Successful ABO and HLA incompatible kidney transplantation in children in the UK.

BACKGROUND: There is increasing evidence of good short-term and medium-term outcomes of ABO incompatible (ABOi) and HLA incompatible (HLAi) kidney transplantation with pre-transplant positive crossmatches in paediatric practice. However, there remain concerns regarding the higher risks of infective complications and antibody-mediated rejections. The aim of our study is to show longer-term follow-up on all ABOi and HLAi paediatric kidney transplant recipients (pKTR) in the UK. METHODS: Questionnaires specifying kidney transplant type, desensitisation requirement and kidney allograft function were sent to 13 paediatric nephrology centres that performed kidney transplantation in children and young people under 18 years of age who received an ABOi and/or HLAi transplant between 1 January 2006 and 31 December 2016. Patient and kidney allograft survival were compared between ABOi, HLAi and ABO/HLA compatible (ABOc/HLAc) groups. RESULTS: Among 711 living donor kidney transplants performed in the UK, 23 were ABOi and 6 were HLAi. Patient survival was 87%, 100% and 96% in ABOi, HLAi and ABOc/HLAc groups, respectively, at median follow-up of 6.8 (3.6-14.0) years post-transplant. Death-censored kidney allograft survival was 100% in all 3 groups at last follow-up. There were no cases of primary non-function in ABOi or HLAi groups, but 2% in the ABOc/HLAc group. There was one reported case of Epstein-Barr viral-induced post-transplant lymphoproliferative disorder. CONCLUSION: Longer term follow-up has shown that ABOi and HLAi kidney transplantation are feasible for pKTR where no compatible donors are available, and that minimising desensitisation should be achieved where possible. A higher resolution version of the Graphical abstract is available as Supplementary information.

Stepwise Approach for Parathyroid Localisation in Primary Hyperparathyroidism.

INTRODUCTION: Primary hyperparathyroidism (PHPT) is a relatively common condition in surgical practice. Availability of localisation studies has shifted the treatment from bilateral neck exploration to selective parathyroidectomy. Several imaging modalities, each with varying sensitivities, are available to detect abnormal parathyroid glands. Ultrasound is almost universally accepted as the first line radiological investigation however its sensitivity is particularly heterogeneous and operator-dependent. MATERIAL AND METHODS: We studied 250 consecutive patients with PHPT who underwent parathyroidectomy in our hospital over a period of 33 months. Pre-operative neck ultrasound, 99mTc-sestamibi and single-photon emission computed tomography (SPECT CT) were performed in 249, 237 and 198 patients respectively. Unilateral and bilateral neck exploration was performed in 190 and 60 patients, respectively. Sensitivity, positive predictive value (PPV) and accuracy were calculated comparing the results with surgical and pathology findings. RESULTS: Mean pre and postoperative PTH and adjusted calcium were, 11 ± 10.6 pmol/L, 1.9 ± 3.6, 2.81 ± 0.2 and 2.45 ± 0.2 mmol/L. There were 71 (29.95%) discordant results between US, compared to sestamibi and SPECT CT. An average of 1.9 parathyroid glands were removed with a mean weight of 0.92 g. Overall success rate based on postoperative PTH levels was 94.8%. Overall sensitivity, PPV and accuracy for US were 80.80%, 92.35%, and 75.73% respectively; for sestamibi were 71.82%, 94.61%, 69.00% and for SPECT CT were; 70.21%, 97.78%, 69.11% respectively. CONCLUSION: Ultrasound performed by an experienced specialist sonographer is highly sensitive in localising abnormal parathyroid glands. It can be used as a main and sole investigation in the majority of patients. Sestamibi, SPECT CT and other investigations should be performed in a step-wise manner and reserved for patients with negative US, failed primary procedure and recurrences.

Paediatric non-heart-beating renal transplantation.

Expanding donor numbers for paediatric transplantation is an urgent, difficult issue. The use of non-heart-beating donor renal transplants has seen a revival in adult practice, with encouraging results. The authors present the first two cases in the UK of paediatric renal transplant from non-heart-beating donors.

Exposure to the field of renal transplantation during undergraduate medical education in the UK.

BACKGROUND: There is a lack of surgeons in the field of renal transplantation, with a predicted shortage of over 20 consultants by the year 2005. Early positive exposure to the field, commencing at undergraduate level, has been identified as being vital to improving rates of recruitment. This study was performed to assess the exposure of undergraduates to the field of renal transplantation during medical education in the UK. METHODS: In October 2004 a questionnaire was sent to the clinical deans of all UK medical schools regarding undergraduate exposure to renal transplantation. RESULTS: Twenty-five replies were received, giving a response rate of 96%. All but one school had a centre for renal transplantation in their region. Three schools (12%) gave no formal lecture or tutorial on the subject during the entire course. Of the remainder, between one to four formal sessions were provided, ranging from 15 minutes to 3 hours duration. Six medical schools (24%) provided no compulsory clinical exposure to renal transplantation, with a further five (20%) saying that students may receive exposure by chance. The average length of attachment was three weeks. Twenty-one medical schools (84%) provided between 1-10% of students a choice to study renal transplantation, as part of electives and special study modules. CONCLUSION: This study reveals a variation between, and within, medical schools in the levels of formal teaching. If the trends in recruitment to renal transplantation are to be reversed, we have an obligation to improve upon the medical education that students currently receive.

A survey of medical students to assess their exposure to and knowledge of renal transplantation.

BACKGROUND: Within the field of renal transplantation there is a lack of qualified and trainee surgeons and a shortage of donated organs. Any steps to tackle these issues should, in part, be aimed at future doctors. METHODS: A questionnaire was distributed to final year students at a single medical school in the UK to assess their exposure to and knowledge of renal transplantation. RESULTS: Although 46% of responding students had examined a transplant recipient, only 14% had ever witnessed the surgery. Worryingly, 9% of students believed that xenotransplantation commonly occurs in the UK and 35% were unable to name a single drug that a recipient may need to take. CONCLUSIONS: This survey demonstrates a lack of exposure to, and knowledge of, the field of renal transplantation. Recommendations to address the problems with the recruitment of surgeons and donation of organs, by targeting medical students are made.