Lactated Ringer as Preservation Solution in Living Donor Renal Transplantation.

BACKGROUND: Optimal organ preservation remains a critical hallmark event in renal transplantation as it is the supply line. Previous studies have shown that the choice of preservation solution may affect transplant outcomes. In this study, we aimed to present the early follow-up results of the graft and patients, using lactated Ringer to preserve kidney allografts with living donors. METHODS: The results of 97 living donor transplant operations performed in Sanko University Hospital were evaluated retrospectively. The patient's evaluation included demographics, dialysis time duration, renal replacement method, primary disease, comorbidity, surgical and clinical complications in the acute period, graft functions, blood levels of calcineurin inhibitor drugs, anastomotic renal artery, warm ischemia, and cold ischemia times. RESULTS: Donor (49 men, 50.5%) and recipient (58 men, 59.7%) demographics, HLA compatibility (mismatch), hospitalization days, and length of warm and cold ischemic time are summarized in Table 1. Primary nonfunction was not defined in any patients, but delayed graft function was observed during the follow-up of 3 patients (3.09%), who were all hypotensive in the post-transplantation period, and positive inotropic infusion was needed for hemodynamic stability. CONCLUSIONS: Lactated Ringer demonstrated efficacy in terms of patient and graft survival, and its lower cost represents a financial advantage, so it can be used in living donor kidney transplantation because it is safe, effective, and inexpensive. Standard preservation solutions may still be recommended in cases with long cold ischemia times, such as paired exchange transplants and cadaveric transplants. Thus, randomized controlled studies are needed for further investigation.

A Single-Center Experience With Kidney Transplantation in Patients Who Had Low Left Ventricular Ejection Fraction.

OBJECTIVES: Left ventricular hypertrophy is one of the most typical cardiac abnormalities detected in patients with end-stage renal disease. In patients with congestive heart failure, the most crucial factor determining patient survival is left ventricular ejection fraction. Herein, we present our experience with living donor kidney transplant recipients with a left ventricular ejection fraction of <50%. MATERIALS AND METHODS: Patients who underwent living donor kidney transplant in our center between November 2008 and November 2021 and had pretransplant left ventricular ejection fraction <50% were included. All patients had dialysis the day before surgery. All patients underwent 2-dimensional echocardiograms after dialysis and were categorized according to New York Heart Association classification, pretransplant and on posttransplant day 5. Demographic parameters and additional data, including pretransplant and posttransplant day 5 New York Heart Association classification, left ventricular ejection fraction at 6 months, and graft survival at 6 months, as well as patient survival data, were analyzed. RESULTS: Our study included 31 patients (mean age of 46.6 ± 18.3; range, 11-77 years). We found significant differences in New York Heart Association classifications before and after transplant, indicating that kidney transplant had a positive effect on pretransplant congestive heart failure in patients with low left ventricular ejection fraction (P = .001). The mean pretransplant left ventricular ejection fraction was 32 ± 9.9% (range, 1%-45%), whereas the mean 6-month posttransplant left ventricular ejection fraction was 52 ± 8.7% (range, 28%-63%) (P < .001). Both graft loss and all-cause mortality rates were 12.9%. CONCLUSIONS: Low left ventricular ejection fraction is not a contraindication for kidney transplant. We suggest that myocardial scintigraphy should be performed in patients with end-stage renal disease and low left ventricular ejection fraction, and kidney transplant should be considered in those without ischemic findings.

Laparoscopic Live Donor Nephrectomy: Experience of High-Volume Center with 2,477 Cases.

OBJECTIVE: Donors' health and safety are mandatory in the living-donor kidney transplantation procedure. Laparoscopic live donor nephrectomy (LLDN) provides an increase in donor numbers with its benefits and becomes a standard of care. We aimed to explain the results, complication rates, tips, and tricks of the largest number of LLDN case series ever performed in the literature. MATERIALS AND METHODS: Between August 2012 and December 2019, 2,477 live donor case files were analyzed retrospectively. Age, gender, hospitalization times, body mass index, warm ischemia times, operation times, numbers of arteries, side of the kidneys, and complications were noted. RESULTS: 1,421 (57.4%) of 2,477 donors were female (p = 0.007). Operation times and warm ischemia times were found longer in right-sided LLDN and donors with multiple renal arteries (p = 0.046, <0.001, and <0.001, respectively). Obesity (BMI >30 kg/m2) did not affect warm ischemia times while prolonging the operation times (p = 0.013). Hospitalization times and numbers of complications were higher in obese donors. CONCLUSIONS: LLDN seems to be a reliable solution with fewer complications and higher satisfaction rates. We hope to illuminate the way with tips and trick points for beginner transplant surgeons based on the experience obtained from 2,477 LLDN cases.

Perioperative Anesthetic Management and Clinical Outcomes in Patients Undergoing Coronary Artery Bypass Grafting and Kidney Transplant in the Same Session.

BACKGROUND: Cardiovascular disease is commonly seen in patients with end-stage renal disease (ESRD) and is a major cause of graft failure and death in patients undergoing kidney transplant. METHODS: The retrospective study included 77 patients with ESRD who underwent combined coronary artery bypass grafting (CABG) and kidney transplant between May 2010 and September 2017. RESULTS: The patients included 65 (84.4%) men and 12 (15.6%) women. Diabetes mellitus (DM) and hypertension (HT) were present in 71.4% and 90.9% of the patients, respectively. Mean postoperative intensive care unit (ICU) stay was 3.4 ± 1.6 days, mean time to extubation was 12.1 ± 3.7 hours, and mean hospital stay was 11.6 ± 3.5 days. In the small group with graft rejection, EF was 41.1 ± 12.3. Two patients underwent second kidney transplant, and 1 patient underwent a third kidney transplant. Mean amount of red blood cells (RBC) and fresh-frozen plasma (FFP) transfusion was 2.6 ± 0.7 and 2.1 ± 0.7 units, respectively. CONCLUSION: The study showed that CABG and kidney transplant can be performed in a combined approach in the same session and that this combined approach is likely to have a more favorable effect on mortality and morbidity compared to the administration of these 2 surgeries in separate sessions.

Evaluation of the Renal Arteries of 2,144 Living Kidney Donors Using Computed Tomography Angiography and Comparison with Intraoperative Findings.

OBJECTIVES: A carefully chosen and suitably prepared kidney donor is essential in living-donor kidney transplantation. Computed tomography angiography (CTA) is an effective imaging method for evaluating the renovascular morphology of donor candidates. The aim of this study was to evaluate renal artery variations in kidney donors using CTA and compare the findings with the number of arteries detected during laparoscopic donor nephrectomy. MATERIALS AND METHODS: The study included 2,144 living donors who underwent pretransplant renovascular assessment using CTA and laparoscopic donor nephrectomy in our center between August 2012 and October 2018. The number of renal arteries to the donor kidney detected on CTA was compared with the number of arteries discovered intraoperatively. RESULTS: The mean age of the 2,144 living kidney donors included in the study was 47.19 ± 13.3 (18-87) years. According to CTA findings, 81.1% (n = 1,738) had a single renal artery, 17.2% (n = 369) had double renal arteries, 1.6% (n = 35) had triple renal arteries, and 0.1% (n = 2) had quadruple renal arteries. The same number of renal arteries were detected by CTA and in laparoscopic donor nephrectomy in 97.9% (n = 2,099) of the donors. In the other 2.1% (n = 45), fewer renal arteries were detected intraoperatively compared to their CTA findings. None of the donors included in the study had a greater number of renal arteries discovered during nephrectomy than by CTA. CONCLUSION: CTA is a highly accurate method for the evaluation of renovascular variations in donor candidates for living-donor kidney transplantation. However, it must be kept in mind that double or multiple renal artery variations may be detected on CTA in 18.9% of donor candidates.

Use of Tacrolimus During Pregnancy After Kidney Transplantaion.

PURPOSE: Motherhood is the greatest privilege that nature gives to women. Although pregnancy is a physiological event for women, every pregnancy is a risky pregnancy. During a normal pregnancy, the health of mother and baby are monitored. In post-transplantation pregnancies, the function of the transplanted organ, along with the mother and the infant, must be monitored, since the continuation of pregnancy depends on both the maternal and infant health and an organ functioning within normal limits. The desire is for every baby to be born in due time and at normal weight, but this is not always possible in pregnancies after transplants. Publications about the pharmocokinetics of tacrolimus are very limited. In this study, we wanted to share our experiences with pregnancy in our clinic. MATERIAL AND METHOD: Patients who used tacrolimus during their pregnancies after renal transplantation (RT) at Antalya Medicapark Organ Transplantation Unit, during November 2008 to July 2018 were included in the study. Patient's gestational age, pregnancy, drug levels, is charge, and labor creatinine clearances were examined. FINDINGS: Four thousand six hundred thirty-five RT occurred between November 2008 to July 2018; 786 of the patients were female between the ages 18 and 45. Thirty-one pregnancies went full term. Twenty-six pregnant women, who used tacrolimus after RT, were included in the study. Five patients had pre-eclampsia, 1 patient had abortus immines, 2 patients had hypertansion due to pregnancy, and 1 patient had aplated placenta. There was a breech presentation in 1 patient with preeclampsia. Acute rejection developed in 3 postpartum patients, but renal values normalized with medical treatment. All the babies were born alive and healthy; postpartum graft loss was not observed. CONCLUSION: If planning to become pregnant after RT,our center recommends waiting at least 2 years after the RT, when graft function should be normal and without any signs of HT and proteinuria. Our recommendation regarding the level of tacrolimus after RT is 4.5 to 7 µg.

Results of minimally invasive surgical treatment of allograft lithiasis in live-donor renal transplant recipients: a single-center experience of 3758 renal transplantations.

Allograft lithiasis is a rare urologic complication of renal transplantation (RT). Our aim is to present our experience with minimally invasive surgical treatment of allograft lithiasis in our series of live-donor renal transplant recipients. In a retrospective analysis of 3758 consecutive live-donor RTs performed in our center between November 2009 and January 2017, the results of minimally invasive surgery for the treatment of renal graft lithiasis diagnosed at follow-up were evaluated. Twenty-two (0.58%) patients underwent minimally invasive surgery for renal graft lithiasis. The mean age was 41.6 years, and duration between RT and surgical intervention was 27.3 months (range 3-67). The mean stone size was 11.6 mm (range 4-29). Stones were located in the urethra in 1, bladder in 2, ureter in 9, renal pelvis in 7 and calices in 3 patients. Surgical treatment included percutaneous nephrolithotomy in 1, cystoscopic lithotripsy in 3, flexible ureteroscopic lithotripsy in 6 and rigid ureteroscopic lithotripsy in 12 patients. No major complications were observed. One patient (4.5%) who underwent flexible ureteroscopy developed postoperative urinary tract infection. All patients were stone-free except two (9%) patients who required a second-look procedure after flexible ureteroscopic lithotripsy for residual stones. Stone recurrence was not observed in any patient during a mean follow-up duration of 30.2 months (range 8-84). Renal transplant lithiasis is uncommon and minimally invasive surgical treatment is rarely performed for its treatment. Endourological surgery may be performed safely, effectively and with a high success rate in these patients.

Ex vivo stone surgery in donor kidneys at renal transplantation.

OBJECTIVE: To report our experience on the outcomes of ex vivo ureteroscopy and ex vivo pyelolithotomy carried out on the donor kidney before living donor renal transplantation. METHODS: Between 2009 and 2016, 13 stone-bearing donor kidneys underwent ex vivo bench surgery after donor nephrectomy. Of these, six patients underwent ex vivo ureteroscopy and seven patients underwent ex vivo pyelolithotomy. Data were analyzed for technical feasibility, intraoperative and postoperative complications, stone clearance, and stone recurrence. RESULTS: The mean stone burden was 9.1 mm (range 5-15 mm). Renal collecting system access and stone extraction were successfully achieved, and a stone-free status was accomplished with both techniques. The mean duration of ex vivo ureteroscopy was 12.5 min (range 9-20 min), and the mean duration of ex vivo pyelolithotomy was 3.1 min (range 1-8 min). One patient in the pyelolithotomy group developed urinary leakage and underwent surgical repair on the third postoperative day. The mean long-term follow-up duration was 49.6 months (range 14-101 months). None of the 13 patients included in the study suffered from stone recurrence. CONCLUSIONS: Our experience suggests that both ex vivo ureteroscopy and ex vivo pyelolithotomy procedures can safely and effectively be carried out in stone-bearing living donor kidneys, without compromising renal allograft function.

Prevalence of Sexually Transmitted Diseases in Asymptomatic Renal Transplant Recipients.

OBJECTIVES: Sexually transmitted diseases, which may be asymptomatic, have the potential to cause serious health problems in renal transplant recipients. The aim of this study was to determine the prevalence of sexually transmitted diseases in sexually active asymptomatic renal transplant patients by using real-time multiplex polymerase chain reaction assays. MATERIALS AND METHODS: This prospective controlled study was conducted between November 2016 and January 2017 in our hospital. Our study group included 80 consecutive, sexually active asymptomatic patients (40 men and 40 women) who had undergone renal transplant in our hospital and who presented to our outpatient clinic for routine follow-up. We also included a control group of 80 consecutive, sexually active nontransplant patients (40 men and 40 women). All patient samples were tested for Gardnerella vaginalis and obligate anaerobes (Prevotella bivia, Porphyromonas species), Candida species, Mycoplasma hominis, Mycoplasma genitalium, Ureaplasma species, Trichomonas vaginalis, Neisseria gonorrhoeae, Chlamydia trachomatis, herpes simplex virus 1 and 2, and Cytomegalovirus by real-time multiplex polymerase chain reaction. RESULTS: The prevalences of infection with Gardnerella vaginalis and obligate anaerobes (P = .043), Ureaplasma species (P = .02), and Cytomegalovirus (P = .016) were found to be significantly higher in the study group versus the control group. However, there was no difference between the 2 groups regarding the prevalence of Mycoplasma infection (P = .70). CONCLUSIONS: Sexually transmitted diseases may occur more frequently in sexually active asymptomatic renal transplant recipients than in nontransplanted individuals. Real-time multiplex polymerase chain reaction analysis may be a suitable method for determining these pathogens.

The outcomes of transurethral incision/resection of the prostate (TUIP/TURP) performed early after renal transplantation.

OBJECTIVE: In the early period after renal transplantation, urinary retention stemming from bladder outlet obstruction (BOO) may directly affect graft success. The aim of this study was to evaluate the early and long-term outcomes of transurethral resection of the prostate (TURP) and transurethral incision of prostate (TUIP) procedures performed in the first month following RT due to BOO. MATERIAL AND METHODS: Between February 2009 and March 2016, 38 male patients underwent TURP/TUIP due to BOO within the first 30 days of renal transplantation. The urodynamic and renal function assessment results of all patients were collected during the pre-and postoperative periods. All patients were followed up for a minimum of 12 months for short and long-term complications. The results were evaluated retrospectively. RESULTS: The mean age of the patients who underwent operations was 59.2±12 years. The median duration of dialysis was 41 months (range 0-180). Before the operation the mean serum creatinine (sCr) level was 1.8±0.7 mg/dL, the mean total PSA level was 1.6±1.1 ng/mL. Of the voiding parameters, the mean Qmax and Qave were measured as 8.2±4.5 mL/sec and 4.6±2.5 mL/sec, respectively. The median post-micturition residual urine (PMR) was 105 mL (range 10-400). TURP/TUIP operations were performed at a median of 19 days (range 8-30) after renal transplantations. None of the patients experienced major complications. In the early postoperative period, 5 patients (13.1%) developed urinary tract infection. The mean decrease in sCr in the first month following TURP/TUIP was 1.4±0.4 mg/dL (p<0.001). The mean Qmax (22.4±11.1 mL/sec), and Qave (11.7±5.4 mL/sec) increased significantly (p<0.001), while the median PMR (15 mL, range 0-205) decreased significantly (p<0.001). The mean follow-up period after the procedure was 46.8±23.3 months. During the follow-up period, 3 (7.8%) patients suffered from urethral stricture and 2 (5.2%) patients from bladder neck obstruction. CONCLUSION: In the surgical treatment of urinary retention arising from BOO in the first month following renal transplantation, TURP/TUIP yield safe and successful results. In addition, regarding the short and long term outcomes, these procedures may be safely performed with low morbidity.

Comparative Results of Transurethral Incision with Transurethral Resection of The Prostate in Renal Transplant Recipients with Benign Prostate Hyperplasia.

PURPOSE: The aim of this study is to compare the results of transurethral incision of the prostate (TUIP) and transurethral resection of the prostate (TURP) for the surgical treatment of benign prostate hyperplasia (BPH) in patients with renal transplantation. MATERIALS AND METHODS: Between April 2009 and May 2016, BPH patients with renal transplants whose prostate volumes were less than 30 cm3 were treated surgically. Forty-seven patients received TURP and 32 received TUIP. The patients' age, duration of dialysis, duration between transplant and TURP/TUIP, preoperative and postoperative serum creatinine (SCr), International Prostate Symptom Score (IPSS), maximum flow rate (Qmax) and postvoidresidual volume (PVR) were recorded. At 1-,6- and 12-month follow-up, early and long-term complications were assessed. Results were evaluated retrospectively. RESULTS: In both groups, SCr, PVR and IPSS decreased significantly after the operation, while Qmax increased significantly (P < .001). There was no difference between the two groups in terms of increase in Qmax and decrease in IPSS, SCr and PVR (P = .89, P = .27, P = .08, and P = .27). Among postoperative complications, urinary tract infection (UTIs) and retrograde ejaculation (RE) rates were higher in the TURP group than the TUIP group (12.7% versus 6.2% and 68.1% versus 25%,respectively), whereas urethral strictures were more prevalent in the TUIP group (12.5% versus 6.3%). CONCLUSION: For the treatment of BPH in renal transplant patients with a prostate volume less than 30 cm3, bothTUIP and TURP are safe and effective.

Results of transurethral resection of the prostate in renal transplant recipients: a single center experience.

OBJECTIVES: The aim of this study was to retrospectively evaluate the early and long-term results of renal transplantation (RT) patients undergoing transurethral resection of the prostate (TURP) due to benign prostate hyperplasia (BPH). MATERIALS AND METHODS: Eighty-nine patients with RT performed in our hospital underwent TURP between November 2008 and March 2016. Results were evaluated along with early and long-term complications. Patients were followed up for a minimum of 12 months. RESULTS: The mean age of the patients was 61.4 ± 7.4 years. The median duration of dialysis was 28 (0-180) months. The median duration between transplantation and TURP was 13 (0-84) months. Before TURP, the mean serum creatinine (sCr) was 1.99 ± 0.83 mg/dL and the mean prostate volume was 33.3 ± 14.6 cm3. The mean Q max, Q ave and PVR values were 9.5 ± 3.7, 5.2 ± 2.2 ml/s and 85(5-480) mL, respectively. None of the patients developed perioperative and postoperative major complications. Twelve patients (13.4%) developed urinary tract infections in the postoperative period. The sCr, IPSS and PVR values significantly decreased, while Q max and Q ave significantly increased at the 1-month follow-up. At the 6-month follow-up, 63 (70.8%) patients had retrograde ejaculation. Patients were followed up for a median of 42 (12-96) months. Three patients (3.3%) were re-operated for bladder neck contracture and eight (8.9%) patients were re-operated for urethral stricture. CONCLUSION: TURP can be safely and successfully applied for the treatment of BPH after RT. LUTS and renal functions significantly improve after the operation. Patients should be followed up for UTIs in the short term and for urethral stricture in the long term.

HPV type 45-positive condyloma acuminata of the bladder in a renal transplant recipient.

Condyloma acuminata (CA) are warty lesions caused by human papilloma virus (HPV) that generally affect the external genitalia and mucocutaneous junctions. Involvement of the urinary tract is rare, and involvement of the urinary bladder is thought to be due to immunosuppression. A 30-year-old woman was diagnosed with urethral CA 12 months after renal transplantation. She underwent transurethral resection (TUR) of the urethral lesions. During the operation, multiple sessile warty lesions were found incidentally inside the bladder and were also removed by TUR. The patient's postoperative course was uneventful. Pathological examination confirmed that the lesions were CA. Multiplex real-time polymerase chain reaction was performed to confirm the HPV genotype and revealed type 45 HPV DNA. CA of the urethra are uncommon, and bladder involvement is extremely rare. This case is the first reported, to our knowledge, to involve HPV type 45 in bladder condyloma. TUR may be the preferred option for the management of CA in the urinary bladder.

How reliable is the Alvarado score in acute appendicitis?

BACKGROUND: We aimed to investigate the reliability of the Alvarado score (AS) in determining acute appendicitis and the different parameters that affect the AS. METHODS: Three hundred and thirteen patients suspected of acute appendicitis (AA) aged 18-70 years were included in this study. Patient data including AS calculated from emergency services and at discharge, follow-up, and operations were recorded. Patients were divided into three groups according to the AS, as AS <4, AS 5-7 and AS 8-10. AA and appendicitis perforation rates were compared according to the different parameters. RESULTS: The mean age of patients (55% females, 45% males) was 30.8±10.8 years. The AA (appendix perforation) rates of 211 patients who underwent operation were found as: AS ≤4: 56.5% (7.7%), AS 5-7: 75.9% (10%), and AS 8-10: 89% (27.8%). The percentage of negative appendectomy was 19.4%. The scoring was more reliable in males with AS 5-7, and the reliability weakened as body mass index (BMI) increased in all groups. CONCLUSION: Patients with AS ≤4 must be followed up and should be informed at the time of their discharge about the slight possibility of appendicitis. The effect of AS in determining the diagnosis of appendicitis is not influenced by age or symptom duration.

Hepatic artery reconstruction with gonodal vein interposition: First case in patients receiving liver from the living donor.

BACKGROUND: Technical problems such as graft and vascular size are more common in living donor liver transplantation (LDLT) than in deceased donor liver transplantation. It is usually possible to get enough length of vessels on the graft, but the opposite situation is devastating. Finding the suitable vessel graft is life-saving in those situations. In this paper we present a case of gonodal vein interpositioning for hepatic artery reconstruction in an LDLT recipient. To the best of our knowledge, this is the first such case to be reported in the literature. CASE REPORT: A 36-year-old man with cirrhosis secondary to hepatitis B underwent LDLT. Within minutes after completing the anastomosis, the artery was thrombosed. Disrupting the anastomosis showed subintimal dissection of the recipient right hepatic artery extending to the gastro-duodenal junction. A 4 cm segment of gonodal vein, which matched the diameter of the recipient hepatic artery, was used as a bridge. The patient's postoperative recovery was excellent and Doppler ultrasonography demonstrated sufficient hepatic arterial blood flow. At long-term follow-up (18(th) months), the patient's graft is still functioning. CONCLUSIONS: Gonodal vein interposition for hepatic artery reconstruction in living donor liver transplantation has not been previously reported. In light of the urgency of this situation, we believe it can be a life-saving reconstruction.