Cold ischemia time in renal transplantation is reduced by a timesheet in a French transplant center.

BACKGROUND: Cold ischemia time (CIT) is associated with delayed graft function (DGF) and transplant outcome. Several strategies to reduce CIT have been proposed. We retrospectively analyzed the effect of using a timesheet on CIT in our center. METHODS: In the last 2 years, we have introduced a timesheet to study the course of organ procurement and transplantation during CIT. Results of our 2-year program (121 transplantations) were compared to those in the preceding 2 years (151 transplantations). The timing of each intervention and the influence of national sharing policy and priority recipients were recorded. RESULTS: CIT decreased significantly from 21.45 to 13.27 hours (P<0.0001) and the DGF rate from 34.7 to 20.7% (P=0.011). Usually, human leukocyte antigen typing was done before kidney removal and the recipient was evaluated in the evening or at night for a transplant procedure starting in the morning. Only 1 of 121 transplantations started during the night. The availability of an operating room was the limiting factor. Sharing organs for national priority with a crossmatch having been performed increased CIT twofold (P<0.0001). CONCLUSION: Using a timesheet significantly reduced CIT to the shortest in France. The timesheet is an indicator of motivation and requires the collaboration of all transplantation personnel. It identified certain habits that may be improved to minimize CIT without reorganizing the unit. Providing quicker access to the operating room should further reduce CIT, the key to better graft survival.

De novo renal cell carcinoma of native kidney in renal transplant recipients.

BACKGROUND: The 10-year risk of developing a solid malignancy is 20% for kidney transplant recipients. The goal of the current study was to investigate the epidemiology and the diagnostic and prognostic parameters associated with de novo malignancies of the native kidney among transplant recipients at the authors' institution (Department of Urology and Renal Transplantation, Hôpital Salvator, Marseille, France). METHODS: The authors reexamined the follow-up of 933 consecutive transplant recipients at their institution between 1987 and 2003. Immunossupressive therapy was not modified in the event of malignant disease, nor was systematic radiologic monitoring of native kidneys performed. All de novo malignancies of the native kidney were included in the current analysis. RESULTS: Among the 933 patients examined, a combined total of 12 malignancies of the native kidney were diagnosed in 11 individuals. For these 11 individuals, the average ages at transplantation and diagnosis were 42.5 and 49.1 years, respectively. Ten malignancies were discovered fortuitously, whereas two were symptomatic. Among the 10 renal echographies performed, there was 1 false-negative result. Tomodensitometry was performed in 11 cases and yielded no false-negative results. The average tumor size was 37 mm. Nephrectomy was performed in 10 cases, and biopsy was performed in 1. Among the 12 kidney malignancies encountered in the current study, there were 7 conventional cell carcinomas, 3 basophilic papillary carcinomas, and 2 chromophobic renal cell carcinomas. Half of all tumors were Furhman Grade 3 lesions, and pT1aN0M0 tumors (2003 TNM staging system) also accounted for half of all malignancies in the current cohort. Two affected transplant recipients died (one due to disease), and the remaining nine are alive without recurrence and with normal renal functioning (median follow-up, 39 months). CONCLUSIONS: There appears to be an increased risk of malignancy of the native kidney in renal transplant recipients, with high-grade and papillary tumors being particularly common. Consequently, systematic radiologic follow-up of native kidneys must be performed for individuals who undergo kidney transplantation.

[Limited prognostic value of surgical biopsy before transplantation of good quality renal transplants]. / Faible intérêt pronostique de la biopsie chirurgicale avant transplantation des bons transplants rénaux.

OBJECTIVE: The purpose of this study was to assess the correlations between histological examination of surgical biopsies before transplantation of good quality donor kidneys and delayed return of renal function and renal function at 1 year in order to determine whether histology could explain the various, sometimes surprising outcomes observed with these good quality transplants. MATERIAL AND METHOD: From November 1999 to March 2002, 110 consecutive renal transplantations were performed in our centre from 79 different donors, not including any "borderline" donors. During preparation of each transplant, a surgical wedge biopsy of the mid-renal cortex was performed. Biopsies were paraffin-embedded then stained with P.A.S. (Periodic Acid Shiff). Histological examination was performed by a single pathologist and focused on the glomeruli (number, morphology), and the morphology of the interstitial space and vessels. Delayed return of transplant renal function was defined by the need for dialysis during the first week after renal transplantation. Immunosuppression and surveillance protocols were standardized and uniform. Transplant function at 1 year was evaluated by serum creatinine and creatinine clearance calculated according to Cockcroft's formula. RESULTS: The mean number of glomeruli per biopsy was 15.0 +/- 10.8. 42 renal biopsies (39.2%). Histological examination did not reveal any vascular, interstitial or glomerular lesions. Among these 42 transplants with normal biopsies, 30 (71.4%) did not develop delayed return of renal function (vs 69% of the transplants with abnormal biopsies, p > 0.05). Mean serum creatinine at 1 year (168.5 +/- 63 micromol/l vs 166.9 +/- 40.5 micromol/l, p > 0.05) and mean creatinine clearance at 1 year (53.4 +/- 17.4 ml/min. vs 48.3 +/- 14.3 ml/min, p > 0.05) were not significantly different between the normal biopsy group and the abnormal biopsy group. CONCLUSION: Histological abnormalities are frequently observed in renal transplants derived from good quality donors. The biopsy result before renal transplantation from "non-borderline" donors was not significantly correlated with the risk of delayed return of transplant function or the renal function at 1 year Biopsy alone cannot constitute a reliable criterion for the selection of renal transplants from "non-borderline" donors.

Neural cell adhesion molecule expression in renal cell carcinomas: relation to metastatic behavior.

Neural cell adhesion molecule (NCAM), a member of the immunoglobulin superfamily, is expressed by a subgroup of renal cell carcinomas (RCCs) and by a limited number of adult organs, including the central nervous system (CNS) and adrenal gland. Because the major function of NCAM is homophilic adhesion between homotypic and heterotypic cells, we hypothesized that NCAM-expressing RCCs should preferentially metastasize to the CNS and adrenal gland. We did a retrospective immunohistochemical analysis of NCAM expression both in 338 primary renal tumors, including 249 conventional RCCs and 31 metastases of conventional RCCs. In primary renal tumors, NCAM was expressed by only 38 (15.2%) conventional RCCs and by no other histological subtypes of renal tumor. This expression correlated with a higher risk of adrenal and CNS metastases (P <0.001). NCAM expression also correlated with tumor size (P <0.001), renal vein involvement (P = 0.02), perirenal invasion (P = 0.02), and Fuhrman grading (P < 0.001). Finally, patients with NCAM-expressing RCCs had a lower survival rate (P = 0.006), especially in the first 2 years after surgery. NCAM expression is of interest both for evaluating the prognosis of patients with conventional RCCs and for determining a subgroup of patients at high risk for adrenal and CNS metastases.