was systematically done. Doppler ultrasound was performed in the first and seventh day after renal transplant, as well as for graft dysfunction at any moment. RESULTS: Recipient ultrasound informs about the existence of acquired renal cystic disease and Doppler ultrasound allows evaluating the vascular state of high risk recipients. In the immediate post-transplant period ultrasound studies are useful for detection of vascular complications, graft obstruction and to control the evolution of acute rejection and acute tubular necrosis. Finally, ultrasound is the technique of choice in the endourological management of surgical complications after renal transplant. CONCLUSION: Ultrasound under urologic control is essential in the evaluation of the kidney transplant recipient, post-transplant follow-up and in the resolution of surgical complications.
Delayed Graft Function↗
Victims of cardiac arrest occurring outside the hospital: a source of transplantable kidneys.
BACKGROUND: The use of non-heart-beating donors could help shorten the list of patients who are waiting for a kidney transplant. Several reports describe acceptable results of transplantations from non-heart-beating donors who had in-hospital cardiac arrest, but few reports describe results of transplantations from non-heart-beating donors who had cardiac arrest that occurred outside of the hospital (Maastricht type I and type II donors). OBJECTIVE: To compare graft survival rates among patients receiving kidneys from heart-beating donors versus type I or type II non-heart-beating donors. DESIGN: Retrospective cohort study of transplantations performed from January 1989 to December 2004. SETTING: Kidney transplant program of a teaching hospital in Madrid, Spain. PATIENTS: 320 patients who received a kidney transplant from non-heart-beating donors (273 type I donors and 47 type II donors) and 584 patients who received a kidney transplant from heart-beating donors divided into 2 groups according to donor age (age <60 years [n = 458] and age > or =60 years [n = 126]). MEASUREMENTS: The primary outcome measure was graft survival. The median follow-up time was 68 months (range, 9 to 198 months). RESULTS: One- and 5-year graft survival rates were 90.7% and 85.5%, respectively, for transplants from heart-beating donors younger than 60 years of age; 79.8% and 73.3%, respectively, for transplants from heart-beating donors 60 years of age or older (P < 0.001); and 87.4% and 82.1%, respectively, for transplants from non-heart-beating donors (P = 0.22 [vs. those from heart-beating donors < 60 years of age] and P = 0.014 [vs. those from heart-beating donors >or = 60 years of age]). Graft survival did not differ between patients who received kidneys from heart-beating donors younger than 60 years of age and patients who received kidneys from non-heart-beating donors. LIMITATIONS: This single-site, observational study was retrospective, and immunosuppressive therapy regimens given to transplant recipients varied over time. CONCLUSIONS: Outcomes of transplants from non-heart-beating donors and younger heart-beating donors are similar, and results for transplants from non-heart-beating donors improved compared with those from older heart-beating donors. On the basis of these results, the authors encourage other transplant units to adopt the use of type I and type II non-heart-beating donors.
Adult↗
[History of Marcel P].
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Acute Kidney Injury↗
Chronic renal allograft dysfunction: the evidence for a change in immunosuppression.
In renal transplantation the calcineurin inhibitors (CNIs) have played a crucial role in the reduction in acute rejection rates. Unfortunately this has not been matched by an improvement in long-term graft survival rate. The development of chronic allograft nephropathy (CAN) is the second most common cause of graft loss, after death from cardiovascular causes. CAN has a multifactorial aetiology that includes immunological and nonimmunological factors relating to both donor and recipient. The use of CNIs has been strongly implicated as a risk factor for the development of CAN. With the ongoing development of new immunosuppressant agents the possibility of avoiding the CNIs now exists. Many studies have been designed to investigate strategies to minimise or avoid CNI exposure and to prolong graft survival. To achieve CNI withdrawal whilst avoiding rejection, additional immunosuppressants need to be substituted into the drug regimen. Long-term side effects of the immunosuppressant used need to be taken into account when drug changes are being considered. In light of current evidence, CNI reduction with optimal use of mycophenolate mofetil appears to be the most effective strategy in managing the patient with CAN.
Chronic Disease↗
Serum immunoreactive interleukin 1 in renal transplant recipients. Association of raised levels with graft rejection episodes.
A solid-phase radioimmunoassay was used for monitoring serum interleukin 1 levels in 12 renal transplant recipients. From 10-fold to 20-fold elevations of interleukin 1 occurred in association with 10 of 12 graft rejection episodes. The interleukin 1 elevation preceded the clinical rejection diagnosis by an average of one day in transplant recipients with initially functioning grafts, and by two days in recipients with delayed onset of graft function. The results show that the release of interleukin 1 into the circulation is an early event in renal allograft rejection and demonstrate the potential utility of interleukin 1 antigenic assays in the early diagnosis of rejection.
Adult↗
The value of repeated renal retransplantations.
The outcome of 64 repeated renal retransplantations (50 third, 13 fourth, and 1 fifth) during a period of 25 years was retrospectively evaluated. The prognosis of third and subsequent grafting was greatly improved if cyclosporine was included in the induction immunosuppressive regimen (one-year graft survival 79.9%, compared with 32.4% if CsA was not used). The onset of graft function was not delayed by CsA and the proportion of never functioning grafts was significantly lower (5.3%) in patients treated with CsA than in those treated without it (43.2%). Survival of the previous grafts for longer than one year favorably influenced the outcome of the subsequent grafts.
Adult↗
The impact of introducing laparoscopic donor nephrectomy to an established renal transplant program.
BACKGROUND: Although the advent of hand-assisted laparoscopic donor nephrectomy (HLDN) has had a positive impact on the donor pool, there is still some concern about its safety. The aim of this study was to assess the impact of a change in surgical access to live-donor nephrectomy on donor-related complication rates, the renal function of the donor, and the graft function of the recipient. METHODS: At our hospital, HLDN was introduced in 1998. Thereafter, we compared 49 consecutive donors undergoing open donor nephrectomy (ODN) between 1987 and 2002 with 57 consecutive donors undergoing HLDN between 1998 and 2002. Donor renal and recipient graft functions were assessed by measuring creatinine levels and urine output, with the addition of warm and cold ischemia time and dialysis requirements in the latter group. Data are presented as means (+/-SD) and analyzed with the Student t-test or Fisher's exact test. RESULTS: The ODN and HLDN donors were comparable for age, gender, body mass index, renovascular anatomy, and preoperative creatinine. Estimated blood loss (370 +/- 280 vs 168 +/- 160 ml, p < 0.0001), time to resumption of oral intake (1.7 +/- 0.5 vs 1.3 +/- 0.7 days, p = 0.01), duration of intravenous narcotic requirements (23 +/- 0.7 vs 1.7 +/- 1.0 days, p < 0.0001), and hospital stay (4.2 +/- 1.4 vs 2.9 +/- 1.3 days, p < 0.0001) were significantly decreased after HLDN. There were no significant differences between ODN and HLDN in operating time (204 +/- 46 vs 202 +/- 49 min), donor-related complication rates (12.2% vs 14%), or donor renal and recipient graft functions. CONCLUSION: The introduction of HLDN to an established renal transplant program led to an improved short-term outcome without any increase in donor-related complication rates or delay in recipient graft function.
Female↗
200 consecutive hand assisted laparoscopic donor nephrectomies: evolution of operative technique and outcomes.
PURPOSE: Despite the popularity of hand assisted laparoscopic donor nephrectomy published experience is less than that with standard laparoscopic donor nephrectomy and few critical assessments of operative maneuvers have been described. MATERIALS AND METHODS: We describe the impact of changes in operative technique made by a single surgeon during 200 hand assisted laparoscopic donor nephrectomies. RESULTS: With a mean operative time of 229 minutes and hospital stay of 1.9 days the rates of conversion to open surgery, intraoperative complications and major postoperative complications were 1%, 1.5% and 6%, respectively. Lasting changes in technique were dissection of a ureteral/gonadal packet, bipolar cautery use on gonadal/adrenal/lumbar veins and resting the kidney before removal. The incidence of ureteral complications decreased from 8% to 5.1% with dissection of the ureter in conjunction with the gonadal vein rather than isolating it. Warm ischemia time decreased from a mean of 186 to 143 seconds with bipolar electrocautery instead of clips to control gonadal/adrenal/lumbar veins. After starting to rest the kidney before removal the incidence of primary graft nonfunction and delayed function decreased from 6.7% to 0% and 30% to 11.8%, respectively, with a corresponding improvement in 2-year graft survival from 83% to 95%. CONCLUSIONS: This large series of hand assisted donor laparoscopic nephrectomies with a mean followup approaching 3 years demonstrates that the procedure is safe for the donor and procures a good specimen. Decreases in ureteral complications, warm ischemia time and graft dysfunction might be attributable to specific changes in our operative technique.
Adult↗
Urinary Tamm-Horsfall protein as a marker of renal transplant function.
In a total of 428 urine samples collected from 15 patients aged between 23 and 60 years after cadaveric kidney transplantation during a postoperative hospital stay, Tamm-Horsfall protein (THP) was quantitatively determined using the ELIAS SYNELISA-THP immunoassay. All patients were treated with azathioprine, cyclosporine, prednisolone, given an intraoperative high-dose single antilymphocyte globulin bolus and discharged with functioning grafts. In clinically uncomplicated courses, even after immediate transplant function, the recovery of graft function took on average 7 days. Thereafter the urinary THP excretion was relatively stable and amounted, on average, to 14.5 +/- 4.9 mg/24 h (i.e. was at the lower limit of normal urinary THP excretion). In cases of delayed onset of graft function of undetermined origin accompanied by extremely reduced urinary THP excretion, the functional recovery, whether spontaneous or brought about by treatment, was characterized by a continuous increase in urinary THP excretion. In connection with interstitial rejections urinary THP excretion seems not to be a recommendable diagnostic parameter. Daily measurement of urinary THP is, however, suitable for monitoring the functional state of transplanted kidneys.
Adult↗
Optimizing muscle synchronization after dynamic cardiomyoplasty. Two educational cases.
Muscle stimulator programming is fundamental in ensuring optimal latissimus dorsi graft function after cardiomyoplasty. The ventricle-muscle synchronization delay has a significant effect on graft function, but can be difficult to optimize. The established method for ensuring appropriate synchronization involves the use of M-mode echocardiography. We present two educational cases in which M-mode and Doppler echocardiography have been instrumental in illustrating electrophysiologic and haemodynamic factors which need to be considered in evaluating an appropriate synchronization delay.
Atrial Fibrillation↗
Effect of cyclosporine on the rate of renal function recovery after renal transplantation.
To assess the effect of cyclosporine therapy on the rate of renal function recovery after renal transplantation, patients with no clinical evidence of rejection and who were treated with either cyclosporine or azathioprine in addition to steroid therapy were studied (n = 74). Of the patients with immediate renal function (n = 57), those receiving organs from living, related donors had a faster recovery rate of glomerular filtration than patients with cadaveric grafts (azathioprine, 15 +/- 2 versus 7 +/- 1 mL/min/day, P = 0.0001; cyclosporine, 14 +/- 3 versus 6 +/- 1 mL/min/day, P = 0.001). Recipients of cadaveric grafts with delayed renal function (n = 17) had a decreased recovery rate of allograft function when treated with cyclosporine as compared to those treated with azathioprine (4 +/- 2 versus 6 +/- 1 mL/min/day, respectively; P = 0.026). Patients on azathioprine achieved better renal function (P = 0.01) than those on cyclosporine (recipients of organs from living, related donors, 59 +/- 5 versus 52 +/- 3 mL/min; recipients of cadaveric grafts, 52 +/- 5 versus 40 +/- 2 mL/min). Thus, even in this early period, cadaveric-graft recipients treated with cyclosporine demonstrate an apparent reduction in creatinine clearance when compared to patients treated with azathioprine.
Adult↗
Early graft function after living donor kidney transplantation predicts rejection but not outcomes.
Poor early graft function (EGF) after deceased donor kidney transplantation (DDKT) has been intensely studied. Much less is known about poor EGF after living donor kidney transplantation (LDKT). Data were collected on 469 LDKTs performed between 1/1/97 and 12/31/01 to determine risk factors for and outcomes associated with poor EGF, defined as either delayed or slow graft function (DGF or SGF). The incidence of DGF and SGF were 4.7% and 10.7%, respectively. Diabetic etiology (OR 2.22; p = 0.021) and warm ischemia time (WIT) (OR 1.05 per min increment; p = 0.0025) emerged as independently associated with poor EGF. Neither functional graft survival nor 1-year graft function differed among the EGF groups. However, DGF and SGF strongly predisposed to acute rejection (AR), which compromised functional graft survival (p = 0.0007) and 1-year graft function. Therefore, we conclude that diabetic etiology of renal disease and WIT are the dominant risk factors for poor EGF after LDKT. Poor EGF did not directly compromise functional graft survival but strongly predisposed to AR. We suggest that immunosuppression should be intensified in the poor EGF setting to maximize LDKT longevity, as AR does impair functional graft survival.
Diabetes Mellitus↗
Impact of intraoperative heparin on laparoscopic donor nephrectomy.
PURPOSE: At many centers systemic heparinization is performed during laparoscopic donor nephrectomy because of concerns regarding graft thrombosis. However, no consensus exists in this regard. We evaluated the impact of intraoperative heparin on donor and recipient outcomes. MATERIALS AND METHODS: Between September 2000 and February 2003, 79 consecutive patients underwent laparoscopic live donor left nephrectomy at our institution. They were sequentially divided into 2 groups, that is group 1-the initial 40 patients who intraoperatively received 5,000 IU heparin intravenously and group 2-subsequent patients who did not receive heparin. The 2 groups were well matched demographically. Data were compared using the paired 2-tailed t test. RESULTS: The 2 donor groups were comparable in regard to mean blood loss (139 vs 179 cc, p = 0.59), intraoperative urine output (1.6 vs 1.6 l, p = 0.74), warm ischemia time (4 vs 4.2 minutes, p = 0.52), operative time (3.5 vs 3.5 hours, p = 0.97), and cold ischemia time (75 vs 82 minutes, p = 0.38). Complications occurred in 1 patient in group 1 (rhabdomyolysis induced acute renal failure) and in 2 in group 2 (chylous ascites and lumbar vein injury, respectively). No graft was lost due to vascular thrombosis in either group. Recipient immediate, early and delayed (6-month) graft function was comparable between the 2 groups. Acute rejection occurred in 5 recipients in group 1 and 1 in group 2. There was 1 recipient death per group at delayed followup. CONCLUSIONS: Routine use of heparin during laparoscopic donor nephrectomy is not necessary. Because of its potential for causing intraoperative or early postoperative hemorrhage, we no longer routinely administer intraoperative heparin during laparoscopic donor nephrectomy at our institution.
Adolescent↗
The UNOS Renal Transplant Registry.
Based upon data reported to the UNOS Renal Transplant Registry between 1998-2001, the overall one- and projected 10-year graft survival rates for 31,720 cadaveric kidney transplants were 89% and 51%, and for 14,162 living donor transplants they were 95% and 68%, respectively. These results represent improvements of 15% and 13%, respectively, over the 10-year graft survival rates reported for transplants performed during 1987-1989. Repeat kidney transplants accounted for 14% of deceased donor kidney transplants during 1998-2001 and the 3-year graft survival rates were significantly lower for second (77%) and multiply regrafted (73%) than for recipients of a first transplant (79%; p < 0.001). About 1,200 newly defined expanded criteria donor (ECD) kidneys were transplanted each year between 1998-2001. ECD kidneys represented 15% of deceased donor kidneys and yielded a significantly poorer 3-year graft survival rate (68%) and half-life (7.1 years) than kidneys from normal donors over age 5 (81% and 11.9 years; p < 0.001). The graft failure rates (censoring death with a functioning graft) were similar among recipients aged 31-50 and those aged 51-70 comparing both ECD and normal kidneys. The effect of HLA matching on kidney graft survival remains essentially unchanged after 30 years even with remarkable improvements in immunosuppression. Considering transplants performed between 1995-2001, matching for antigens at the HLA-A,-B, and -DR loci resulted in a 16% higher projected 10-year graft survival rate when compared with grafts mismatched for 5-6 HLA antigens (p < 0.001). The 10-year graft survival difference associated with HLA matching in US transplants performed between 1979-1984 and reported to the UCLA Registry before the introduction of cyclosporine was also 16%. The 3-year graft survival rates for zero HLA-DR mismatched normal kidney grafts (excluding ECD kidneys) were 83%, the same as for recipients of 0 HLA-BDR mismatched grafts. Those with one or 2 DR antigens mismatched had significantly poorer outcomes (80% and 77%, p < 0.001). Living donor transplants from offspring to parents and from genetically unrelated donors including spouses increased more than 5-fold since 1994. In 2001 the number of non-spouse unrelated donors surpassed the number of spouses (701 and 616, respectively). Despite the growing number of these HLA-disparate living donor transplants, their 3-year graft survival rates and half-lives remain as high as those for related donors sharing one HLA haplotype with the recipient. Laparoscopic donor nephrectomy now accounts for more than half of living donor surgeries reported to UNOS. There was no difference in graft survival or in early graft function associated with the type of donor surgery for 19,223 living-donor transplants between 1998-2001. Kidney transplants from non-heartbeating donors are beginning to increase and despite a significantly higher incidence of delayed function, 3-year graft survival rate was 79% for transplants between 1998-2001, the same as for conventional brain-dead deceased donor transplants.
Graft Survival↗
The influence of preservation injury on rejection in the hepatic transplant recipient.
The records of 215 liver transplant recipients were reviewed and the degree of preservation injury was estimated by the initial aminotransferase levels. This was compared with the incidence of rejection found in the subsequent 30 days. Those with aspartate aminotransferase greater than 2000 U/L were classified as having severe preservation injury while those with ASAT less than 600 U/L were considered to have had minimal preservation injury. There were no significant differences between these groups in recipient age, sex, cold ischemia time, preoperative physical status, panel-reactive antibodies, or cytotoxic crossmatch. The solution used for organ preservation and the donor age were the only factors that were found to be significantly different between the groups. Older donors were more common in the severe preservation injury group. Severe preservation injury was found more frequently in grafts preserved in Eurocollins solution and the group with minimal preservation injury more frequently used Wisconsin solution. There was significantly more rejection seen in the severe preservation injury group (71%) than in the group without preservation injury (33%). Although there was more rejection in the severe preservation injury group, the rejections were not more severe as judged by the need for multiple courses of therapy or the need for OKT3. Recurrent rejection was also not more frequent in either group. Graft survival was worse in the severe preservation injury group, with a significant increase in early graft loss, but no difference in the frequency of chronic rejection. Recovery of graft function was also delayed in the preservation injury group.
Adenosine↗
Ischemic heart disease--major cause of death and graft loss after renal transplantation in Scandinavia.
Causes of graft loss and death were studied in 1347 recipients of primary renal transplants followed for 5 years after transplantation irrespective of graft function. Immunosuppression consisted of high or medium dose CsA and prednisolone or low dose CsA and prednisolone and azathioprine. In recipients of cadaver grafts, death with a functioning transplant was more common than graft rejection after the first posttransplant year, accounting for 49% and 41% of the graft losses, respectively. Of deaths with a functioning graft, 53% were due to ischemic heart disease (IHD) and 10% were due to other vascular disease. In the 55- to 64-year-old age group, the risk of death from IHD was 6.4 times higher in the transplanted nondiabetic patients, 8.6 times higher in the dialysis patients (European Dialysis and Transplant Association figures), and 20.8 times higher in the transplanted diabetic patients than in the general population (national figures). A multivariate Cox regression analysis showed that old age, diabetes mellitus, occurrence of acute rejection, pretransplant transfusions, delayed onset of graft function, and male gender were significant for death in IHD. We conclude that, in comparison to reports from other regions, Scandinavian renal transplant recipients are at high risk of dying of IHD. Future advances in long-term renal graft survival will depend largely on the success of preventing myocardial infarction and death in this patient population.
Adult↗
Lipopolysaccharide-binding protein as a new and reliable infection marker after kidney transplantation.
The early and reliable differentiation of rejections, viral infections and bacterial infections is one of the main problems after organ transplantation. One promising solution to this problem is the lipopolysaccharide-binding protein (LBP), which is regulated upwards in gram-negative sepsis and related conditions. Therefore, the aim of our study was to explore the diagnostic potential of LBP serum levels in well-defined, non-infectious and infectious events after kidney transplantation (KTx). In a retrospective study the LBP serum levels were measured in a total of 686 serum samples from 52 kidney graft recipients. In all pre-KTx sera tested, the mean LBP level was 8.8+/-3.5 microg/ml (reference range: 2.0-15.2 microg/ml). In 7 of 52 recipients without intraoperative T-cell depletion, the mean LBP level was significantly ( P<0.01) increased (13.0+/-1.5 microg/ml) at post-KTx day 1, but was within the reference range. In contrast, the intraoperative T-cell depletion by antilymphocyte antibodies resulted in a significant ( P<0.01) increase to 25.8+/-11.4 microg/ml (range: 13.3-47.2 microg/ml). In recipients with immediate ( n=14) or delayed ( n=9) graft function without any other complications, all post-KTx values (except the post-KTx peak) were within the reference range. In 10 recipients with steroid-sensitive rejections and in 11 recipients with steroid-resistant rejections, no rejection-associated changes of the LBP levels could be shown. In six recipients with cytomegalovirus infection, the detection of an antigenemia (pp65) also was not associated with alterations of the LBP levels. In addition, there was no correlation between LBP levels and the number of pp65-positive leukocytes in peripheral blood. In contrast, a strong elevation of LBP levels was seen in five recipients with gram-positive bacteremia as well as in other severe bacterial infections (e.g., purulent extravasate, heavily infected grafts, bacterial pneumonia and contaminated hematoma). In two recipients with superinfected (bacterial and mycotic or viral) Pneumocystis carinii pneumonias requiring assisted ventilation, LBP levels were elevated, too. Thus, in our study only systemic non-viral infections and massive lymphocytolysis were associated with elevated LBP serum levels.
Acute-Phase Proteins↗