A case-control comparison of the results of renal transplantation from heart-beating and non-heart-beating donors.

INTRODUCTION: The decline in heart-beating brainstem dead organ donors has necessitated the search for other organ sources. In the field of renal transplantation one alternative source currently available, but little used, is that of kidneys from non-heart-beating donors (NHBD). Reticence to use NHBD kidneys is in part due to concerns over the effect that warm ischemic may have subsequent graft function. Presented here are the results of the NHBD renal transplants at the Leicester transplant unit, and compared with matched heart-beating donor transplants as a case control analysis. METHODS: In order to analyze any differences in graft performance between the two organ sources, the confounding effect of other variables known to influence the outcome of renal transplantation was minimized by matching NHBD and HBD transplants for the following criteria: donor age and sex, first or re-transplant, anastomosis and cold times, tissue match and PRA sensitisation. Transplant performance was assessed primarily by graft survival, the statistical evaluation of which was by log rank analysis of Kaplan-Meier curves. RESULTS: 72 NHBD and 192 HBD transplants were performed over an eight year period. Of the 192 HBD transplants, 105 matched one or more of the NHBD by the criteria outlined above, and thus constituted the control group for comparison. There was no significant difference in overall graft survival between the two groups. The 5 year survival for the NHBD was 73% compared with 65% for HBD kidneys. When death with a functioning graft is treated as censored data, then these figures become 75% and 81% respectively, again without statistical significance. CONCLUSION: NHBD kidneys are a valuable additional source of organs for transplantation, with long-term survival, comparable to transplants from HBD.

Surgical anatomy of the parathyroid glands in secondary hyperparathyroidism.

Parathyroidectomy is commonly required in patients with hyperparathyroidism secondary to end stage renal failure. Most descriptions of parathyroid anatomy are based on studies of normal glands. The details of parathyroid anatomy in 60 consecutive patients undergoing total parathyroidectomy for hyperparathyroidism secondary to renal failure are presented. Comparisons are made with the anatomical locations in series of normal glands. Based on these findings a strategy is proposed for the successful identification of all the parathyroid glands in patients undergoing parathyroidectomy for renal hyperparathyroidism.

Arteriovenous fistula using transposed basilic vein.

BACKGROUND: Patients who need long-term haemodialysis often require multiple operations to maintain their vascular access. The options for secondary or tertiary access procedures may become increasingly limited. Prosthetic conduits are commonly used in difficult cases but are associated with a high incidence of complications. METHODS: The brachial artery-transposed basilic vein arteriovenous fistula has been used in preference to a prosthetic graft on 31 occasions. RESULTS: There were no technical failures and 28 of these fistulas matured. No major infective complications occurred. CONCLUSION: This procedure should be considered before resorting to a prosthetic graft for vascular access.

Urological complications in renal transplantation: impact of a change of technique.

OBJECTIVE: To determine whether the change from the Leadbetter-Politano technique to a stented extravesical technique for the vesico-ureteric anastomosis in renal transplantation has altered the incidence of urological complications. PATIENTS AND METHODS: Data were retrieved from a prospective computerized database and by case-note review on 248 consecutive renal transplants performed between January 1990 and June 1996. The characteristics of the donor. recipient and organ were noted, together with the technique used for the vesicoureteric anastomosis and the occurrence of major and minor urological complications. RESULTS: The Leadbetter-Politano technique was used in 140 transplants and the stented extravesical technique in 108. There were no significant differences in the donor, recipient or organ characteristics between the groups. The stented extravesical technique was associated with a significantly lower rate of major complications (< 2%) and clinically significant haematuria than with the Leadbetter-Politano technique. CONCLUSION: Changing from the Leadbetter-Politano technique to a stented extravesical technique for the vesico-ureteric anastomosis has been a major factor in reducing the incidence of urological complications in our transplant practice.

Work-load generated by the establishment of a non-heart beating kidney transplant programme.

The work-load generated by a non-heart-beating donor (NHBD) kidney transplant programme over a 3-year period is reported. A total of 73 referrals were made, 64 from the Accident department and 9 from the wards. Organ procurement was performed in 24 cases (33%) and resulted in the retrieval of 44 kidneys. Reasons for failure to achieve organ procurement were; refused consent (n = 13; 18%), relatives unavailable to ask for consent (n = 9; 12%), technical problems with catheter insertion or perfusion (n = 10; 14%), transplant staff unavailable (n = 1; 1%), long asystolic period (n = 8; 11%) and donor unsuitable for other reasons (n = 8; 11%). Of the 44 kidneys retrieved, 30 were transplanted locally, 8 were transplanted at other United Kingdom centres and 6 were discarded. Locally transplanted NHBD kidneys represented 21% of the total transplant programme during the time period under study. We conclude that NHBD kidneys are a good source of additional organs for transplantation, but only one-third of referrals result in a successful procurement procedure. Moreover, the setting up of a successful programme is labour-intensive and requires a highly committed staff.