Stented Lich-Gregoir ureteroneocystostomy: case series report and cost-effectiveness analysis.

UNLABELLED: Extravesical ureteroneocystostomy to reestablish urinary tract continuity in renal transplantation has been examined through a meta-analysis of more than 14,000 kidney transplants leading to the finding that stented anastomosis was associated with a lower urologic complication rate compared with nonstented anastomoses. Fourteen stents must be used to prevent one urologic complication. We now report the urologic complication rate in our case series in which a stented Lich-Gregoir anastomosis was routinely utilized. We present a cost-effectiveness analysis regarding the usage of ureteral stents. METHODS: The records of 395 consecutive renal transplants were reviewed. Minimum follow-up time was 6 months. The standard anastomosis was a Lich-Gregoir with a 6- or 8-F 12- or 14-cm J-J stent. Monitored urologic complications included postoperative vesicoureteral leak or ureteral necrosis, obstruction or stricture, or clinically significant hematuria. Charges in 2004 US dollars were reported by the hospital accounting office. RESULTS: Four urologic complications were noted-three leaks and one stricture (complication rate of 1.0%). There were no stent-related complications requiring reoperation. There were no cases in which the urologic complication led to graft loss or patient death. Total charges associated with stent use were $1,087 per patient, or $15,218 per urologic complication prevented. CONCLUSIONS: The urologic complication rate in this case series is similar to the five previously published randomized trials, as well as our previously published meta-analysis. These results support the routine use of a ureteral stent. Our analysis suggests that stent use is cost effective.

Risk of early renal allograft failure is increased for patients with antiphospholipid antibodies.

Renal allograft thrombosis can cause transplant failure. Because antiphospholipid antibodies (aPA) are associated with thrombosis, we investigated pretransplant sera from patients with early renal allograft failure to determine if aPA were present. Fifty-six final cross-match (FxM) sera from patients whose transplant failed within 16 days were compared to FxM sera from the next sequential transplant patients. The sera were tested for IgG, IgM, and IgA antibodies to cardiolipin, phosphatidylserine, and phosphatidylethanolamine. aPA were identified in 57% of FxM sera from patients with early non-function versus 35% of FxM sera from patients with functioning grafts (P = 0.02). Historical sera from 11 aPA-positive patients contained aPA up to 18 months prior to transplantation. Since aPA were present in historical sera, testing for aPA can identify certain patients at risk for early allograft failure. The involvement of aPA in early allograft loss is supported by studies demonstrating aPA recovery from an explanted failed transplant.

Osmotic separation of pancreatic exocrine cells from crude islet cell preparations.

A novel approach is introduced here to selectively lyse exocrine cells in an islet preparation by hypo-osmotic treatment. Time to hypotonic cell lysis required for the islet cells was much longer than that for the exocrine cells, which permits a possibility of selectively killing the exocrine cells by hypotonic treatment. The first set of experiments was designed to select an appropriate osmolality for the hypotonic treatment. Kinetic changes in cell volume in response to extracellular anisosmolalities (30 to 90 mOsm/kg) were recorded using an electronic particle counter. The results indicated that, when exposed to a 30 mOsm/kg solution, islet cells swelled slowly to reach volumetric equilibrium in approximately 3 min. There was no significant hypotonic cell lysis observed even at the end of 4 min (n = 4). In contrast, pancreatic exocrine cells, when exposed to the same solution, expanded rapidly to the lytic volume and burst within 30 s. Significant exocrine cell lysis was invariably achieved within 30 s when cells were exposed to the osmolalities below 60 mOsm/kg. For osmolalities between 70 to 80 mOsm/kg, exocrine cell lysis was highly variable. When cells were exposed to 80 to 90 mOsm/kg, no significant cell lysis was observed. Thus, an osmolality of 50 mOsm/kg is recommended for hypotonic treatment, as it maximizes the lysis of exocrine cells without unnecessarily stressing (osmotically) the islet cells. The second set of experiments (time-course experiments, 20 to 120 s) was designed to determine the length of exposure time for which the exocrine cells were irreversibly damaged but the islet cells had only swollen to such a degree that cell function is restored upon returning to an isotonic condition. Viability of the hypotonic treated cells was evaluated at two different levels: membrane integrity, measured by combined fluorescent dye staining with propidium iodide (PI) and carboxyfluorescein diacetate (CFDA), and mitochondrial function, measured by colorimetric MTT assay. The results showed that hypotonic treatment in a 50 mOsm/kg solution for 30 s resulted in over 85% loss of the membrane integrity for the exocrine cells. About 90% of these membrane lysed cells lost mitochondrial function (n = 3). By contrast, under the same treatment, less than 15% of the islet cells lost membrane integrity and mitochondrial function (n = 3). In conclusion, hypotonic treatment with a 50 mOsm/kg solution for 20 to 30 s at room temperature is sufficient to lyse the majority of the contaminating exocrine cells in an islet cell preparation, while maintaining function in the islet cells.

Water permeability and its activation energy for individual hamster pancreatic islet cells.

Coupled with the rapid development of clinical pancreatic islet transplantation, there is an increasing requirement for cryopreservation of viable islets. Fundamental cryobiology requires determination of several cryobiophysical parameters to predict optimal cryopreservation procedures. These include water permeability or hydraulic conductivity (Lp) and its activation energy (Ea), the permeability of the cell plasma membrane to a cryoprotectant(s) (Ps) and its Ea, the osmotically inactive fraction of cell volume (Vb), and the intracellular ice formation temperature. For islet cells, these parameters have not previously been reported. In the present studies, the Lp, its Ea, and Vb were determined for isolated individual golden hamster pancreatic islet cells. The Lp and Vb parameters were also measured for corresponding exocrine cells. Both islet and the exocrine cells appeared to be ideal osmometers over the experimental range when examined by the Boyle Van't-Hoff relationship (linear regression, r = 0.99 for both types of cells). Extrapolation of these plots generated Vb values of 0.40 for the islet cells and 0.45 for the pancreatic exocrine cells. To determine the Lp, kinetic changes of cell volume over time (dv/dt) in response to anisoosmotic conditions (ranging from 145 mOsm/kg to 1.35 Osm/kg) were measured using an electronic particle counter. The experimental data were fitted to generate the Lp values by least-squares curve fitting to a differential equation describing osmotic water movement across the plasma membrane. For pancreatic islet cells, the Lp was determined to be 0.25 +/- 0.03 microns/min/atm (mean +/- SD, n = 14) at 22 degrees C, 0.54 +/- 0.07 (n = 10), 0.06 +/- 0.008 (n = 9), and 0.01 +/- 0.001 (n = 9) at 37, 8 and 0 degrees C, respectively. The Ea for Lp was calculated from the slope of the Arrhenius plot based upon the mean Lp values at the four different temperatures. The Ea was 16.21 Kcal/mol between 0 and 37 degrees C. Based upon these values, an optimal cooling rate for cryopreserving pancreatic islet cells is predicted to be approximately 0.5 degrees C min. The Lp for the individual exocrine cells was determined to be 3.73 +/- 1.75 microns/min/atm (n = 13) at 22 degrees C, which was approximately 10 times the Lp value of the corresponding islet cells.

Maintenance of adequate hemodialysis access. Prevention of neointimal hyperplasia.

The maintenance of adequate hemodialysis vascular access is frequently complicated in the patient with polytetrafluoroethylene (PTFE) A-V hemodialysis grafts by venous anastomotic stenosis. This stenosis is caused by neointimal hyperplasia (NIH), a response to vascular injury. In this study, the authors prospectively analyzed the effect of a short-term regimen consisting of administration of two medications, heparin and low molecular weight dextran, on the development of NIH at the venous anastomosis in 79 patients with PTFE A-V hemodialysis grafts. In addition, they evaluated other parameters' effects on the development of NIH. In comparison with control subjects, heparin had some effect in minimizing the development of NIH in the PTFE grafts when evaluated radiologically at 3 months, although this effect was not statistically significant. Low molecular weight dextran, however, had no trend or statistically significant effect on this venous anastomotic narrowing. Interestingly, patient age, use of calcium channel blockers, and presence of diabetes mellitus (DM) all appeared to affect the development of NIH. Increasing age and use of calcium channel blockers was associated with decreased development of NIH; conversely, DM was associated with worsened NIH. In evaluation of access survival (time to first access failure), degree of venous anastomosis stenosis at 3 months was not predictive. Patient time on dialysis pre graft placement was the only measured parameter related to access failure. The method of dialysis pre graft placement (hemodialysis versus peritoneal dialysis) was not a significant factor in early access failure. Pharmacologic treatment of venous anastomotic narrowing in PTFE hemodialysis grafts due to NIH continues to be difficult. Short-term treatment with the tested medication failed to statistically affect NIH. Patient age, use of calcium channel blockers, and presence of DM were all factors in the development of NIH. Of measured parameters, time on dialysis pre graft placement was the only factor correlated with early access failure. In future treatment regimens, one should consider more prolonged treatment. In addition, noted risk factors should be considered when determining type of renal replacement therapy.

Liver transplantation.

A multidisciplinary approach is necessary in addressing the needs of a patient with end-stage liver disease. The development of the liver transplant program at MHI was a natural extension of the transplant and critical care programs already in place. The case report described exemplifies that valuable input from ancillary support groups is necessary for a successful liver transplant program. Experience gained in the area of liver transplantation not only benefits liver transplant patients but also extends to other areas of clinical medicine. One year ago, an Indiana resident had to travel out of state to receive this specialized form of care. Today this is no longer the case.

Potent immunosuppression overcomes immunologic high-risk factors in recipients of cadaveric renal allografts.

With the introduction of more potent immunosuppressive regimens, increasing numbers of kidney transplant recipients traditionally viewed as being at high immunologic risk for rejection and graft loss have been accepted. These include recipients of multiple grafts, sensitized patients as measured by high panel reactive antibody (PRA), and patients with current warm B or historical positive crossmatches. Since November 1983, all recipients of cadaver kidneys have been treated with cyclosporine and prednisone. In addition, most also received a short posttransplant course of antilymphocyte globulin and long-term azathioprine. With these regimens, retransplantation, sensitization, current B-cell crossmatch and historical B- and/or T-cell crossmatch do not affect graft survival.

OKT3 treatment of steroid-resistant renal allograft rejection.

The monoclonal antibody, Orthoclone OKT3 (OKT3), has been used with great efficacy in a prospective multicenter trial as therapy for first rejection episodes in cadaveric donor (CD) renal allograft recipients treated with azathioprine (AZA) and prednisone (P). However, although almost all rejection episodes were reversed, recurrent rejection occurred in approximately two-thirds of OKT3-treated patients in this earlier trial; infections also occurred in about two-thirds of patients, often related to the additional immunosuppression necessary to reverse the rerejection episodes. In the current series of patients, OKT3 was used to treat rejection in CD renal graft recipients in a protocol differing from the multicenter trial in two respects: baseline immunosuppression was cyclosporine (CsA) and P or CsA, AZA, and P (probably more potent immunosuppressive combinations than the AZA and P in the multicenter trial); and OKT3 treatment was reserved for rejection episodes resistant to 3 bolus infusions of methylprednisolone (MP), 5-10 mg/kg, rather than as primary therapy for first rejection episodes. Using this protocol, 46 of 74 rejection episodes (62%) diagnosed between 3/85 and 3/86 in CD renal allograft recipients were treated successfully with MP. Of the remaining 28 steroid-resistant rejection episodes, 27 (96%) were reversed with a 7-14-day course of OKT3, 5 mg/day. Only 5 recurrent rejection episodes (19%) have been observed in the 2-14-month follow-up period after OKT3 treatment; infections have occurred in 10 patients (36%), and three grafts (11%) have been lost in OKT3 treated patients. These results suggest that recurrent rejection and subsequent infection after OKT3 is used to treat rejection may be reduced in a protocol where CD renal allograft recipients are treated with baseline immunosuppression regimens including CsA and where OKT3 is reserved for steroid-resistant rejection. This approach appears to be both more cost-effective than, and as effective therapeutically as, treating all first rejection episodes with the monoclonal antibody.

Elective conversion from cyclosporine to azathioprine in recipients with stable renal function 6 months after kidney transplantation.

The average cost of cyclosporine over the first 6 months after renal transplantation has been $2450/recipient for recipients with stable renal function. Fifty-nine percent of all patients transplanted in 1984 do not have a third-party payment mechanism for outpatient medicines and many cannot afford cyclosporine. The expense of cyclosporine has, thus, mandated developing a protocol for conversion from cyclosporine to azathioprine. Using a protocol, which included a short overlap of cyclosporine and azathioprine and a temporary, modest increase in prednisone dose, 27 renal allograft recipients with stable renal function have undergone conversion of their immunosuppressive regimen approximately 6 months posttransplant with a minimum follow-up of 4 months from conversion. There has been no graft loss or patient death. Mean serum creatinine has been reduced in recipients with stable function after conversion (1.4 mg/dl 3 months postconversion compared to 1.8 mg/dl preconversion). However, acute breakthrough rejection has occurred in four recipients (15%), and, after reversal of rejection, mean serum creatinine is elevated (3.1 mg/dl) in this group. Only a single patient developed an infection during the conversion period. Thus, a policy of conversion from azathioprine appears to be a reasonable compromise for those patients who cannot afford long-term outpatient treatment with cyclosporine.