Outcomes of kidney grafts refused by one or more centers and subsequently transplanted at a single United Kingdom center.

INTRODUCTION: The rate-limiting factor in kidney transplantation is the shortage of donor organs with resulting steady increase in patients on the transplant waiting list. In our center we have seen an increase in the use of kidneys refused as unsuitable by one or more centers in the United Kingdom (UK). This study was performed to analyze the outcomes of transplantation from kidneys refused by one or more centers and subsequently transplanted by our institution. METHODS: We performed a retrospective analysis using the UK Transplant database of donor grafts refused by one or more centers and subsequently transplanted by us from January 2000 to December 2005. We documented the reason for refusal, donor and recipient factors, incidence of graft rejection, and primary and delayed graft function. Graft function and patient survival at 3 years were compared with standard donor grafts. RESULTS: From January 2000 to December 2005, we performed 623 renal transplantations, including 60 (9.6% from donors who were refused by one or more centers and 402 "standard" donor grafts. The main reasons for initial refusal included: elderly donor 25% (median age, 61 years), better HLA match required 33.3%, anatomical 5%, medical history of donor 6.6%, virology 4.8%, prolonged cold ischemia time 3.3% (median, 33.5 hours), and organ damage 1.6%. The 3-year median creatinine levels of donor grafts refused by multiple centers was 126 mumol/L compared with 135 mumol/L for standard grafts (P = .97). Three-year graft and patient survival rates were 86.6% and 96%, for grafts refused by multiple centers and 87% and 95%, for standard grafts, respectively. Upon multivariate analysis none of the above variables were significant predictors of 3-year failure of grafts refused by multiple centers. CONCLUSIONS: Nearly 10% of kidney transplants in our center were performed with grafts refused by one or more centers as "unsuitable." The graft and patient survivals were similar to those of standard grafts. None of the factors for refusal of kidneys by other centers predicted graft failure at 3 years. There may be an element of subjective assessment and subsequently a "cascade effect" involved in refusal of some of these kidneys.

The risk of gallbladder cancer from polyps in a large multiethnic series.

BACKGROUND: The aim of this study is assess whether patients with Indian ethnic background are at an increased risk of developing gallbladder cancer (GBC) if they have been diagnosed with ultrasonic abnormalities of the gallbladder. METHODS: Between January 1998 and July 2006, 137,655 abdominal ultrasound examinations were performed in Leeds Teaching Hospitals NHS Trust. After the exclusion of repeat scans and those performed for renal or pelvic disease, 71,431 reports were included in this analysis. Patients in whom the diagnosis of GBC has been made without histology have been identified from the database of Northern and Yorkshire Cancer Registry and the presence of GBC was correlated with ultrasonic gallbladder abnormalities. RESULTS: Gallbladder polyps (GBP) were detected in 3.3% of patients and these were larger than 10 mm in 0.1% of the cases. Age above 60 years, Indian ethnic background, single GBP larger than 10mm, the presence of gallstones, severe gallbladder wall thickening and irregular thickening were independently associated with the higher odds of developing GBC. The prevalence of malignancy in those with GBP was significantly higher among patients with Indian ethnic background compared to Caucasian patients, 5.5% versus 0.08%, p<0.001. CONCLUSIONS: The presence of GBP, irrelevant of size, amongst patients of Indian ethnic decent, is an indication for further investigation and/or cholecystectomy.

Warm ischemia in transplantation: search for a consensus definition.

UNLABELLED: "Warm ischemia" is a term used to describe ischemia of cells and tissues under normothermic conditions. In the transplant setting, this term is used to describe two physiologically distinct periods of ischaemia: (1) Ischemia during implantation, from removal of the organ from ice until reperfusion, and (2) Ischemia during organ retrieval, from the time of cross clamping (or of asystole in non-heart-beating donors), until cold perfusion is commenced. These periods of warm ischemia differ in their nature and the magnitude of their pathophysiologic consequences. In much transplant literature, however, the term "warm ischaemia" is used to describe both of these periods indiscriminately. This paper attempts to produce a definition to distinguish between the two periods of warm ischemia. METHODS: We conducted a questionnaire survey of all UK transplant surgeons. The definitions proposed in the survey were: (a) warm ischemia and re-warm ischemia; (b) first warm ischemia and second warm ischemia; (c) in-situ warm ischemia and ex-vivo warm ischemia; (d) warm ischemia in donor and warm ischemia in recipient; (e) no opinion or other opinion. RESULTS: There was a 64% response rate among 134 consultants with no consensus definition being reached. The majority of consultants (31.4%) preferred the terms "warm ischemia in donor", and "warm ischemia in recipient" to distinguish the two periods. CONCLUSIONS: This paper highlights the need to adopt uniform terms to avoid confusion between different types of warm ischemia in transplantation.

The role of (99m)technetium-labelled hepato imino diacetic acid (HIDA) scan in the management of biliary pain.

OBJECTIVE: To assess the outcome of laparoscopic cholecystectomy on the basis of an abnormal provocative (99m)technetium-labelled hepato imino diacetic acid (HIDA) scan for patients with typical biliary pain and normal trans-abdominal ultrasound (TUS) scan. PATIENTS AND METHODS: Prospective data were collected for 1201 consecutive patients with typical biliary symptoms. Patients who were found to have a normal TUS and upper GI endoscopy subsequently underwent cholescintigraphy (HIDA scan). Patients with an abnormal HIDA scan, i.e.<40% ejection fraction with Sincalide (cholecystokinin octapeptide)--were offered cholecystectomy. Symptoms and histology were reviewed postoperatively. RESULTS: In all, 48/1201 (4%) patients with typical biliary symptoms had a normal ultrasound and endoscopy; 35/48 patients had an abnormal provocative HIDA scan and all underwent laparoscopic cholecystectomy. Histology in all cases revealed chronic cholecystitis and 18 patients had sludge or microlithiasis within the gallbladder. At 6-week follow-up, 31 of the 35 patients were completely asymptomatic or improved. Furthermore, 79% of patients remained symptom-free or improved at a median follow-up of 28.5 months (range 4-70). CONCLUSIONS: HIDA scan is a useful clinical tool as an adjunct to the diagnosis and management of patients who present with typical biliary pain and a normal TUS scan.