Exchange of best practices within the European Union: surgery standardization of abdominal organ retrieval.

Considering the growing organ demand worldwide, it is crucial to optimize organ retrieval and training of surgeons to reduce the risk of injury during the procedure and increase the quality of organs to be transplanted. In the Netherlands, a national complete trajectory from training of surgeons in procurement surgery to the quality assessment of the procured organs was implemented in 2010. This mandatory trajectory comprises training and certification modules: E-learning, training on the job, and a practical session. Thanks to the ACCORD (Achieving Comprehensive Coordination in Organ Donation) Joint Action coordinated by Spain and co-funded under the European Commission Health Programme, 3 twinning activities (led by France) were set to exchange best practices between countries. The Dutch trajectory is being adapted and implemented in Hungary as one of these twinning activities. The E-learning platform was modified, tested by a panel of Hungarian and UK surgeons, and was awarded in July 2013 by the European Accreditation Council for Continuing Medical Education of the European Union of Medical Specialists. As a pilot phase for future national training, 6 Hungarian surgeons from Semmelweis University are being trained; E-learning platform was fulfilled, and practical sessions, training-on-the-job activities, and evaluations of technical skills are ongoing. The first national practical session was recently organized in Budapest, and the new series of nationwide selected candidates completed the E-learning platform before the practical. There is great potential for sharing best practices and for direct transfer of expertise at the European level, and especially to export this standardized training in organ retrieval to other European countries and even broader. The final goal was to not only provide a national training to all countries lacking such a program but also to improve the quality and safety criteria of organs to be transplanted.

De novo Prograf versus de novo Advagraf: are trough level profile curves similar?

BACKGROUND: According to the clinical trials, Advagraf (ADV) has efficacy and safety profile similar to Prograf (PROG). The aim of this study was to compare the graft functions, dosages, and tacrolimus (TAC) trough level profile curves of patients on de novo PROG and ADV therapy. METHODS: The ADV group included 39 de novo renal cases who had received initial immunosuppression (IS) with once-daily TAC (1 × 0.2 mg/kg from day1 after transplantation). We compared them with a PROG group of 38 transplant patients who received equivalent IS with twice-daily TAC (2 × 0.1 mg/kg from day1). In both groups, the IS was combined with antimetabolites and steroids. The mean follow-up time was similar (13.5 ± 7 days) in both groups after renal transplantation until the emission of the patients from our clinic. RESULTS: TAC mean total daily dose was reduced and whole-blood trough levels decreased over the time in early postoperative days. Only on day 3 and day 4 after transplant, a significant higher adjustment in the ADV dosage was necessary to achieve sufficient TAC trough levels. The average TAC trough level profile curves were similar in PROG and ADV groups, but the individual curves were very different. Mainly in patients on ADV therapy, the initial concentrations were often >30 ng/mL, and in some cases on the 9th posttransplant day decreased to <5 ng/mL, then slowly increased into the required therapeutic range. CONCLUSIONS: The results demonstrate that patients after renal transplantation can be safely treated de novo with ADV. Setting the required therapeutic TAC blood levels may require more attention to avoid the "fluctuations" of trough level profile curve during the early postoperative period. Our data suggest that dose adjustment of ADV can be carried out more carefully compared with PROG on the basis of clinical symptoms and the value of TAC blood levels to avoid acute rejection and toxicity.

Endogenous thrombin potential and examination of a further 31 analytes in liver transplant candidates.

BACKGROUND: To predict the change in patient status and differentation of the basic diseases, endogenous thrombin potential (ETP), clinical chemistry, and coagulation variables were measured in liver transplant-listed patients with different etiologies. METHODS: Differences in values of ETP and analytes of 30 control persons and 164 cirrhotic patients were examined by means of binary logistic regression. The relationship between the analytes and ETP parameters were analyzed by means of Spearman correlation. The different etiologies of cirrhosises were studied by factor and discriminant analyses. Binary logistic regression was applied to forecast changes in clinical status. Survival analysis was carried out with the appropriate variable. RESULTS: International Normalized Ratio and activated partial thromboplastin time values were higher, whereas the area-under-the-curve values were lower in cirrhosis than in healthy subjects. A strong relationship was found only between the peak height and the anti-thrombin III (ATIII) values. In the factor analysis, 3 factors were found, which explained 81.6% of the total variance. Combination of aspartate aminotransferase and ATIII mostly separated the basic disease groups from each other in the discriminant analysis. From 35 variables, the lactate dehydrogenase (LDH) and ATIII have been suited for predicting the change in patient status. Eighty percent of patients with low ATIII and high LDH levels had deterioration of their clinical status. CONCLUSIONS: Our study demonstrated that the ETP parameters did not provide additional information compared with "conventional" coagulation tests in cirrhosis. On the basis of our study, LDH and ATIII appear to be promising analytes to assess the clinical status of patients with cirrhosis. In our opinion, the classification system of liver transplant-listed patients can be improved with their use.

Increasing living donor kidney transplantation numbers in Budapest.

Living related kidney donations (LRD) have had a significant impact on therapy of kidney diseases. Due to their ease of scheduling in the general surgery program and better half-life of about 21.6 versus 13.8 years for deceased donor kidneys, this approach has revolutionized nephrology and transplantation medicine. Since the first Hungarian LRD which was performed in 1974 in Budapest, Hungary, donations have expanded especially in the last 3 years. This has been followed in 2000 by living unrelated kidney donations (LURD). Since 2000 LURD can be also performed in Hungary. From the 251 LRD in our country in the last 3 years, 79 living donations have accounted for nearly one-third of the cases. In comparison of 2008, and 2011 the absolute numbers of LRD as well as LURD have more than doubled from 9 to 20 and 6 to 14 respectively. Based on international ranking data from the global observatory on donation and transplantation Budapest has improved from 1.20 in 2000 to 6.20 LRD per million persons (p.m.p.) in 2010. The increase in LURD has also led to some side effects: an increase in recipient age from 26 years in 2000 to 46 in 2011 and greater HLA mismatches. In 2010, Budapest ranked higher than Croatia or Portugal but still behind Germany (8.13 LRD p.m.p.) and the leading countries: the Netherlands (28.49 LRD p.m.p.) and Norway (16.94 LRD p.m.p.). Because of the tremendous progress in LRD, the gap between today's leading countries and Budapest is closing.

Kidney transplantation in hereditary coproporphyria using tacrolimus and mycophenolate mofetil: a case report.

BACKGROUND: The porphyrias are a group of disorders of the heme biosynthesis pathway that may present with acute life-threatening attacks, commonly exacerbated by a wide variety of medications. Many newer immunosuppressive medications, which are in use following kidney transplantation, have not been fully explored in acute porphyrias. CASE REPORT: A 53-year-old woman received a kidney from a deceased donor, after being on hemodialysis for 4 years. Hereditary coproporphyria was diagnosed at age 19 years. We administered tacrolimus, mycophenolate mofetil and steroid immunosuppression. In the immediate post-transplant periods she displayed abdominal pain and transient uroporphyrin elevation in parallel with slightly elevated (15 ng/mL) tacrolimus concentrations. As the target tacrolimus level was achieved, these findings disappeared. CONCLUSIONS: Tacrolimus, mycophenolate- mofetil, and steroid therapy for hereditery coproporphyri was safe, in the long term.

Successful treatment of renal failure caused by multiple myeloma with HLA-identical living kidney and bone marrow transplantation: a case report.

Here we have described a successful HLA-identical living allogeneic kidney transplantation after bone marrow transplantation in a patient with end-stag liver disease caused by multiple myeloma (MM). Our case is unique, because this combined transplantation is rarely possible and because of our unique immunosuppressive and management strategies. A 45-year-old man with ESRD MM and κ light-chain nephropathy was diagnosed. Cytostatic treatment resulted in partial remission, so autologous peripheral stem cell transplantation (SCT) was performed leading to a complete remission; however the patient remained anuric. The patient's HLA-identical brother offered to be a donor of peripheral stem cells for collection and cryopreservation. Kidney transplantation was performed with a combination of tacrolimus sirolimuns, and methylprednisolone. With a well-functioning kidney graft, allogeneic SCT was performed in the incipient relapse phase of MM, after total body irradiation. Severe oropharyngeal infections, diarrhea, sepsis, and renal failure. Fearing acute renal rejection, we administered steroid bolus. He experienced therapy with gradual restoration of kidney function. Then, steroid-responsive acute graft-versus-host disease (grade II, predominantly bowel) was diagnosed on the background of diarrhea, which returned once. Later he experienced a left subclavian vein thrombosis at the site of a central venous catheter and sepsis. Having recovered from these events, the patient enjoys good health, with stable kidney function and normal protein excretion. After the steroid was stopped, a bone marrow biopsy revealed full-donor type normocellular hemopoiesis. Because of the chimerism, we gradually discontinued the immunosuppression including, sirolimus and finally tacrolimus, since with minimal trough levels there were no complications. Bone marrow biopsy showed a complete remission. In MM with ESRD HLA-identical combined kidney and bone marrow transplantation from a living donor may offer not only complete remission and good renal function, but also good health without immunosuppression.

Examination of carbohydrate metabolism parameters after simultaneous pancreas-kidney transplantation.

End-stage renal failure, a frequent complication of type 1 diabetes mellitus, requires renal replacement therapy. Our team examined the laboratory parameters of carbohydrate metabolism in 18 patients with type 1 diabetes at 10 to 89 months after simultaneous pancreas-kidney transplantation. We compared these results with those of 17 patients with type 1 diabetes who had formerly received kidney-alone transplantations, and were undergoing insulin treatment, as well as with those of 16 metabolically healthy controls. The hemoglobin A1c (HbA1c) and blood glucose levels of the pancreas-kidney transplant recipients were within the normal ranges, not differing significantly from those of the healthy controls. In contrast, the HbA1c and glucose levels were significantly elevated among kidney transplanted diabetic subjects. However, fasting and 2-hour insulin levels of pancreas-kidney transplant patients were significantly higher than those of the controls, indicating insulin resistance. According to these results, the insulin secretion by the pancreas graft sufficiently compensated for insulin resistance. Thus 10 to 89 months after successful pancreas-kidney transplantation, carbohydrate metabolism by type 1 diabetic patients was well controlled without antidiabetic therapy.

Superiority of AbCross enzyme-linked immunosorbent assay cross-match over the B-cell complement-dependent lymphocytotoxicity cross-match.

BACKGROUND: The AbCross enzyme-linked immunosorbent assay (ELISA) cross-match is a recently introduced solid phase cross-match technique with several technical advantages over the currently available Antibody Monitoring System ELISA cross-match. METHODS: In the present study, we investigated the potential superiority of AbCross over the traditional complement-dependent lymphocytotoxicity (CDC) B-cell cross-match (BXM). Pretransplant sera of 271 kidney transplant recipients who were transplanted at our center between 1998 and 2010 were tested in ELISA screening for the presence of human leukocyte antigen (HLA) antibodies and in AbCross and CDC for antibody reactivity against solubilized donor HLA class I and II antigens and donor B cells, respectively. RESULTS: Patients positive for HLA class I or II antibodies on ELISA screening had a significantly poorer graft outcome 2 years after transplantation than recipients who were negative for HLA antibodies (21% vs 6% graft loss; P = .002). Corresponding with this finding, 37 recipients positive for HLA antibodies in AbCross against donor HLA class I or II antigens had a 2-year post-transplant graft loss rate of 19%, which is significantly higher than the 8% rate in 186 recipients who were negative for both antibody classes in AbCross (P = .043). The 2-year graft loss rate in 34 AbCross positive but BXM negative patients was 21%, compared with 7% in 172 AbCross and BXM negative patients (P = .012) and 9% in 11 AbCross negative but BXM positive patients (P = .39). CONCLUSIONS: Our data indicate that the AbCross ELISA cross-match is superior to the CDC BXM, most likely because it detects antibodies against donor HLA antigens at a higher sensitivity.

Efficacy of sotrastaurin plus tacrolimus after de novo kidney transplantation: randomized, phase II trial results.

Sotrastaurin, a novel immunosuppressant, blocks early T cell activation through protein kinase C inhibition. Efficacy and safety of sotrastaurin with tacrolimus were assessed in a dose-ranging non-inferiority study in renal transplant recipients. A total of 298 patients were randomized 1:1:1:1 to receive sotrastaurin 100 (n = 77; discontinued in December 2011) or 200 mg (n = 73) b.i.d. plus standard tacrolimus (sTAC; 5-12 ng/mL), sotrastaurin 300 mg (n = 75) b.i.d. plus reduced tacrolimus (rTAC; 2-5 ng/mL) or enteric-coated mycophenolic acid (MPA) plus sTAC (n = 73); all patients received basiliximab and corticosteroids. Composite efficacy failure (treated biopsy-proven acute rejection ≥ grade IA, graft loss, death or loss to follow up) rates at Month 12 were 18.8%, 12.4%, 10.9% and 14.0% for the sotrastaurin 100, 200 and 300 mg, and MPA groups, respectively. The median estimated glomerular filtration rates were 55.7, 53.3, 64.9 and 59.2 mL/min, respectively. Mean heart rates were faster with higher sotrastaurin doses and discontinuations due to adverse events and gastrointestinal adverse events were more common. Fewer patients in the sotrastaurin groups experienced leukopenia than in the MPA group (1.3-5.5% vs. 16.5%). Sotrastaurin 200 and 300 mg had comparable efficacy to MPA in prevention of rejection with no significant difference in renal function between the groups.

History of eurotransplant.

In 1967, the Dutch immunologist Jon van Rood called Eurotransplant into life. From the beginning it was a non-profit private foundation. Initially it was a loose cooperation, where tissue typing laboratories and transplantation centers joined to achieve a better result for their kidney patients, a longer survival based on better immunological matching from a bigger donor pool. Other centers from the Benelux states, Germany and Austria soon joined the first few cooperating centers. Switzerland was also a member of Eurotransplant, but left the organization in 1978. Based on the pioneering work of the Leiden histocompatibility lab, the allocation system became more and more sophisticated and was extended to other solid organs. Since the 1980s Eurotransplant has allocated donor livers, hearts, and pancreas. Thereafter, the allocation also included lungs and small bowel. From 1996 a new kidney allocation system, the ETKAS, was introduced, and after the Acceptable Mismatch program and the Eurotransplant Senior Program (known unofficially as "old-for-old" program) were introduced. The main principle remains to adapt the allocation rules continuously according to the newest scientific data serving all organs. In 1991 the German reunification centers in the former Eastern Germany became part of Eurotransplant. In 1999, Slovenia, and in 2007 Croatia joined Eurotransplant. For the transplant centers in these two countries, membership meant positive changes and is regarded as a success story. Both donor numbers and transplant possibilities increased and equal chances are assured for their patients on the common Eurotransplant waiting list. Hungary, joining Eurotransplant next year, hopes to experience the same.

Decrease in cold ischemic times as a result of protocol changes of urgent immunogenetic testing during cadaveric kidney transplantation in Hungary.

BACKGROUND: Based on national ethics committee permission, the procedure of urgent immunogenetics testing prior to cadaveric kidney transplantation was changed in Hungary from January 1, 2011 allowing HLA typing of the donor and prospective crossmatching using peripheral blood samples from the donor prior to the definitive declaration of brain death. The aim of the current study was to compare key indicators of transplantation primarily cold ischemic time [CIT], between time periods with outcomes. METHODS: The following indicators were systematically collected prospectively and retrospectively for each deceased heart-beating donor transplantation between January 1, 2010 and October 31, 2010 (n = 114) versus January 1, 2011 and October 31, 2011 (n = 91): CIT for the first and second kidney; laboratory turnaround times (TAT), and time for final preparation of the selected recipient. RESULTS: As a result of the new procedure, the CIT for the first kidney decreased from 16.5 ± 3.5 to 12.4 ± 3.2 hours (P < .001). Similarly, for the second kidney the parameters were a 19.8 ± 3.4 versus 16.0 ± 3.8 hours (P < .001). As a consequence of more hands-on time in the laboratory, the TAT increased from 5.6 ± 0.8 hours to 7.2 ± 1.1 hours (TAT1) followed by an additional 4.2 ± 1.0 hours (TAT2). We also compared the times necessary for preparation of immunologically suitable recipients for transplantation, namely, 9.5 ± 2.3 hours in the earlier system, increasing to 15.5 ± 4.3 hours during the new procedure. CONCLUSION: As a consequence of the procedural change, the CIT parameter decreased significantly for both kidneys, which may have contributed to improved short-term outcomes of transplantation. The time available for final preparation of selected recipients was increased allowing improvements in CIT.

Role of early systemic inflammatory response in simultaneous pancreas-kidney transplantation.

Pancreas grafts are susceptible to surgical complications mostly related to exocrine secretions and the low microcirculatory blood flow through the gland. During simultaneous kidney-pancreas transplantation, the systemic response depends on reperfusion of two organs acute graft pancreatitis, immunotherapy, coagulopathy, bleeding, and other factors. We performed a retrospective review of 10 adult simultaneous pancreas-kidney transplant patients to evaluate progression of early postoperative inflammation in the absence of infection. All patients were treated with four-drug therapy. We performed analyses of procalcitonin (PCT), C-reactive protein, serum creatinine, amylase, and lipase levels over the first 5 postoperative days. Relatively high peak PCT levels (maximum 130 ng/mL) were reached within 24 to 48 hours postoperatively followed by a moderate decrease. Consistent with this observation, the serum creatinine, amylase, and lipase levels decreased continuously to normal concentrations within the first week. The increased PCT levels seemed depend upon the surgical procedure and intraoperative events. PCT was superior to C-reactive protein to discriminate infection from inflammation in this setting. The dynamics of PCT levels, rather than absolute values, seemed to be important. Lack of a decrease in PCT levels after the peak, suggested an infectious complication or the development of sepsis. Monitoring and assessment of PCT levels may help in early recognition of infection and institution of therapy.

The safe introduction of angiotensin-converting enzyme inhibitor in renal allograft recipients.

Antihypertensive and renoprotective treatment with angiotensin-converting enzyme inhibitor (ACEI) or angiotensin II receptor blocker is indicated in almost all chronic renal failure patients. However, this treatment is not widely used for renal allograft recipients mainly because of the potential side effects, including a decrease in renal function as well as onset of hyperkalemia or anemia. Herein we investigated the effects of ACEI introduction to hypertensive renal transplantation patients who did not display renal artery stenosis. At least 2 months after transplantation, we exchanged amlodipine (5 mg) for either ramipril or perindopril (5 mg) in 25 patients who were free of renal artery stenosis as determined indirectly by measuring the renal arterial resistance index with the noninvasive, inexpensive Doppler ultrasound method. The resistance index was evaluated again at 2 weeks. Systolic and diastolic blood pressure, serum creatinine, calculated creatinine clearance, serum potassium, hemoglobin and hematocrit were also measured before as well as at 2, 4, and 12 weeks after conversion to ACEI. The conversion did not change the mean renal arterial resistance index, nor did it influence renal function or blood count, and it was equally effective for controlling blood pressure. The serum potassium level increased at 2 and 4 weeks; however, it was within the normal range in all patients. Our data suggested that measurement of the renal arterial resistance index is a noninvasive, inexpensive, and reliable preselection method before introduction of ACEI in renal allograft recipients.

Measurement and clinical significance of interleukin 28B in hepatitis C virus-infected liver transplant patients.

One-third of the liver transplantations are performed because of hepatitis C cirrhosis all over the world and also in Hungary. The recurrence rate is practically 100%, influencing graft and patient survivals; within 5 years cirrhosis develops again in 20% to 30% of cases. The therapy is pegylated interferon α-2a and α-2b plus ribavirin as for nontransplanted subjects with the goal to eradicate the virus and maintain graft function. In 25% to 45% of treated patients, it is possible to achieve a sustained virological response (SVR). The response is influenced by viral, donor, and recipient factors. We investigated the genotype of 68 liver recipients transplanted because of hepatitis C virus (HCV) infection between September 1998 and February 2011. We focused on the interleukin (IL) 28B gene locus single nucleotide polymorphism found on chromosome 19; the rs12979860 minor allele (homozygous [wild TT and CC], heterozygous [CT]) in relation to the interferon response. Ten percent of the patients belonged to the CC, 62% to the CT, and 28% to the TT group, and 83% of the CC group became negative or therapy is still ongoing. The CT genotype reached 15.4% SVR with ongoing treatment for most patients. In TT carriers showed a 23.5% SVR. Our patients formed a homogenous group regarding the surgical team, the therapy, and the HCV genotype. Ninety percent belonged to the possible "hard to treat" group. The 10% CC group gave the highest number of SVR and HCV polymerase chain reaction negativity upon antiviral therapy. Regarding our results, one has to take in consideration the small patient number and the fact that the cirrhotic patients were listed for transplantation where they could not be treated or became therapy-resistant. IL28B is just one predictive factor among others for successful posttransplant HCV therapy; further examinations are needed to fully understand its role.

Significance of mycophenolate monitoring in liver transplant recipients: toward the cut-off level.

Mycophenolate mofetil blocks the "de novo" -purine synthesis to reduce the incidence and severity of acute rejection episodes. There has been an increased interest in utility of monitoring mycophenolic acid (MPA) levels, however currently the MPA monitoring is not part of the protocol following liver transplantation. We assessed whether trough MPA monitoring could be advisable in liver transplant patients or not. For this reason MPA levels of 56 liver transplants were measured on 3, 5, 10, 14, 21, 30, 60, and 180 posttransplant days. The optimal cut-off of MPA level (≥1.73 mg/L) for all (56) and ≥1.34 mg/L for ciclosporin-treated- and ≥1.98 mg/L for the tacrolimus-treated transplants were calculated by statistical analysis to reduce the incidence of acute rejection. MPA concentrations of 3 days period before the day of clinical diagnosis acute rejection were well below the cut-off value. Only 3 (16%) out 19 patients with acute rejection had higher MPA levels than the cut-off value on the day of diagnosis of acute rejection. In conclusion, our data suggests that MPA predose level monitoring, especially in the early "filling phase" after transplantation, is applicable in liver allograft recipients given adjunctive MMF, protecting them from the ineffective immunosuppression.

Vladimir P. Demikhov, a pioneer of organ transplantation.

Vladimir P. Demikhov was born in a Russian peasant family in 1916. As a biology student at The Moscow University in 1937, he constructed a metal artificial heart and maintained the circulation of a dog for 5.5 hours. From 1946, after his military service, he worked in the Surgical Institute of The Moscow Academy of Sciences performing heterotopic heart transplantations in dogs. In 1947, he performed the first orthotopic lung transplant. Later he performed complex cardiothoracic transplantations as well as renal and hepatic transplantations. He restarted his investigations with the artificial heart and performed coronary bypass operations in dogs. In 1954 he performed a head transplantation, for which he gained worldwide infamy. Stalinist propaganda advertised this fact as the superiority of Soviet science. In fact, it was the upper body of a smaller dog to the neck of a bigger one. The two heads could eat and drink separately. But he could not overcome the problems of rejection, so the longest survival was 1 month among 20 such operations. His influence on the pioneers of transplantation is unquestionable. He was an innovative creative man, and many pioneers of transplantation highly appreciated his work. Demikhov contributed to clinical heart and lung transplantation by demonstrating the possibility of their experimental realization; furthermore, he motivated the pioneers of coronary bypass operations with his work. He died in 1998, but before that was honored with a high state award and the "Pioneer Award" of the International Society for Heart and Lung Transplantation.

Childbirth after organ transplantation in Hungary.

BACKGROUND: The first successfully delivered newborn after organ transplantation was reported in 1963; since then, >14,000 women have delivered after transplantation. Patients with an end-stage organ disease develop fertility disturbances. One year after a successful solid organ transplantation with stable graft function, fertile women can give birth to a child from a medical point of view. Pregnant transplant patients do experience a high risk of graft function worsening, a rejection episode, and opportunistic infections. Furthermore, the medical therapy may influence teratogenicity. METHODS: Between 1974 and September 1, 2010, 5 Hungarian centers performed 6802 solid organ transplantation and lungs were grafted in Vienna, Austria. The organ distribution was: 5971 kidney, 454 liver, 187 heart, 90 combined pancreas-kidney, 5 combined islet-kidney, and 95 lung transplantation. There were no pregnancies among heart, lung, and pancreas recipients. RESULTS: In all, 3.9% of the renal and 14.3% of the fertile liver transplanted women gave birth to children. To wit, 23 kidney recipients delivered 27 healthy children (17 boys and 10 girls). In 4 cases, 2 children were born, twice as twins. Among liver recipients, 8 women delivered 8 healthy babies. There was no hepatitis C or B virus-positive patient among the mothers. There was no graft insufficiency, rejection or birth defect. Transplanted mothers often display toxemia or preeclampsia during pregnancy requiring cesarean section. The relatively higher ratio of liver recipients was perhaps due to the rarer occurrence of extrahepatic organ damage, like diabetic nephropathy or cardiomyopathy, and the reversible nature of hepatorenal or hepatopulmonary syndrome. CONCLUSION: Delivery of a child by a transplanted mother carries an high risk, requiring interdisciplinary cooperation. The quality of life of solid organ recipients can be significantly raised by childbirth under appropriate circumstances.

The significance of the circumaortic left renal vein and other venous variations in laparoscopic living donor nephrectomies.

Among the several vascular variation those concerning the venous system of the kidneys show the most significant variability. They often play an important role when it comes to choosing the kidney to be removed for transplantation. Based on our prior studies, we have surveyed these variations. When performing a laparoscopic living donor nephrectomy owing to the limited field of vision and the restricted possibilities for preparation, preoperative radiologic planning is of utmost importance. We evaluated 55 donors who underwent laparoscopic nephrectomies using the 16-section multidetector-row computed tomography angiography. Among the donors who underwent surgeries we observed circumaortic veins (CAV) in three cases, retroaortic veins in 6 cases, multiple renal veins in 10 cases, and a lumbar vein draining into the left renal vein (RV) in 30 cases. In the 2 cases wherein CAVs were discovered, the team decided to use the other kidney. In 1 case, due to a short right RV, we chose the left kidney. The complex development of the CAV that is sometimes difficult to reconstruct in 3D poses a challenge for both the radiologist and the surgeon.

H1N1 vaccination in pediatric renal transplant patients.

BACKGROUND: Solid organ transplant recipients undergoing immunosuppressive therapy are considered to be at high risk of serious infectious complications. In 2009, a new influenza pandemic caused serious infections and deaths, especially among children and immunocompromised patients. Herein we have reported the safety and efficacy of a single-shot monovalent whole-virus vaccine against H1N1 infection in the pediatric renal transplant population. METHODS: In November and December 2009, we vaccinated 37 renal transplant children and adolescents and measured their antibody responses. Seroprotection, seroconversion, and seroconversion factors were analyzed at 21 days after vaccination. RESULTS: None of the vaccinated patients experienced vaccine-related side effects. None of the patients had an H1N1 influenza infection after vaccination. All of the patients showed elevations in antibody titer at 21 days after vaccination. In contrast, only 29.72% of the patients achieved a safe seroprotection level and only 18.75% a safe seroconversion rate. More intense immunosuppressive treatment displayed negative effect on seroprotection and seroconversion, and antibody production significantly increased with age. No other factor was observed to influence seroprotection. CONCLUSIONS: We recommend vaccination of children and adolescent renal transplant recipients against H1N1 virus. However, a single shot of vaccine may not be sufficient; to achieve seroprotection, a booster vaccination and measurement of the antibody response are needed to assure protection of our patients.

A single-center experience with kidney transplantation in the verteberal, anal, cardiac, tracheoesophageal, renal, and limb birth detects (VACTERL) association.

VACTERL association is a nonrandom association of birth defects in vertebral, anal, cardiac, tracheoesophageal, renal, and limb structures. Renal anomalies are observed in ∼60%-90% of VACTERL patients. We present 3 cases to demonstrate the clinical and surgical challenges that these patients present for renal transplantation. One pediatric and 2 adult patients with the VACTERL association were transplanted at a single center; their follow-up times were 6 years, 4 years, and 3 months. Only 1 of them had a suitable native bladder to receive the kidney graft; the other 2 required bladder augmentation, 1 of which was performed after the loss of the first graft. None of these patients had an uneventful posttransplantation course. Two patients had acute rejection episodes, and 2 had reoperations for urologic complications. One patient needed a surgical intervention owing to a sigmoid prolapse. All 3 grafts worked at last examination. The 2 patients with bladder reconstructions and longer follow-ups suffered recurrent pulmonary and urinary infections and had been hospitalized several times during each posttransplantation year. In conclusion, multiorgan involvement in VACTERL patients greatly complicates medical care after transplantation; urinary tract reconstruction seems to be essential before transplantation.