Native nephrectomy in transplant patients with autosomal dominant polycystic kidney disease.

INTRODUCTION: This study examined the clinical indications and timing for native nephrectomy (NN), together with the associated pathological findings in transplant patients with autosomal dominant polycystic kidney disease (ADPKD) at our institute over a period of 20 years. METHODS: A retrospective review was performed of ADPKD patients who had undergone both kidney transplantation and NN. Patients were identified from the kidney transplant database between 1988 and 2008 at Guy's and St Thomas' Hospital and the notes reviewed. All NN specimens were re-reviewed and reported according to current guidelines. RESULTS: There were 157 kidney transplants performed for ADPKD (114 cadaveric and 43 living donor). Of these, 31 required NN (28 bilateral). The timing of NN was pre-transplant in 10 cases, at the time of the transplant in 1 case and post-transplant in 20 cases. The indications for NN were urinary tract infection (n=14, 45%), pain (n=12, 39%), tumour suspicion (n=3, 10%), haematuria (n=1, 3%) and space (n=1, 3%). Mortality in this NN series was 3%, with a 65% surgical morbidity rate. The length of hospital stay post-NN was significantly longer with open compared with laparoscopic techniques (p=0.003). There were two renal cell carcinomas (RCCs) in this series. Both patients presented with macroscopic haematuria (bilateral pT1a papillary RCCs in one case and a pT3b clear cell RCC in the other case). The incidence of RCC in this series of ADPKD transplant patients was 1.3%. CONCLUSIONS: We have demonstrated that the majority of ADPKD patients do not require NN, with only 20% of our series undergoing this procedure. The timing of NN is variable and dictated by indication. NN was only required to make space for transplantation in one case (combined kidney and pancreas transplant). The main indications for NN were recurrent infection and pain, where NN can provide a successful outcome. Laparoscopic NN can be performed safely in patients with ADPKD. Haematuria in such patients should not be assumed to be of benign origin and requires exclusion of urinary tract malignancy as the incidence of RCC in this population is at least as common as in the general population.

Intraoperative assessment of kidney allograft perfusion by laser-assisted indocyanine green fluorescence videography.

BACKGROUND: Kidney allograft function crucially depends on the quality of organ perfusion. Duplex sonography, however, frequently reveals hypoperfused segments that remained undetectable to visual inspection intraoperatively. To date, no imaging system supplementing the surgeon's experience has achieved clinical acceptance. The present work examines whether laser-assisted indocyanine green (ICG) fluorescence-videography can be used as a safe and sensitive technique for the intraoperative assessment of renal allograft perfusion. METHODS: Intraoperative assessment of organ perfusion by laser-assisted ICG fluorescence videography (IC-VIEW) was performed in 10 consecutive de novo renal transplantations. The IC-VIEW system allows the visualization of graft perfusion by the fluorescein dye ICG that emits infrared light after exposure to laser light. RESULTS: Perfusion measurements were successful in all 10 transplant recipients. Fluorescence videography produced brilliant, sharply contrasted images of the organs, allowing the detection of even small perfusion deficits. Remarkably, this technique detected 1 large perfusion defect that had remained imperceptible to visual inspection. Repositioning of the graft led to a homogeneous overall perfusion. There were no complications with the ICG injection or the imaging device. CONCLUSION: Laser-assisted ICG fluorescence videography is a feasible and safe technique for the intraoperative assessment of renal allograft perfusion.

Pressure ulcer predictors in ICU patients: nursing skin assessment versus objective parameters.

OBJECTIVE: To evaluate objective parameters and subjective nursing assessment as pressure ulcer risk factors for intensive care unit (ICU) patients, and compared them with the performance of a general assessment tool (Waterlow scale). To validate the newly developed assessment method. METHOD: This prospective epidemiological study involved 698 patients admitted to an ICU between April 2001 and December 2004 without pressure ulcers and who stayed in the ICU for more than 72 hours. Objective parameters routinely determined during the first 24 hours in the ICU as well as subjective nursing assessment on admission were analysed for their significance as pressure ulcer risk predictors. RESULTS: Of the 698 patients 121 (17%) developed pressure ulcers in the ICU. With univariate analysis, a variety of objectively measurable parameters relating to organ dysfunction, circulatory impairment and sepsis showed significant association with the occurrence of pressure ulcers. When multiple logistic regression was performed, subjective nursing skin assessment parameters outweighed these parameters as pressure ulcer risk predictors. A risk function comprised of five skin-related and one other parameter yielded an overall correct pressure ulcer prediction proportion of 84.6%. With receiver-operator characteristic curve analysis, the area under the curve (AUC) was 0.82. Results were validated in 329 patients treated in the same ICU between January 2005 and May 2006, yielding an AUC of 0.80. CONCLUSION: Nursing skin assessment is an important pressure ulcer risk stratification tool in the ICU despite the availability of a large number of objectively measureable ICU specific parameters in these patients.

Performance of a minimally invasive uncalibrated cardiac output monitoring system (Flotrac/Vigileo) in haemodynamically unstable patients.

BACKGROUND: Early haemodynamic assessment is of particular importance in the evaluation of haemodynamically compromised patients, but is often precluded by the invasiveness and complexity of the established cardiac output (CO) monitoring techniques. The FloTrac/Vigileo system allows minimally invasive CO determination based on the arterial pressure waveform derived from any standard arterial catheter, and the algorithm underlying CO calculation was recently modified to allow a more precise estimate of aortic compliance. METHODS: Using the new software, we studied 25 haemodynamically unstable patients who had a radial artery catheter and underwent invasive haemodynamic monitoring with the PiCCO system. PiCCO-derived transpulmonary thermodilution and pulse contour CO (reference-CO) were compared with the CO values obtained with the FloTrac/Vigileo system (AP-CO). Reported CO values are indexed to body surface area. Agreement between reference-CO and AP-CO recorded during routine clinical care was assessed using Bland-Altman statistics. RESULTS: Overall bias between the reference-CO and the AP-CO (n=324) was 0.68 litre min(-1) m(-2) with a high percentage error of +/- 58.8% (95% limits of agreement +/- 1.94 l min(-1) m(-2)). There was a significant difference (P<0.001) between the radial and the femoral mean arterial pressures, and bias was significantly larger for a mean pressure difference of >5 mm Hg (0.93 vs 0.57 litre min(-1) m(-2), P=0.032). No connection was found between the norepinephrine dose and the CO agreement. CONCLUSIONS: Despite the updated algorithm, AP-CO still showed a limited agreement with the reference-CO and systematically underestimated the CO so that the method is not suitable to replace invasive CO monitoring at present.

A systematic review of hand-assisted laparoscopic live donor nephrectomy.

We provide a systematic review of hand-assisted laparoscopic live donor nephrectomy (HALDN), a relatively new procedure. Medline search of HALDN between 1995 and 2002 was conducted. Published studies were scored by two independent assessors using a modified form of 11 generic questions. All questions required one of three responses: 0--criterion not reported, 1--criterion reported but inadequate, 2--criterion reported and adequate. The studies were placed according to their scores in category A (score 20-22), category B (17-19) and category C (16 or less). Higher scores indicate better quality of studies. Where possible, statistical analysis of comparative data was performed. Most reports of HALDN are expert series, some comparative and a few prospective. There was good correlation between the assessors (r = 0.91), and of the seven published series on HALDN, two fell into category B and five into category C. At present, there is only one published randomised-controlled trial of HALDN vs. open donor nephrectomy; this is the only such trial in laparoscopic urology. HALDN allows kidneys to be harvested with short operating and warm ischaemia times and fewer ureteric complications. HALDN is a relatively new and effective technique, designed to make kidney donation more attractive and minimally invasive without affecting recipient outcomes. More prospective data of this technique is needed, and wide variation in reported outcome parameters need to be standardised to allow meaningful comparison.

Renal function following pregnancy in renal transplant recipients.

We set out to analyse the effect of pregnancy and hypertension in renal transplant recipients and review serum creatinine levels as a marker of graft function, before, during and after pregnancy. The study was conducted at a major tertiary referral centre in London. This was a retrospective analysis of renal transplant patients who had achieved a successful pregnancy. During the period 1967-1998, there have been 272 women of childbearing age with successful renal transplants functioning for over 1 year. Within this population there have been 66 pregnancies in 41 patients resulting in 53 births. Among the pregnancies that progressed beyond 24 weeks, preterm delivery occurred in 32 (60.4%). The mean gestation was 35.7 (range 30-41), mean birth weight was 2365 grams (range 908-3430 grams) with 47%of infants weighing <2500 grams. There were vaginal deliveries in 14 (26%), the rest delivered by caesarean section. Patients that developed hypertension in late pregnancy tended to have higher pre-pregnancy creatinine levels and a deterioration of graft function postpartum. Serum creatinine levels greater than 130 micromol/l before pregnancy predict deteriorating renal function postpartum. Kaplan-Meier life survival analysis showed that the risk of subsequent graft loss is associated with increased serum creatinine levels (130-180 micromol/l) before pregnancy. Pregnancy figures in our unit are favourable compared to those reported in the literature. Poor pre-pregnancy renal function (creatinine 130-180 micromol/l) and previous hypertension is associated with a significant risk of graft failure. Creatinine levels currently deemed as being acceptable during the pregnancy of renal transplant recipients may need to be reappraised.

The asystolic donor syndrome: transaminitis and thrombocytopenia after non-heartbeating renal transplantation.

BACKGROUND: The use of kidneys from non-heartbeating donors (NHB) remains controversial. An increased incidence of delayed primary function and primary nonfunction is common. We report a characteristic syndrome of transaminitis and thrombocytopenia after NHB renal transplantation, which may be predictive of graft outcome. METHODS: Two case histories are presented, followed by a retrospective analysis of 38 NHB renal grafts performed at Guy's Hospital from 1988 to 1994. Changes in alanine aminotransferase (ALT) and platelet count were compared between recipients of kidneys from NHB and heartbeating donors (HB). To control for possible effects of antilymphocyte globulin (ALG), two matched control groups receiving HB kidneys with (n=32) and without (n=32) ALG were also compared. RESULTS: ALT was elevated in 32 of 38 (84%) of NHB recipients and 19 of 64 (30%) controls (P<0.001). Mean peak ALT was 172+/-20 U/L in NHB and 42+/-6 U/L in HB kidneys (P<0.001). Use of ALG did not influence mean peak ALT. Elevated ALT predicted impaired graft function (P<0.02) and was associated with an increased length of delayed primary function (P<0.001) and risk of transplant nephrectomy (P<0.05). Thrombocytopenia (<100 x 10(9) cells/L) occurred in 18 of 38 (47%) NHB recipients and in 20 of 64 (31%) controls (P<0.05). Mean nadir platelet count (x 10(9) cells/L) was 113+/-10 in NHB, 128+/-9 in HB with ALG, and 164+/-9 in HB without ALG (both P<0.05 vs. NHB). Patients who underwent graft nephrectomy (n=9) had a disproportionate fall in platelet count (mean nadir, 80+/-11 x 10(9) cells/L; P<0.05). CONCLUSIONS: Transaminitis and thrombocytopenia occur commonly after NHB kidney transplantation and are predictive of graft outcome. Recognition of these changes may assist the early management of NHB renal recipients, and also reduce investigation of "anomalous" results in this setting.

The ontogeny of adhesion molecules expressed on the vascular endothelium of the developing human skin.

One of the important functions of adhesion molecules is to regulate the trafficking of lymphocytes and other leucocytes between the different organs and tissues of the body. These molecules are expressed on both the endothelial cells and the leucocytes, enabling them to adhere to one another and ultimately lead to extravasation of the leucocytes from the circulation into the surrounding tissue. P and E-selectin promote 'rolling' of leucocytes along the blood vessel walls, whereas ICAM-1 and VCAM-1 mediate subsequent firm adhesion, thus committing the leucocytes to extravasation. We have investigated the expression of the above endothelial adhesion molecules in relation to the developing dermal vasculature of fetal skin using histology and immunocytochemistry. This study showed that already at 11 wk of gestation some dermal vessels expressed P-selectin and ICAM-1. However, by 18 wk these molecules were identified on a significant number of vessels, including small capillaries supplying the forming dermal pegs. In contrast, E-selectin and VCAM-1 molecules were rarely seen in all specimens examined. Our results show that even at 11 wk of gestation, the fetal skin has a mechanism in place for circulating leucocytes to extravasate and provide primitive immunosurveillance. Furthermore, the similarities between the distribution of P-selectin and ICAM-1 in the 18 wk fetal skin and in the normal adult skin were striking. These findings may shed light on our understanding of how the fetus detects and reacts to infections and may, in the future, lead to advances in the management of some intrauterine infections.

How to initiate a marketing perspective in a health services organization.

Recognizing employees as the initial market of a health services organization epitomizes the internal marketing concept in action. A training module is presented to focus on the marketing role of all personnel and to involve many employee groups as active participants in the marketing process.

Canine pancreatic endocrine function after interruption of pancreatic exocrine drainage.

Pancreatic endocrine function was studied in forty dogs after ligation or free i.p. drainage of the pancreatic duct, with or without simultaneous partial pancreatectomy. Shrinkage and fibrosis of the pancreas occurred in all dogs, with equal severity in the open duct and duct-tied groups. Fasting blood sugars remained within the normal range but fasting levels of plasma insulin and glucagon were reduced. Dynamic tests of endocrine function indicated that partial pancreatectomy reduced the insulin response to i.v. injection of dextrose or glucagon and delayed the reestablishment of glucose homeostasis. Glucose tolerance was normal in dogs with intact pancreases, but duct ligation was associated with deteriorating recovery after glucagon injection. The precise coordination of circulating glucose, insulin, and glucagon levels seen in normal dogs was lost in both partial and intact pancreas groups and these disturbances were attributed to the fibrotic changes arising from interference with the ductal drainage. Both ligation and free i.p. drainage of the pancreatic duct therefore resulted in abnormalities of islet function. When combined with partial pancreatectomy, both techniques were associated with significant pancreatic endocrine insufficiency.

Effect of two antibacterial mouth sprays and dentifrices on dental plaque and gingivitis in beagle dogs.

Plaque inhibition by dilute mouth sprays and dentrifrices containing benzethonium chloride and chlorhexidine gluconate was compared in beagle dogs. Agents with chlorhexidine gluconate produced less plaque than their benzethonium chloride or placebo counterparts, but the differences were not significant when compared to mean control scores registered during interexperimental recovery periods.