Development of an objective, standardized tool for surgical assessment of deceased donor kidneys: The Cambridge Kidney Assessment Tool.

Quality assessment in kidney transplantation involves inspection to identify negative markers of organ quality. However, there is a paucity of evidence guiding surgical appraisal, and currently there is no evidence to differentiate important features from those that can be safely ignored. We propose a method to standardize surgical assessment and derived a simple rule to rapidly identify kidneys suitable for transplantation. Donor and recipient data were recorded alongside clinical outcomes in a prospectively maintained database. We developed a proforma (Cambridge Kidney Assessment Tool, CKAT) and used it to assess deceased donor kidney transplants. Factors predictive of utilization were identified by multivariate and univariate logistic regression analysis of CKAT-assessment scores, and test performance was evaluated using standard 2 × 2 contingency tables. Ninety-seven kidneys were included at a single center (2013-2014), and 184 CKAT assessments were performed. A CKAT threshold of "Carrell + Perfusion >3" was highly specific (99%) and performed favorably to consultant opinion (specificity 95%). 96% of the kidneys implanted in accordance with the rule survived to 1 year (mean eGFR 45.3 mL/min/1.73 m2 ). To our knowledge, this is the first attempt to objectively define macroscopic features that are relevant to kidney utilization. Common language could support training in organ assessment and ultimately help address unnecessary discard of donor kidneys.

Outcomes of primary arteriovenous fistulas in patients older than 70 years.

BACKGROUND: The population of elderly hemodialysis patients is increasing, yet the most suitable approach for providing permanent hemodialysis access remains unclear. Here we report outcomes using an approach aimed predominantly at creating radiocephalic (RC) fistulas. METHODS: A single-center retrospective cohort study was performed in which access outcomes for primary arteriovenous fistulas created between January 1, 2005, and December 31, 2012, in patients aged 70 years or older were compared. RESULTS: During the study period, 204 RC, 1 brachiobasilic, and 9 brachiocephalic (BC) primary fistulas were created initially for patients requiring dialysis. Immediate failure rates for RC fistulas were lower than for BC fistulas but not significantly so (12% vs 22%; Fisher's exact text, P = .319). One-year primary and secondary patency for RC fistulas was 54% and 66%, respectively, and similar for those created in patients between 70 and 80 years old and in those older than 80 years. The secondary patency rate at 1 year for RC fistulas using cephalic vein of diameter <2.5 mm was lower than for fistulas created with cephalic vein >2.5 mm (49% vs 72%; log-rank test, P = .005). Creation of a BC fistula was associated with a significantly higher incidence of steal syndrome than with an RC fistula (10% vs 2%; Fisher's exact text, P = .009). CONCLUSIONS: RC fistulas formed in the elderly carry a lower risk of steal syndrome than BC fistulas and offer the potential for further revision surgery, such that acceptable secondary patency is achieved for RC fistulas formed using even small (<2.5 mm) cephalic veins.

Tattoo of vascular cannulation site as a self-cannulation aid.

BACKGROUND: Haemodialysis can be provided either in a healthcare setting or home environment. Patients receiving dialysis at home report a better quality of life. Patients or their carers must be able to cannulate their fistula confidently and independently when dialysing at home. METHOD: We describe a patient with a functional fistula which was difficult to palpate, leading to difficulties in cannulation and multiple referrals to the home therapies team. PROCEDURE: A series of discrete dots were tattooed to delineate the borders of the fistula and served to guide cannulation. RESULTS: Following this simple intervention, our patient was able to self-cannulate confidently, dialysing at home four times per week. There were no further referrals to the home therapies team. CONCLUSION: Permanent tattoo of the skin to guide cannulation can used when a fistula is difficult to palpate or if a further superficialisation procedure is not desired. Patients have to be made aware that the markings are permanent and might outlast the fistula.