The postanesthesia care of an adult renal transplant recipient.

Renal transplantation is the most common type of solid organ transplant performed in this country. For the PACU nurse, the immediate postoperative care of a renal transplant recipient can present a very unique and interesting challenge. Like all patients arriving to the PACU, the initial assessment of an immediate postoperative renal transplant recipient should first address the routine postsurgical concerns of airway, respiration, and hemodynamics. Most renal transplant programs have set protocols for the care required during the immediate posttransplant stay in the PACU. The postanesthesia nurse caring for these patients must become knowledgeable of these protocols. The following is a review of the immediate postanesthesia care for both the "fresh" renal transplant and the care of the long-term renal transplant recipient who has had surgery.

Bilateral single ureteral ectopia in a boy.

Bilateral single ureteral ectopia is exceedingly rare, with fewer than 80 cases reported. Fewer than 20 cases have been reported in males. We describe a recent patient with bilateral single ureteral ectopia with bilateral megaureter and ureteral orifices opening into the prostatic urethra.

Extensive upper and mid ureteral loss in newborns: experience with reconstruction in 2 patients.

PURPOSE: We describe our experience with reconstruction of the ureter in 2 patients who sustained extensive upper and mid ureteral loss as newborns. MATERIALS AND METHODS: Two male patients, a 1-month-old and a neonate, sustained extensive ureteral loss due to candidal infection involving the retroperitoneum and ureter. The 1-month-old sustained a loss of the middle third of the ureter, and the neonate sustained a 3 cm. loss of the upper ureter. The first case was managed with a combination of renal mobilization and an extensive Boari flap, while the second was managed with renal mobilization and nephropexy with primary ureteropyelostomy. RESULTS: Both patients had a successful outcome with no evidence of anastomotic stenosis or obstruction. CONCLUSIONS: Extensive upper and middle third ureteral defects may be primarily bridged successfully in pediatric patients using the standard technique of renal mobilization combined with ureteropyelostomy and a Boari flap, respectively.

Technique for laparoscopy-assisted complicated peritoneal dialysis catheter placement.

Peritoneal dialysis is widely accepted for the chronic management of end-stage renal disease. Especially in patients suspected of having intra-abdominal adhesions, the application of laparoscopic surgical techniques has significantly changed our surgical approach to dialysis catheter placement. The blind placement of peritoneal dialysis catheters in this patient group can be both dangerous, because of the higher risk of bowel injuries, and unsuccessful, because of immediate catheter misplacement or entrapment. We describe a relatively simple step-by-step approach to laparoscopy-assisted peritoneal dialysis catheter placement with omentectomy in these more complicated cases.

Increased early rejection rate after conversion from tacrolimus in kidney and pancreas transplantation.

CONTEXT: A successful immunosuppression regimen for combined kidney and pancreas transplants is tacrolimus, mycophenolate mofetil, and prednisone. However, not all patients tolerate these immunosuppressants especially tacrolimus. OBJECTIVE: To evaluate the efficacy of cyclosporine as a rescue agent for tacrolimus toxicity in combined kidney and pancreas transplants. DESIGN: Retrospective. SETTING: Single center. PATIENTS: Thirty-five combined kidney and pancreas transplants were performed between July 1994 and January 1999. All patients were insulin dependent diabetics with end-stage renal disease. Twenty-eight (mean age: 36 years and 57% female) were available with at least 12 month follow-up. INTERVENTIONS: Conversion to cyclosporine following renal (biopsy proven) or pancreatic dysfunction. MAIN OUTCOME MEASURES: Toxicity, rejection rate, and patient/transplant organ survival. RESULTS: Nineteen transplant recipients (68%) were continuously maintained on tacrolimus while nine (32%) required conversion to cyclosporine 75 +/- 20 days post-transplant. Reasons for conversion included: hyperglycemia (n=2), hemolytic-uremic syndrome (n=1), and severe tacrolimus nephrotoxicity (n=6). By 12 months post-transplant, the 19 patients maintained on tacrolimus had 5 rejections (26%). Three of the 9 patients (33%) converted to cyclosporine had an acute rejection prior to conversion. Seven of these 9 patients (78%; P=0.017 vs. patients maintained on tacrolimus) had rejections an average of 25 +/- 4 days post-conversion. Four of the 7 patients had no previous rejections prior to conversion. In spite of increased rejections, the 1- and 2-year patient/graft survivals were unchanged by converting. CONCLUSIONS: Converting to cyclosporine from tacrolimus was associated with an increased risk of acute rejection especially within the first 30 days post conversion.