CT-Based Hounsfield Units for Pre-donation Liver Steatosis Assessment: Enhancing Transplant Outcomes and Efficiency.

Steatotic liver grafts are associated with increased post-transplant complications and graft failure. The field of transplantation faces a challenge in the absence of a reliable pre-donation protocol for quantitatively assessing steatosis in cadaveric liver grafts. Current pre-donation evaluation protocols often involve non-contrast computed tomography (CT) scans of the chest and/or abdomen as an initial step in organ donation assessment. These routine scans have the potential to identify and quantify hepatic fat content when more than 20% of the liver parenchyma is affected. By incorporating both abdominal and thoracic CT scans during the donor workup, an assessment of the quality of the liver and spleen can be achieved. Our study is based on the hypothesis that a precise pre-donation evaluation utilizing Hounsfield units (HU) derived from CT images of the liver and spleen can provide transplant programs with crucial data regarding the extent of steatosis. This approach is envisioned as a significant advancement that could potentially eliminate the need for preoperative liver biopsies by offering essential information to streamline the evaluation process.

Therapeutic Donor Kidney Transplant Outcomes: Comparing Early US Experiences Using Optimal Matching.

Background: Therapeutic donors (TDs) are individuals who undergo organ removal for medical treatment with no replacement organ, and the organ is then transplanted into another person. Transplant centers in the United States have started using TDs for kidney transplantation (KT). TD-KT recipient outcomes may be inferior to those of non-TD-living-donor (non-TD-LD)-KT or deceased-donor (DD)-KT because of the conditions that led to nephrectomy; however, these outcomes have not been sufficiently evaluated. Methods: This was a retrospective cohort study using Organ Procurement and Transplantation Network data. Via optimal matching methods, we created 1:4 fivesomes with highly similar characteristics for TD-KT and non-TD-LD-KT recipients and then separately for TD-KT and DD-KT recipients. We compared a 6-mo estimated glomerular filtration rate (eGFR) between groups (primary endpoint) and a composite of death, graft loss, or eGFR <30 mL/min/1.73 m2 at 6 mo (secondary). Results: We identified 36 TD-KT recipients with 6-mo eGFR. There was also 1 death and 2 graft losses within 6 mo. Mean ± SD 6-mo eGFR was not significantly different between TD-KT, non-TD-LD-KT, and DD-KT recipients (59.9 ± 20.7, 63.3 ± 17.9, and 59.9 ± 23.0 mL/min/1.73 m2, respectively; P > 0.05). However, the 6-mo composite outcome occurred more frequently with TD-KT than with non-TD-LD-KT and DD-KT (18%, 2% [P < 0.001], and 8% [P = 0.053], respectively). Conclusions: Early graft function was no different between well-matched groups, but TD-KT demonstrated a higher risk of otherwise poor 6-mo outcomes compared with non-TD-LD-KT and DD-KT. Our results support selective utilization of TD kidneys; however, additional studies are needed with more detailed TD kidney information to understand how to best utilize these kidneys.

A Case Report of Triple Organ Transplantation From a Donor After Circulatory Death Using Thoraco-Abdominal Normothermic Regional Perfusion.

Organ transplantation with donation after circulatory death can potentially increase the donor pool. Here, we report the rare case of triple-organ (heart/liver/kidney) transplantation from a donor after circulatory death using thoraco-abdominal normothermic regional perfusion. The recipient was a 61-year-old man with end-stage heart failure, liver failure, and kidney failure secondary to arrhythmogenic right ventricular dysplasia. He received a heart/liver/kidney transplantation from a donor after circulatory death. The course was complicated with primary graft dysfunction of the heart that resolved on postoperative day 3. The patient was discharged on postoperative day 39. He has no evidence for rejection on heart biopsy, and all 3 organs exhibit stable function. The use of donation after cardiac death donors greatly increases the donor pool and should be considered for patients requiring multiorgan transplantation. The use of thoraco-abdominal normothermic reperfusion is not only a feasible method for multiorgan procurement but also provides enhanced protection for all transplanted organs.

Comparison of Short-Term Outcomes in Kidney Transplant Recipients from SARS-CoV-2-Infected versus Noninfected Deceased Donors.

BACKGROUND: Acceptable post-transplant outcomes were reported in kidney transplant recipients from donors with coronavirus disease 2019 (COVID-19); however, there are no comparative studies with well-matched controls. METHODS: This multicenter, prospective observational study, which included three transplant centers in the United States, enrolled 61 kidney recipients from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-infected deceased donors. Using optimal matching methods, we matched every recipient to three comparators receiving kidneys from SARS-CoV-2-negative deceased donors with otherwise highly similar characteristics in the same transplant centers to compare 6-month eGFR. RESULTS: Among recipients of SARS-CoV-2-infected donor kidneys, one recipient died with a functional graft within 6 months. Mean 6-month eGFR was not significantly different between SARS-CoV-2-infected and noninfected donor groups (55±21 and 57±25 ml/min per 1.73 m 2 , respectively; P = 0.61). Six-month eGFR in recipients from SARS-CoV-2-infected donors who died of reasons other than COVID-19 was not significantly different from those from SARS-CoV-2-negative donors (58±22 and 56±25 ml/min per 1.73 m 2 , respectively; P = 0.51). However, recipients from donors who died of COVID-19 had significantly lower 6-month eGFR than those from SARS-CoV-2-negative donors (46±17 and 58±27 ml/min per 1.73 m 2 , respectively; P = 0.03). No donor-to-recipient SARS-CoV-2 transmission was observed. CONCLUSIONS: Six-month eGFR was not significantly different between recipients of kidneys from SARS-CoV-2-infected and noninfected donors. However, those receiving kidneys from donors who died of COVID-19 had significantly lower 6-month eGFR. Donor-to-recipient SARS-CoV-2 transmission was not observed.

Persistent Bleeding after Coil Embolization of a Pancreatic Transplant Pseudoaneurysm: Should Covered Stents Be the Primary Management?

Life-threatening arterial complications after pancreatic transplantation can be dire. Pseudoaneurysms can be challenging to treat. There are multiple strategies to treat such complications. We present a case of pancreatic pseudoaneurysm which was initially treated by coiling followed by subsequent covered stent placement for a more durable outcome. We advocate for a "stent first" approach to these lesions if feasible.

Autotransplantation as a feasible intervention for combined nutcracker syndrome and Loin Pain Hematuria Syndrome.

Anterior Nutcracker Syndrome (NCS) can occur when the aorta and superior mesenteric artery compress the left renal vein. Loin pain hematuria syndrome (LPHS) occurs as kidney pain resulting from a past insult to the kidney, most commonly from nephrolithiasis. We herein present a case of previously treated NCS. Three months after treatment with GVT, the pelvic congestion was resolved but left flank pain continued concerning for undiagnosed Loin Pain Hematuria. Additionally, we present a treatment algorithm that provides a differential pathway for diagnosis and treatment of combined NCS and LPHS.

Robotic-assisted Kidney Transplantation With Simultaneous Bilateral Nephrectomies Is an Efficient, Feasible, and Safe Way to Manage Patients With Renal Failure Secondary to Adult Polycystic Kidney Disease.

Kidney transplantation has become the standard of care for end-stage renal disease secondary to adult polycystic kidney disease. Open surgical techniques remain the gold standard, although minimally invasive methods have gained traction in recent years. Native nephrectomy is frequently needed secondary to size or symptoms. Continued developments in surgical technology have allowed for the introduction of computer-assisted surgery (Robotics). We aim to describe the feasibility, safety, and efficiency of simultaneous laparoscopic bilateral nephrectomy and robotic-assisted kidney transplantation to treat end-stage renal kidney transplantation secondary to polycystic kidney disease. In this initial experience, 3 patients underwent kidney transplantation with a simultaneous bilateral nephrectomy. All patients tolerated the procedure well with no postoperative blood transfusions, dialysis, or surgical site infections. Simultaneous laparoscopic bilateral nephrectomy and robotic-assisted kidney transplantation may be feasible, safe, and efficient techniques. Complications were minimal, with short hospital stays. Supplemental Video; http://links.lww.com/TXD/A352.

Efficacy and utility of robotic single-access bilateral nephrectomy (r-SABN) in end-stage renal disease patients.

PURPOSE: Bilateral native nephrectomies are needed in ESRD patients with select indications in a pre-transplant setting. Yet, the perioperative morbidity is significant in this population. Herein we evaluate the efficacy and utility of r-SABN. METHOD: A total of 12 patients were consented at a single center. Of 12 patients, 3 patients did not meet study criteria and were excluded. Preoperative, perioperative, and postoperative data were prospectively collected from 9 patients from electronic health records and administered postoperative surveys. Patients were assessed at 30-180 days postoperatively for follow-up. RESULTS: Mean operative time was 204.3 ± 59.7 min (142.0-314.0) and estimated blood loss during operation was 94.4 ± 87.3 ml (25.0-300.0). The mean length of hospital stay was 2 ± 0.7 days (1-3) for all patients. Total post-operative opioid usage was normalized to morphine dose equivalents (MDE) and calculated to be 56.1 ± 30.4 mg (30.8-101.8). Patients experienced a fourfold and tenfold respective increase in weekly structural and incidental physical activity from 30 to 180 days postoperatively. There were no procedure related intraoperative or postoperative complications reported in the cohort. CONCLUSION: Overall, r-SABN afforded the patients low morbidity. Longitudinal studies are in progress to further assess the efficacy and outcome of this procedure. In a single-center study, we demonstrate r-SABN is viable and provides a novel tool for treatment of ESRD patients requiring this procedure.

One-Year Post Hoc Analysis of Renal Function for Live Kidney Donors That Were Enrolled in an Enhanced Recovery After Surgery Pathway With Ketorolac.

Background and Objective Opioid exposure is a concern after live donation for kidney transplants (LDKT). We previously theorized that an enhanced recovery after surgery (ERAS) pathway for LDKT will reduce perioperative narcotic use. The aim of this post hoc analysis of merged data from two ERAS trials was to review the one-year follow-up to determine if the exposure to ketorolac versus placebo had any significant impact on long-term kidney function after LDKT. Methods One-year post hoc analysis of merged data from two ERAS LDKT, prospective, double-blind, randomized clinical trials were combined involving a total of 72 patients undergoing nephrectomy for LDKT. Kidney functions of both the ERAS groups' versus placebo were compared prospectively and blinded at one year using estimated glomerular filtration rate (eGFR) and total protein (TP) in the urine in compliance with United Network for Organ Sharing (UNOS) live donor requirements. Results There was no significant difference in postoperative eGFR at one year between ERAS and placebo groups. TP urine at one-year post-operative was significantly lower in the ERAS cohort by 4.7 mg/dl (95% CI 0.48 ~ 8.82, p = 0.025). Conclusions The ERAS groups' exposure to ketorolac did not negatively affect kidney function at one year after LDKT.

Small bowel obstruction caused by a bezoar following an adult simultaneous liver-kidney transplantation: A case report.

BACKGROUND: Small bowel obstructions (SBOs) are common following a large intra-abdominal operation; however, SBOs caused by bezoars are unreported in patients following liver-kidney transplantation procedures, particularly in adults. CASE SUMMARY: A 65-year-old Caucasian female presented with nausea and nonbilious emesis during her postoperative course following a simultaneous liver-kidney transplantation. She developed worsening nausea and vomiting with significant abdominal distension and obstipation. Computed tomography imaging showed a marked abnormal dilation of multiple small bowel loops with a distinct transition point that was suggestive of a small bowel obstruction. An exploratory laparotomy revealed a foreign body in the intestinal track approximately 30 cm from the ileocecal valve. The foreign body was extracted and identified as a bezoar with hair follicles and old digestive contents. Following the operation, the patient demonstrated rapid clinical improvement with resolution of nausea, emesis, and progress in bowel motility. CONCLUSION: SBOs caused by bezoars can occur immediately following a liver-kidney transplantation and should not be discounted as a diagnosis.

Page kidney phenomenon in kidney allograft following abdominal trauma.

The page kidney phenomenon is often associated in patients with abdominal trauma. External compression from a renal hematoma can cause hypertension, and presentation can be delayed following the initial injury. For patients who have a kidney allograft, page kidneys may lead to renal insufficiency and acute renal failure due to the absence of a contralateral kidney to compensate. This case report discusses the identification and management of a page kidney in a kidney allograft recipient within three months following transplantation.

Successful Utilization of a Live Donor Kidney with Angiomyolipoma.

The gap between the kidney transplant recipient list and the number of organs available for transplantation continues to grow. Kidneys from living donors are a major source of high-quality organs. However, they commonly have benign conditions such as cysts and benign tumors that present as operative challenges. This case presents a donor kidney that had a benign angiomyolipoma. The kidney was donated in a standard, minimally invasive fashion. The tumor was then removed on the back table and transplanted without an issue. Both donor and recipient enjoyed a speedy recovery with no significant complications.

Renal Auto-Transplantation for Loin Pain Hematuria Syndrome Using a Multidisciplinary Team Model: Intermediate-Term Results.

Background Patients with loin pain hematuria syndrome (LPHS) can find relief via multiple modalities, few provide long-term pain control like renal auto-transplantation (RAT). This study evaluates the intermediate effectiveness of the RAT procedure's ability to achieve long-term pain control and quality of life improvement. Methods All patients with suspected LPHS were seen by a multi-disciplinary team (MDT) composed of urologists, interventional radiologists, and transplant surgeons. Clinical history and physical exam, lab values, imaging findings, and response to renal hilar block (RHB) were used to determine LPHS and candidacy for potential RAT. Preoperative, one-year, three-year, and five-year postoperative pain assessment scores and quality of life surveys were administered to each LPHS and potential RAT patient. Results Eighty-four LPHS patients were referred for the evaluation of and consultation for the option of RAT. Sixty-four of these patients underwent RHB of which 60 (93.8%) had a positive response, defined as a temporary reduction of pain score by >50%. Forty-six of the 60 patients who responded favorably proceeded to RAT. At the one-year follow-up, there was a 75% reduction in pain with 88.9% of patients experiencing a 50% reduction in pain. At one year, the mean Beck Depression Inventory (BDI) decreased by 65.4%, from an average of 23.7 to 8.2. Similarly, at three years (n = 5) and five years (n = 3), the mean pain scores were 2 and 1. Conclusions The MDT evaluation of potential LPHS patients with our protocol and treatment results in an improvement in pain and depression scores in these selected patients.

Two-stage Enteric Exclusion to Salvage a Pancreas Transplant After an Early Post-transplant Leak.

Early technical complications after pancreas transplantation are almost always unsalvageable. The two most common complications are vascular thrombosis and duodenal anastomotic leaks. We present a case of a duodenal stump leak that led to a large abscess and severe sepsis. The pancreas was salvaged by repairing the leak and creating a proximal diverting ileostomy. Several months later, the ileostomy was reversed. This was done by creating a defunctionalized Roux limb to exclude the pancreas. The patient healed well and continued to enjoy excellent glucose control.

Renal hilar block predicts long-term success of renal auto-transplantation for loin pain hematuria syndrome.

PURPOSE: In patients with loin pain hematuria syndrome (LPHS), a response to percutaneous renal hilar blockade (RHB) and a multidisciplinary team (MDT) evaluation predicts patient's potential renal auto-transplantation (RAT) success. METHODS: A pain assessment was performed using a 0-10 numeric pain rating scale prior to a percutaneous RHB under CT guidance. If the pain score was reduced > 50% immediately after the RHB, patients were evaluated for RAT by a MDT. Pre-operative and 1-year post-operative quality-of-life surveys were administered to each RAT patient. RESULTS: 43 LPHS patients were referred for RHB. Of the 38 patients who received a RHB, 31 had > 50% reduction in pain scores. Pre- and post-RHB mean pain scores were 6/10 and 0.7/10, respectively, in patients who had > 50% reduction in pain. 22 of the patients who responded favorably then proceeded to RAT. Twelve patients had at least 1-year follow-up after RAT. All patients had a meaningful decrease in their pain. Mean pain score at 1 year was 0.8/10 for an 85% overall reduction in pain. 92% of patients experienced a ≥ 50% reduction in pain at 1 year. Mean Beck Depression Inventory (BDI) score (0-66) 1 year after RAT decreased from 25.2 pre-op (moderate depression) to 12.8 post-op (minimal depression). CONCLUSIONS: A MDT approach utilizing a RHB should be considered as a tool to select appropriate LPHS patients for RAT to achieve long-term success in reducing chronic pain and depression while increasing quality of life.

Prospective, double-blind, randomized clinical trial comparing an ERAS pathway with ketorolac and pregabalin versus standard of care plus placebo during live donor nephrectomy for kidney transplant.

Opioid exposure is a concern after live donation for kidney transplant. We theorized that an enhanced recovery after surgery pathway (ERAS) using pregabalin preoperatively to desensitize nerves followed by the nonsteroidal anti-inflammatory drug ketorolac, during and after surgery, can control pain, thus requiring less perioperative narcotics. The aim of this study was to determine if the use of a nonopioid analgesic ERAS protocol for donor nephrectomies could decrease the use of narcotics without an increase in complications compared with standard of care (SOC). This is a single-center, prospective, double-blind, randomized clinical trial involving a total of 62 patients undergoing nephrectomy for live donor kidney transplant. Length of hospital stay (LOS) was significantly reduced by 10% in the ERAS group versus the SOC-plus-placebo group. Morphine dose equivalents were significantly reduced by 40% in the study group versus the SOC-plus-placebo group. The use of this nonopioid analgesic ERAS pathway for donor nephrectomies decreased the use of narcotics without an increase in complications compared with SOC. There was significantly reduced LOS and less narcotic use in the study group versus the SOC-plus-placebo group. (ClinicalTrials.gov registration number: NCT03669081).

Evaluating a Change in Surgical Antibiotic Prophylaxis in Kidney Transplant Recipients.

The purpose of this study was to retrospectively evaluate if a change in practice from January 2013 to August 2015 affected the rate of surgical-site infections following kidney transplantation at the single academic medical center. More patients were found to have a surgical-site infection when surgical antibiotics were only given intra-operatively despite a lower incidence of risk factors identified in the literature when compared to the cohort who received antibiotics intra-op and post-op for 24 hours.