Contemporary Management of Renal Transplant Recipients With De Novo Urolithiasis: A Single Institution Experience and Review of the Literature.

OBJECTIVES: We report on the long-term follow-up of managing allograft stones at a single tertiary referral institution and review the relevant literature. MATERIALS AND METHODS: A retrospective analysis of renal allograft recipient charts was performed to identify patients who developed allograft lithiasis between 1974 and 2009. Patient and stone characteristics, diagnoses, treatments, and outcomes were described. RESULTS: Sixteen patients developed 22 stones after a median follow-up of 170 months (range, 51-351 mo). The mean (standard deviation) and median diameter of the stones were 13.8 (8.5) mm and 11 mm. Among these, 3 stones were treated conservatively, 3 by shock-wave lithotripsy, and 7 by cystolitholapaxy. Seven patients underwent percutaneous treatment in the form of percutaneous nephrostomy tube fixation and spontaneous passage of stone (1 stone), shock-wave lithotripsy (1 stone), antegrade stenting (1 stone), and percutaneous nephrolithotomy (6 stones). All patients were stone free after treatment, except for 2 patients whose stones were stable and peripheral on long-term follow-up. CONCLUSIONS: Allograft lithiasis requires a multimodal treatment tailored according to stone and graft characteristics. Protocols regarding spontaneous passage can be adopted if there is no harm to the graft and the patient is compliant. Careful attention to the anatomy during percutaneous nephrostomy tube placement is mandatory to avoid intestinal loop injury. A more attentive follow-up is required for early stone management.

Salvage of grafts with vascular thrombosis during live donor renal allotransplantation: a critical analysis of successful outcome.

OBJECTIVES: To report a high-volume institution experience with salvage techniques for vascular accidents during live donor renal allotransplantation. METHODS: Between March 1976 and January 2011, 2208 recipients underwent live donor renal allotransplantation. A retrospective review of recipients with vascular accidents - renal artery thrombosis and renal vein thrombosis - was carried out. Salvage procedures were recorded and their outcomes were assessed. RESULTS: A total of 23 (1%) vascular accidents occurred, including renal artery thrombosis and renal vein thrombosis in 19 (0.8%) and four (0.18%) recipients, respectively. All renal artery thrombosis patients were treated by open revascularization and the graft was salvaged in 12 patients (63%). Two renal vein thrombosis events were resolved by percutaneous catheter-directed thrombolytic therapy. Of the other two allografts, one was salvaged by thrombectomy and revascularization, and the other was lost. On univariable analysis, older recipients (P = 0.003), pretransplant hypertension (P = 0.001), more human leukocyte antigen mismatches (≥3; P = 0.036), shorter ischemia time (≤45 min; P = 0.004) and longer time to diagnosis (>3.5 days; P = 0.013) were significantly associated with non-salvage of the graft after vascular accidents. Nevertheless, none of these variables were significant on the multivariable analysis. Over a median follow up of 35 months, the median (range) serum creatinine was 2 mg/dL (range 0.8-8.8 mg/dL), and 11 (79%) recipients were living with functioning grafts. CONCLUSIONS: Despite the devastating complications, vascular accidents are salvageable and revascularization is crucial for graft salvage. Angiographic percutaneous techniques are viable alternatives for renal vein thrombosis.

Long-term functional outcome of percutaneous nephrolithotomy in solitary kidney.

OBJECTIVE: To evaluate the long-term functional outcome of percutaneous nephrolithotomy (PNL) for calculi in solitary kidneys and to determine factors leading to renal function deterioration. MATERIALS AND METHODS: The computerized files of patients with solitary kidneys who underwent PNL between January 2002 and December 2009 were retrospectively reviewed. Patients with follow-up <2 years were excluded. Complications, secondary procedures, and stone-free rates were recorded. Changes in the renal function were judged by comparing preoperative and postoperative estimated glomerular filtration rates. Preoperative, intraoperative, and postoperative factors that may affect renal function were tested using univariate and multivariate analyses to define risk factors for deterioration of renal function on long-term follow-up. RESULTS: The study included 200 patients (133 men [66.5%] and 67 women [33.5%] with mean age 52.3 ± 11.7 years). Complications were reported in 34 patients (17%). Severe bleeding was noticed in 10 patients (5%). The overall stone-free rate was 89.5%. After a mean follow-up of 3 ± 1.4 years (range, 2-8), there was significant improvement of the estimated glomerular filtration rate from 57 to 64 mL/min (P <.001). Thirty-one patients (15.5%) showed deterioration of the renal function. Multiple punctures and postoperative bleeding were independent risk factors for renal function deterioration (odds ratio was 3.7 and 4.5, respectively). CONCLUSION: PNL for calculi in solitary kidneys provided significant improvement in renal function at long-term follow-up. Multiple punctures and severe bleeding are independent risk factors for deterioration of the kidney function.

Recoverability of renal functions after relief of partial ureteric obstruction of solitary kidney: impact of ferulic acid.

UNLABELLED: What's known on the subject? and What does the study add? It is known that the kidney damage continues even after release of ureteric obstruction. This study found that giving ferulic acid, antioxidant, after release of ureteric obstruction enhanced the recovery of kidney functions in solitary kidney. OBJECTIVE: To evaluate the effect of ferulic acid (FA) on the recovery of renal function and renal damage after relief of partial ureteric obstruction (PUO) of a solitary kidney. METHODS: Male mongrel dogs (n = 32) were classified into three groups: sham (eight), control (12) and study (12). A right nephrectomy was carried out and dogs in the study and control groups were subjected to 4 weeks of PUO. Serum creatinine, creatinine clearance (CrCl) and renographic clearance (RC) were measured at baseline, after 4 weeks of obstruction and 8 weeks after relief of obstruction. Markers of lipid peroxidation (malondialdehyde [MDA]), superoxide dismutase (SOD), and reduced glutathione (GSH), and immunostaining of markers of apoptosis (caspase 3 and Bcl2), cell proliferation (Ki67) and interstitial fibrosis in the kidney were evaluated at the end of experiment. RESULTS: Ferulic acid enhanced the recovery of serum creatinine, CrCl and RC by an extra 22%, 26% and 33.7%, respectively, of the basal values at 8 weeks, after relief of 4 weeks' obstruction. In addition, FA caused a significant decrease in MDA and a significant increase in GSH and SOD. Ferulic acid also significantly reduced the interstitial fibrosis, and caspase 3 expression, and significantly increased the expression of Bcl2 and Ki67 in kidney tissues at 8 weeks after relief of the obstruction. CONCLUSION: Ferulic acid enhances the recoverability of renal function and minimizes the renal damage through reduction of oxidative stress, tubular apoptosis and the interstitial fibrosis in the solitary kidney after relief of PUO.

Toward a standardized system for reporting surgical outcome of pediatric and adolescent live donor renal allotransplantation.

PURPOSE: There is a lack of a standardized reporting methodology for surgical complications of pediatric renal transplantation. We applied Martin criteria and the modified Clavien-Dindo classification in pediatric renal transplantation. MATERIALS AND METHODS: We retrospectively reviewed the charts of 447 patients 20 years or younger who underwent renal transplantation between March 1976 and January 2011. Martin criteria were fulfilled and complications were graded according to the modified Clavien-Dindo classification. For early complications grades I and II were considered low grade and III to V high grade. A similar grading system was adopted for late complications. RESULTS: A total of 84 early complications (18.5%) occurred in 77 transplant recipients (17%). Of grade I complications 37 (8.1%) were asymptomatic lymphoceles. Grade II complications were observed in 2 patients (0.4%). Grade IIIa complications included aspiration of hematoma (1 case), percutaneous nephrostomy fixed for ureteral obstruction (3), percutaneous tube drain for symptomatic lymphoceles (7) and antegrade ureteral stenting for ureteral leakage (6). Grade IIIb complications included exploration for wound dehiscence (1 case), revision of ureterovesical anastomosis (8), marsupialization of lymphoceles (4), hemorrhage (3) and vascular thrombotic accidents (6). Graft nephrectomy (grade IVa) complications occurred in 2 transplant recipients. Among 4 mortalities (grade V) only 1 patient died due to surgical complications. On multivariate analysis delayed graft function was the only predicator of high grade surgical complications (p = 0.005). High grade surgical complications affected recipient but not graft survival. CONCLUSIONS: Using a standardized, high quality reporting methodology is feasible in pediatric renal transplantation. However, consensus should be sought regarding medical complications and a grading system should be developed for reporting of late complications.

Vascular and haemorrhagic complications of adult and paediatric live-donor renal transplantation: A single-centre study with a long-term follow-up.

OBJECTIVES: To compare the haemorrhagic and vascular complications between paediatric and adult renal transplant recipients with a long-term follow-up. PATIENTS AND METHODS: Between March 1976 and December 2006, in all, 1865 live-donor renal transplants were carried out. Patients were stratified according to their ages into two groups; paediatric (⩽18 years; 259) and adult (>18 years; 1606). Variables assessed included incidence, risk factors, management and sequelae of vascular and haemorrhagic complications. The effect of these complications on patient and graft survival was compared. RESULTS: Haemorrhage requiring active intervention (percutaneous drainage or surgical exploration) was reported in seven children (2.7%) and 29 adults (1.8%), while thrombotic or stenotic complications were recorded in two children (0.77%) and 19 adults (1.18%; P < 0.05). Female gender, delayed onset of diuresis and acute tubular necrosis were significant predictors of vascular complications on univariate analysis, but none remained significant on multivariate analysis. In adults, vascular complications had a significant negative effect on mean (SD) 10-year graft survival compared to patients with no complications, at 19.8 (7.63)% vs. 55.7 (1.66)% (P = 0.01). Children who developed vascular complications had a significantly higher 5- and 10-year graft survival rate than adults (P = 0.01). CONCLUSION: The incidence of vascular complications is comparable in paediatric and adult transplants. Vascular complications had a significant negative influence on graft survival in adult recipients. Children who developed vascular complications appear to tolerate its effects and have a better graft survival than have adults.

Recoverability of renal function after relief of chronic partial unilateral ureteric obstruction: The effect of an angiotensin-converting enzyme inhibitor (enalapril).

OBJECTIVES: We evaluated the effect of an angiotensin-converting enzyme inhibitor (enalapril) on renal function during and after the relief of partial unilateral ureteric obstruction (UUO). MATERIALS AND METHODS: Thirty-two male mongrel dogs were classified into three groups: sham (eight), control (12; left partial UUO + no medication) and study (12; left partial UUO + enalapril). Dogs in the study and control groups were subjected to 4 weeks of partial UUO. After that, the dogs were re-opened and subjected to Lich-Gregoir vesico-ureteric re-implantation, and were killed humanely by the end of the eighth week after relief of obstruction. The study and control groups were evaluated at baseline, after 4 weeks of obstruction and at 4 and 8 weeks after relief of obstruction, by measuring selective creatinine clearance (CCr), selective renographic clearance (RCr) and renal resistive index (RI). The sham group had sham surgery at 4 and 8 weeks and was evaluated as the other two groups. RESULTS: Sham surgery showed no significant effect on any of the evaluated variables. Compared with the control, enalapril offset the reductions of CCr and RCr by an extra 11% and 12% of the basal values by the end of the fourth week of obstruction, respectively. Moreover, compared with the control, enalapril enhanced the recovery of CCr by an extra 10% and of RCr by an extra 23% of the basal values at 8 weeks after relief of the 4-week obstruction. In addition, the increase in RI was significantly less in the enalapril group. CONCLUSION: Enalapril decreases the deterioration of renal function in partial UUO and enhances the recoverability of renal function after relief of obstruction.

Long-term outcome of grafts with multiple arteries in live-donor renal allotransplantation: Analysis of 2100 consecutive patients.

PURPOSE: To analyse the long-term outcome in relation to multiple graft arteries (MGA) in live-donor renal transplantation, and assess its effect on graft and patient survival. PATIENTS AND METHODS: Between March 1976 and November 2009, a total of 2100 live-donor renal transplants were carried out at our centre. Patients were stratified according to the number of graft arteries into two groups, i.e. MGA (two or more arteries; 237 patients) and single-graft artery (SGA; 1863 patients). Variables assessed included patient demographics, site of vascular anastomosis, ischaemia time, onset of diuresis, delayed graft function, acute tubular necrosis (ATN), acute rejection, vascular and urological complications. Moreover, long-term patient and graft survival were compared among both groups. Patients were followed up for a mean (SD) of 112 (63) months. RESULTS: Grafts with MGA were associated with a prolonged ischaemia time (P = 0.001) and ATN (P = 0.005). Vascular thrombosis (arterial and venous) had a higher incidence in MGA (2.5%) than SGA (0.6%) (P = 0.01). Both groups were not significantly different for the onset of diuresis, acute rejection and urological complications (P = 0.16, 0.23 and 0.85, respectively). Graft and patient survival were comparable in both groups. The mean (SD) 1-, 5-, 10- and 20-year graft survival rates (%) for MGA were 96.1 (1.26), 86.6 (2.39), 61.3 (4.42) and 33.8 (7.23), and 97.5 (0.36), 86.8 (0.84), 66.0 (1.35) and 37.3 (2.76) for SGA (P = 0.54). CONCLUSIONS: Although there was a higher incidence of prolonged ischaemia time, ATN and vascular thrombosis in live-donor renal transplants with MGA, it did not adversely affect patient or graft survival. The early, intermediate- and long-term follow-up showed an outcome comparable to that in patients with SGA.

Recoverability of renal function after relief of chronic partial unilateral ureteral obstruction: study of the effect of angiotensin receptor blocker (losartan).

OBJECTIVES: To evaluate the effect of angiotensin receptor blocker (losartan) on renal function during and after relief of partial unilateral ureteral obstruction (PUO). METHODS: A total of 32 male mongrel dogs were classified into 3 groups: sham (8), control (12; left PUO + no medications), and study (12; left PUO + losartan). Dogs of the study and control groups were subjected to 4 weeks of PUO. After that, they were reopened and subjected to Lich-Grigoir ureterovesical reimplantation and then were killed by the end of 32 weeks after relief of obstruction after being evaluated at basal condition; fourth week of obstruction; and at 4, 8, and 32 weeks after relief of obstruction by measurement of selective creatinine clearance (CCr), selective renographic clearance (RC), and renal resistive index. Sham group underwent sham surgery at 4 and 32 weeks and evaluated as the other 2 groups. RESULTS: Sham surgery showed no significant effect on any of the evaluated parameters. Compared with the control, losartan saved reduction in CCr by 11% and RC by 20% of the basal value by the end of the fourth week of obstruction, respectively. Moreover, compared with the control, losartan enhanced regain of CCr by 26% and RC by 26% also of the basal value at 32 weeks after relief of fourth week obstruction, respectively. In addition, the increase in renal resistive index was significantly less in the losartan group. CONCLUSION: Losartan decreases the deterioration of renal function in PUO and enhances recoverability of renal function after relief of obstruction.

Rotoresection versus transurethral resection of the prostate: short-term evaluation of a prospective randomized study.

PURPOSE: We compared in a prospective fashion the short-term outcome of rotoresection to transurethral resection of the prostate. MATERIALS AND METHODS: A total of 50 patients with bladder outlet obstruction secondary to benign prostatic hyperplasia were randomized into 2 groups, rotoresection and transurethral resection of the prostate. Mean+/-SD patient age was 60.76+/-5.85 years in the rotoresection and 64.24+/-6.84 in the transurethral resection groups. All patients had an International Prostate Symptom Score of 8 or more, maximum free flow rate less than 15 ml per second, prostate volume 20 to 100 ml and prostate specific antigen 1 to 4 ng/ml. Pressure flow study revealed bladder outlet obstruction (Schafer's grade 3 or more). Patients were assessed at 1, 3 and 6 months by International Prostate Symptom Score, maximum free flow rate, transrectal ultrasound, pressure flow study, hemoglobin and urinalysis. RESULTS: At 6 months International Prostate Symptom Score decreased from 26.2+/-4.06 to 5.32+/-1.52 in the rotoresection group and from 22.84+/-4.56 to 7+/-1.4 in the transurethral resection group. Maximum free flow rate increased from 7.87+/-2.24 to 25.29+/-10.39 ml per second in the rotoresection group and from 9.44+/-2.29 to 25.2+/-5.8 ml per second in the transurethral group. Prostate volume decreased from 41.2+/-16.58 to 17.24+/-7.61 ml in the rotoresection group and from 40.6+/-16.93 to 18.28+/-8.75 ml in the transurethral group. Detrusor pressure at maximum flow and Schafer grade decreased from 79.84+/-26.8 cm H2O and 4.24+/-0.97 to 38.8+/-18.8 cm H2O and 1.24+/-0.93 in the rotoresection group, and from 63.04+/-21.08 cm H2O and 3.48+/-0.65 to 34.16+/-12.7 cm H2O and 1+/-0.7 in the transurethral group. Dilutional hyponatremia was higher with transurethral resection of the prostate (p=0.005) but no patient showed manifestations of the transurethral syndrome. Mild stress urinary incontinence was noted in 4 patients in the rotoresection group and in 3 in the transurethral group. CONCLUSIONS: Rotoresection is a safe and effective method of treating bladder outlet obstruction resulting from benign prostatic hyperplasia, and its efficacy is comparable to transurethral resection of the prostate.