Outcomes of small pediatric donor kidney transplants according to donor weight.

A small pediatric deceased donor (SPD) weight cutoff whether to transplant as en bloc (EB) or single pediatric (SP) kidney is uncertain. Using UNOS/OPTN data (2000-2019), 27 875 SPDs were divided by (i) EB (11.4%) or SP (88.6%) and (ii) donor weight [≤10 (5.4%), >10-15 (8.3%), >15-18 (3.7%), >18-20 (2.9%), and >20 kg (79.7%)]. SP >20 kg and adult deceased donors (grouped by Kidney Donor Profile Index, KDPI, <30, 30-85, and >85) were used as references. The primary outcome was 10-year graft failure. In SP <10 kg, the hazard ratio (HR) for overall graft failure was 1.64 (1.38-2.20) compared with EB <10 kg, and 1.45 (1.18-1.80) compared with SP >20 kg. In SP >10-15 kg, HR was 1.31 (1.12-1.54) compared with EB >10-15 kg, and 1.04 (0.91-1.18) compared with SP >20 kg. In SP >15 kg, the risk was the same as SP >20 kg. Ten-year overall graft survival of SP 12 kg was comparable to SP >20 kg (62% vs. 57%). Ten-year death censored graft failure of SP >10-15 kg (70%) and SP >15-18 kg (70%) was like the adult donors with KDPI 30-85 (67%). In conclusion, we recommend single kidney transplants from SPDs with weight >12 kg to adult recipients in centers with experience in SPD transplants to optimize organ utilization.

Randomized controlled trial of a quadratus lumborum block with liposomal bupivacaine for postoperative analgesia in laparoscopic donor nephrectomy.

Perioperative pain management is an important consideration in early recovery and patient satisfaction following laparoscopic donor nephrectomy. Transmuscular quadratus lumborum block has been described to reduce pain and opioid usage following several abdominal surgeries. In this prospective single-blind randomized controlled trial, we compared 52 patients who adhered to our institutional donor nephrectomy Early Recovery After Surgery pathway, which includes a laparoscopic-guided transversus abdominus plane block, to 40 patients who additionally received a transmuscular quadratus lumborum block with liposomal bupivacaine. Compared to control patients, those who received the block spent longer in the operating room prior to the surgical start (65.4 vs. 51.6 min, P < .001). Both groups had similar total hospital length of stay (33.3 h vs. 34.4 h, P = .61). Pain scores from postoperative days 0-30, number of patients requiring opioids, postoperative nausea, and pain management satisfaction were similar between both groups. Patients who received the block consumed less opioid on postoperative day 1 compared to controls (P = .006). No complications were attributable to the block. The quadratus lumborum block provides a safe pain management adjunct for some patients, and may reduce opioid use in the early postoperative period when combined with our standard institutional protocol for kidney donors.

Adrenal Function After Laparoscopic Nephrectomy: The Zurich Clinical Trial.

This manuscript reviews the outcomes of a European clinical trial to evaluate the effects of living kidney donation on adrenal function. The study shows that left-sided donor nephrectomy is associated with transiently reduced adrenocortical responsiveness, which returns to baseline after 28 d.

Avoiding Futility in Simultaneous Liver-kidney Transplantation: Analysis of 331 Consecutive Patients Listed for Dual Organ Replacement.

OBJECTIVE: We sought to evaluate outcomes and predictors of renal allograft futility (RAF-patient death or need for renal replacement therapy at 3 months) after simultaneous liver-kidney transplantation (SLKT). BACKGROUND: Model for End-Stage Liver Disease (MELD) prioritization of liver recipients with renal dysfunction has significantly increased utilization of SLKT. Data on renal outcomes after SLKT in the highest MELD recipients are scarce, as are accurate predictors of recovery of native kidney function. Without well-established listing guidelines, SLKT potentially wastes renal allografts in both high-acuity liver recipients at risk for early mortality and recipients who may regain native kidney function. METHODS: A retrospective single-center multivariate regression analysis was performed for adult patients undergoing SLKT (January 2004 to August 2014) to identify predictors of RAF. RESULTS: Of 331 patients dual-listed for SLKT, 171 (52%) expired awaiting transplant, 145 (44%) underwent SLKT, and 15 (5%) underwent liver transplantation alone. After SLKT, 39% experienced delayed graft function and 20.7% had RAF. Compared with patients without RAF, RAF recipients had greater MELD scores, length of hospitalization, intraoperative base deficit, incidence of female donors, kidney and liver donor risk indices, kidney cold ischemia, and inferior overall survival. Multivariate predictors of RAF included pretransplant dialysis duration, kidney cold ischemia, kidney donor risk index, and recipient hyperlipidemia. CONCLUSIONS: With 20% short-term loss of transplanted kidneys after SLKT, our data strongly suggest that renal transplantation should be deferred in liver recipients at high risk for RAF. Consideration for a kidney allocation variance to allow for delayed renal transplantation after liver transplantation may prevent loss of scarce renal allografts.

Use of Polyethylene Glycol Electrolyte Solution Expedites Return of Bowel Function and Facilitates Early Discharge after Kidney Transplantation.

BACKGROUND: Delay in the return of bowel function often prolongs hospitalization after kidney transplantation, leading to increased patient morbidity and health care costs. Polyethylene glycol (PEG) solution has been observed to aid the return of bowel function in postoperative patients undergoing abdominal surgery. STUDY DESIGN: Using a 2-arm, single-surgeon, nonrandomized study, we compared the addition of PEG along with early resumption of diet with a control group using only early resumption of diet in kidney transplantation patients. RESULTS: There were 51 subjects in the control group and 47 subjects in the PEG intervention group. The primary outcomes measure, time to bowel movement, was significantly shorter than the control group by an entire day (2.9 ± 1.1 days vs 4.0 ± 1.3 days; p < 0.001). In propensity score analysis, patients receiving PEG had bowel movements sooner (-1.06 ± 0.25 days; p < 0.001) and decreased lengths of stay (-1.16 ± 0.27 days; p < 0.001). CONCLUSIONS: Polyethylene glycol significantly reduced time to return of bowel function and postoperative length of stay. By adding PEG to the postoperative protocol, we can help to reduce costs of hospitalization and improve overall outcomes in renal transplantation patients.

Prevalence of incidental findings on abdominal computed tomography angiograms on prospective renal donors.

OBJECTIVE: To evaluate the prevalence of incidental findings on preoperative abdominal computed tomography angiography-computed tomography urography in asymptomatic prospective renal donors. METHODS: A Health Insurance Portability and Accountability Act (HIPAA)-compliant, Institutional Review Board (IRB)-approved retrospective study of 1,597 subjects undergoing renal transplant evaluation from June 1, 2006, to March 31, 2011, was performed. Candidates underwent multiphasic multidetector computed tomography angiography-computed tomography urography for presurgical evaluation of renal vascular and parenchymal anatomy. All scans were reviewed by one of three fellowship-trained abdominal radiologists. The diagnoses were made on the basis of computed tomography characteristics of each lesion, and pathology confirmation was available for seven patients. We calculated the prevalence of each incidental finding, performed Fisher exact test or chi-square test for categorical variables between the cohort that did and did not undergo donor nephrectomy, and performed simple linear logistic regression analysis of incidental findings which predicted renal donation. RESULTS: Of the 1,597 potential donors, 58.4% were female, and the mean age was 42.6 years (range, 18-74). One thousand one hundred ninety-five (74.9%) had a total of 2,105 incidental findings. Based on American College of Radiology Incidental Findings Committee White Paper on Managing Incidental Findings on Abdominal Computed Tomography, 17.3% had incidentalomas and 1.1% required follow-up. Majority of the incidental findings (16 of 17) were in patients who did not undergo renal donation. The prevalence of pathologically proven malignancy was 0.1% (3 of 1,597). CONCLUSION: Preoperative computed tomography angiography-computed tomography urography not only identifies vascular anatomy but may also help detect clinically significant unanticipated findings in an otherwise healthy population.

Revised Cardiac Risk Index (RCRI) is a useful tool for evaluation of perioperative cardiac morbidity in kidney transplant recipients.

BACKGROUND: We evaluated a published Revised Cardiac Risk Index (RCRI) to determine if this preoperative cardiovascular risk stratification tool would be useful in the kidney transplant recipient population. METHODS: We identified all kidney transplants from 2005 to 2009 (n=1652) at our institution. We performed a detailed retrospective chart review of (a) all recipients who underwent preoperative coronary angiography (n=169) and (b) an age-matched and transplantation year-matched group who did not undergo coronary angiography (n=156). Charts were reviewed for the presence of specific preoperative cardiovascular risk factors and perioperative cardiovascular complications (as defined by RCRI plus elevation of troponin) from time of surgery to hospital discharge. The total number of risk factors for each patient was compared with the occurrence of postoperative cardiac complications to identify a possible association. RESULTS: The number of risk factors was highly predictive of cardiovascular complications (receiver operating characteristic area, 0.77; P<0.0001). History of coronary artery disease was most strongly associated (odds ratio, 20.59; confidence interval, 4.73-89.53; P=0.0001) and history of congestive heart failure was also significantly associated with cardiac complications (odds ratio, 2.95; confidence interval, 1.01-8.59; P=0.0475). CONCLUSION: The RCRI is a useful tool for cardiac risk stratification in kidney transplantation and could be used to develop protocols for intraoperative and postoperative care to minimize complications.

Intermediate-term outcomes associated with kidney transplantation in recipients 80 years and older: an analysis of the OPTN/UNOS database.

BACKGROUND: An increasing number of patients 80 years and older have received a kidney transplant in the United States, but their outcomes are not well described. Using Organ Procurement and Transplantation Network/United Network of Organ Sharing data, outcomes of recipients 80 years and older were evaluated. METHODS: Thirty-one thousand one hundred seventy-nine elderly recipients defined by age 60 years and older receiving kidney transplants from 2000 to 2008 were stratified: ages 60 to 69 years (n=24,877), 70 to 79 years (n=6,103), and 80 years and older (n=199). Cox regression models were used to compare patient, graft, and death-censored graft survival. RESULTS: The majority of recipients 80 years and older was male (82.9%), white (87.9%), and less likely to have diabetes or coronary artery disease. More expanded criteria donor (ECD) but fewer living donor transplants were performed among 80 years and older compared with those younger than 80 years. Perioperative mortality, defined as death within 30 days posttransplant, was rare (60-69 years: 1.4%; 70-79 years: 1.5%; and ≥80 years: 2.5%) but tended to be higher among those 80 years and older compared with recipients 60 to 69 years (hazard ratio [HR] 1.67; 95% confidence interval [CI] 0.69-4.05). At 2 years, survival was lower for 80 years and older (73%; HR 2.42; 95% CI 1.91-3.06) and 70 to 79 years (86%; HR: 1.42; 95% CI: 1.34-1.51) compared with recipients 60 to 69 years (89%). There was a greater risk of graft loss among recipients 80 years and older compared with those 60 to 69 years (HR 1.78; 95% CI 1.42-2.23); however, no difference in death-censored graft survival was observed (0.89; 0.57-1.39). Among recipients 80 years and older, no difference in survival was observed between standard criteria donor and ECD recipients. CONCLUSION: Although perioperative mortality was uncommon among elderly recipients (1.5%), a trend toward higher perioperative mortality was observed in recipients 80 years and older. There was no difference in survival among standard criteria donor and ECD recipients.

Urological complications of renal transplant in patients with prolonged anuria.

BACKGROUND: Because of the shortage of deceased donor kidneys, some patients are on dialysis for over 10 years before renal transplantation. Many of these patients are anuric. We reviewed the urological complications in renal transplant recipients with anuria on hemodialysis for more than 10 years, compared with preemptive transplant recipients. METHODS: The records of 4012 renal transplants from January 1988 to September 2007 were retrospectively reviewed. A total of 2735 deceased donor transplants were performed during this period. We identified a group of patients who were on hemodialysis for over 10 years and made less than 500 mL of urine per day. We compared the rate of urologic complications in this group with patients who were never on dialysis and had normal bladder function based on history and physical examination. RESULTS: Seventy-two patients met the strict inclusion criteria. There were 41 recipients in the anuric group and 31 recipients in the preemptive group. The surgical complications were not significantly different between the two groups (P=0.503). However, the anuric group required five more hospital admissions for complicated urinary tract infections (P=0.044). CONCLUSIONS: Renal transplant recipients who have been anuric for a prolonged period have higher rates of complicated urinary tract infections, but the long-term risks of urological complications are not significantly different.