Long-term donor outcomes after living kidney donation.

Kidney transplant is the first choice of treatment for end-stage renal failure. The issue of long-term donor safety again has been raised by recent increases in living-donor kidney transplants worldwide, relaxation of donor selection criteria, and the introduction of new surgical techniques. In this review, we collated the results of various studies to discuss the effects of donation on the quality of life of donors, encompassing their physical, mental, and social well-being. We found that the health risks donors face are minimal in the long term with respect to renal function, hypertension, and life span. Furthermore, donors scored higher in quality of life studies than did persons in the general population. Despite these findings, there is a clear need to monitor the minimal risks with long-term follow-up of donors to promptly recognize and treat any negative health effects. Such data from thorough follow-up studies also would provide accurate information on longterm donor health and improve the safe expansion of donor selection criteria.

Surgical management of multiple donor veins in renal transplantation.

The surgical aspects of renal transplantation have been standardized for decades regarding normal anatomy of donor kidneys. In certain situations, as in multiple donor veins, there are still challenges regarding the technical management. In > 95%, there is only one renal vein, or the additional vein/veins are so small that they can be ligated without hesitation. In < 5%, there are two main draining veins, and they can be similar in diameter. The management of these cases varies. Some surgeons implant both veins separately, leave them on a common caval patch, or implant the smaller vein into the larger vein as an end-to-side anastomosis, allowing for one venous anastomosis in the recipient. We describe two cases of donor kidneys with two similar-sized veins and conclude that ligation of the smaller vein, even if its size is substantial (up to 1 cm), can be the safest option to avoid surgical complications.

A Grynfeltt hernia: report of a case.

Superior lumbar hernia (Grynfeltt hernia) is an uncommon variety of abdominal wall defect. There are three types of lumbar hernia: congenital, acquired, and incisional hernias. Diagnosis depends largely on the capacity for clinical suspicion, and confirmation is based on imaging tests. We report a case of an acquired lumbar hernia diagnosed by computed tomography (CT), which was treated successfully at our institution.

Pediatric kidney transplantation: historic hallmarks and a personal perspective.

Over the last five decades, pediatric kidney transplantation (Tx) has proved to be a viable therapeutic alternative for children with end-stage renal disease. Patient and graft survival rates, as well as long-term quality of life, have improved dramatically during this time, as a result of advances in surgical techniques, immunosuppression, and pre- and post-operative care. The inspired, hard work of multi-disciplinary clinical teams, combined with the determination and courage of the young patients and their families, have fueled the success of pediatric kidney Tx. It is with similar optimism and drive that we face the great challenges of the future, such as maximizing the donor pool and inducing tolerance.

Successful partial transplant pancreatectomy with end-to-side duct-to-ureter anastomosis: salvage of a pancreatic allograft.

Segmental pancreatic transplantation has been abandoned because of the high incidence of technical complications. We report the first case in the literature of the salvage of a partially ischemic pancreatic allograft. The procedure consisted of resecting the head of the pancreas and draining the residual segment to the ureter with a duct-to-ureter end-to-side anastomosis. The postoperative course was uneventful, and 15 months after surgery graft function is satisfactory with a urinary amylase level of 5000 U/h. The duct-to-ureter drainage technique should be part of every transplant surgeon's repertoire, because in emergency situations like the one described, it can be used to save a pancreatic allograft.

Reversal of steal syndrome following creation of arteriovenous fistula by banding with a Gore-Tex cuff: a new technique.

Steal syndrome, especially in elderly patients with peripheral vascular disease, is a serious complication following creation of an arteriovenous fistula (AVF) that, if neglected, can lead to amputation. The classic maneuver to deal with the steal syndrome is the ligation of the AVF and performance of another procedure to gain dialysis access. We describe a simple technique of effectively reversing the steal syndrome by banding the vein of the AVF with a ringed Gore-Tex cuff that salvages the AVF and allows its immediate use for dialysis.

Pre-emptive transplants for patients with renal failure: an argument against waiting until dialysis.

BACKGROUND: Pre-emptive kidney transplants have not been favored in some centers because of concern about possible increased noncompliance and allegedly inferior long-term results. We analyzed our experience with pre-emptive kidney transplants to determine whether such concerns are justified. PATIENTS AND METHODS: Between January 1, 1984, and June 30, 1998, we performed 1849 adult primary kidney transplants: 385 pre-emptive (recipients not undergoing dialysis, ND) and 1464 non-pre-emptive (recipients undergoing dialysis, D). Results were subdivided by donor source: cadaver (CAD) and living donor (LD). ND recipients tended to be younger, but otherwise, the two groups were similar. Posttransplantation quality of life in recipients was evaluated using the nationally standardized Short Form Health Survey (SF-36). The posttransplantation employment status of the recipients was also evaluated. RESULTS: The patient survival rate 5 years posttransplantation was significantly better for ND (vs. D) recipients for both CAD (92.6% vs. 76.6%, P=0.001) and LD (93.3% vs. 89.5%, P=0.02) transplants. The 5-year patient survival rate was significantly higher for ND recipients compared with recipients undergoing dialysis for < 1, 1-2, and > 2 years pretransplantation for both CAD (P=0.0005) and LD (P=0.0001) transplants. The graft survival rate 5 years posttransplantation was similar between ND and D recipients for CAD transplants, but significantly better for ND (vs. D) recipients of LD transplants (92.3% vs. 84.8%, P=0.006). For CAD transplants, the 5-year graft survival rate was not different when ND recipients were compared with recipients undergoing dialysis for < 1, 1-2, and > 2 years pretransplantation; for LD transplants it was significantly higher for ND recipients compared with recipients undergoing dialysis for < 1, 1-2, and > 2 years pretransplantation (P=0.04). The incidence of acute and chronic rejection was no different between ND and D recipients for either CAD or LD transplants, and it was also not affected by the pretransplantation time undergoing dialysis. Graft loss secondary to the recipient's discontinuation of immunosuppressive therapy (a crude estimate of compliance) was similar between ND and D recipients. Five years posttransplantation, the SF-36 scores regarding the recipient's quality of life and the employment status were similar for ND compared with D recipients, regardless of donor source. CONCLUSIONS: ND recipients do not seem to have higher rates of noncompliance than D recipients. Results for ND recipients seem to be superior than for D recipients, supporting the contention that renal failure patients should, if possible, undergo transplantation before dialysis.

Donor selection for xenotransplantation: detection of Galalpha1-3Gal on different porcine organs.

The expression of the major porcine xenoantigens (Galalpha1-3Gal) in different tissues varies between species. The selection of suitable donors and the interpretation of studies which attempt to prevent hyperacute rejection are dependent on donor expression of Galalpha1-3Gal. Screening of large number of animals to find potential Galalpha1-3Gal negative donors requires a robust, tissue-based and practical method of assessing Galalpha1-3Gal expression. In this study, we have assessed the expression of Galalpha1-3Gal in a variety of pig organs using anti Galalpha1-3Gal antibody. Biopsies of heart, kidney, ear and tail were obtained from 20 outbred pigs. Biopsies were fixed in formalin and stained with a human anti Galalpha1-3Gal antibody obtained from pooled human AB serum passed down a Galalpha1-3Gal immunoadsorbent column. Tissue from all 4 organs from all 20 pigs expressed Galalpha13Gal. This study shows that detection of Galalpha1-3Gal on an ear or tail biopsy is a simple but very reliable method for assessing Galalpha1-3Gal expression on the heart and kidney and facilitates donor selection for xenotransplantation.

Use of the inferior epigastric artery as a jump graft for reconstruction of a lower pole artery for renal transplantation.

Before a kidney can be transplanted, the reconstruction of a damaged lower pole artery is vital to preserve the blood supply of the ureter.

Small bowel transplantation.

Many patients die each year lacking only a functional small bowel to survive. The minimum amount of small intestinal absorptive surface required to sustain life varies from patient to patient. Prolonged survival with oral alimentation alone has been reported in a few patients with an intact duodenum and as little as 15-45 cm of residual jejunum. However, without long-term total parenteral nutrition (TPN), prolonged patient survival is the exception rather than the rule. Chronic parenteral nutrition is associated with complications, including sepsis, venous thrombosis, metabolic disorders and liver dysfunction. From studies of patients currently on long-term TPN, it would appear that there are between two and three patients per million of population per year who develop irreversible small bowel failure. It is estimated that 20 new patients/year in the UK receiving home TPN would be potential candidates for small bowel transplantation.

Use of vascular closure staples in vascular access for dialysis, kidney and pancreas transplantation.

We report our experience with the use of the vascular closure staples (VCS) in vascular access for dialysis, as well as in kidney and pancreas transplantation. We used the VCS for 50 endogenous arterio-venous fistulas (AVFs). There were no complications. The use of the VCS contributed in creating an excellent anastomosis and minimising operative time. All AVFs are in use for dialysis (follow up two months to one year). The excellent results from our experience with the use of VCS for vascular access encouraged us to use them in kidney and pancreas transplantation. We performed six cadaveric kidney transplants (the first operation was the first application of the VCS in kidney transplantation in Europe) and two cadaveric pancreas-kidney transplants (the first operation being the first application of the VCS in pancreas transplantation in the world). There were no complications. The use of VCS created an excellent anastomosis and minimised warm ischaemia time. All kidney transplant recipients have normal creatinines (follow up 1-5 months) and the recipients of pancreatic transplants are insulin independent (follow up 1-3 months).

Transplantation of an annular pancreas with enteric drainage.

Annular pancreas (AP) is an uncommon congenital anomaly which often does not become symptomatic until late life. We report a case of successful transplantation of an AP in a type I IDDM woman. The whole pancreas with a duodenal cuff was procured from a 41-year-old previously healthy female. The AP was identified at the time of procurement and did not appear to have caused any significant duodenal obstruction. The graft was transplanted on the external iliac vessels and the exocrine secretions were drained enterically. In order to avoid any possible injury to the ductal system, a side-to-side duodenojejunal anastomosis was fashioned using the first and the second portion of the duodenum, leaving about 2 cm of free duodenal margin proximal to the pancreatic ring. The postoperative course was uneventful and at 1 month graft function is unremarkable. Although challenging from a technical point of view, transplantation of an AP is a safe procedure which allows good results. Given the limited number of organ donors and the difficulty in HLA-matching, every AP should be considered suitable for transplantation.

Successful procurement of 50 pancreatic grafts using a simple and fast technique.

The procurement of a pancreatic graft must be as meticulous as possible and with minimum handling and blood loss so that the transplant procedure can be carried out with no complications. We describe the technique we are using in our institution which, contrary to others, requires that most of the dissection for donor pancreatectomy be done after crossclamping and intravascular flushing of the abdominal organs. We have performed 50 consecutive procurements of pancreatic grafts using this technique. All grafts were successfully transplanted with no evidence of post-transplant primary non-function or graft pancreatitis. We believe that this technique is faster and minimises handling of the pancreas and blood loss resulting in excellent post-transplant metabolic function of the pancreatic graft.

Refashioning of an aneurysmatic arterio-venous fistula by using the multifire GIA 60 surgical stapler.

We describe a technique for refashioning an aneurysmatic arterio-venous fistula by using the multifire GIA 60 surgical stapler. After obtaining proximal and distal control of the aneurysmatic vein each aneurysmal segment of the anterior wall of the vein is excised by applying the GIA 60 stapler. The layer of the staple-line is re-enforced with one layer of 6/0 prolene continuous suture. After completion of the procedure, the size of the vein is reduced by approximately 50%. The AVFs were successfully re-used for dialysis within four weeks postoperatively.