Robotic assisted living donor nephrectomy - the first in the Czech Republic.

INTRODUCTION: A kidney transplant is the best method for treating terminal kidney failure. Long-term results of kidney transplants from living donors are significantly better than transplants from dead donors. Living kidney donors are healthy people who undergo a major operation in order to improve the health of another person. Therefore, major emphasis is on safety, low level of invasiveness and a desirable cosmetic effect of the donor nephrectomy. Since 2012, the Department of Urology at the University Hospital in Olomouc has performed 12 kidney harvestings from living donors. The kidney harvesting was conducted using various techniques. CASE REPORT: The first robotic assisted kidney harvesting in the Czech Republic was performed in June 2022. The donor was a 57-year-old man who donated his kidney to his 32-year-old daughter. The left kidney was evaluated as suitable for kidney harvesting. The operation took 174 min. The kidney's warm ischemia was 145 s. Based on the Clavien Dindo classification, no 2nd degree or high post-operative complications were recorded. The donor's pre-operative glomerular filtration was 1.63 mL/s. Six months post-operation, it went down to 1.19 mL/s. This represents a 27% decrease. The kidney recipient did not require early dialysis. Six months post-operation, the recipient's glomerular filtration was 2.03 mL/s. CONCLUSION: In the hands of experienced professionals and transplantation centres, robotic assisted donor nephrectomy is a feasible and safe option for this operation. It not only provides all the advantages of a laparoscopic operation but it also adds other technical improvements and minimizes intraoperative stress on the surgeon. Currently, the global trend is moving towards increasing the ratio of robotic assisted donor nephrectomies.

Brachial artery aneurysm as a late complication of arteriovenous fistula.

INTRODUCTION: Brachial artery aneurysm (BAA) is a rare late complication of arteriovenous fistula (AVF). It brings the risk of peripheral embolism and hand ischemia and is defined by brachial artery diameter above 10 mm or by regional dilatation by >50%. BAA is described in the literature in closed radiocephalic arteriovenous fistulas after kidney transplantation. The aim of the study was to analyze the prevalence of BAA and of their more dangerous forms. METHOD: A observational one center study performed on patients after kidney transplantation with AVF or arteriovenous graft (AVG). We invited all patients followed up for kidney transplantation in our center. Arterial diameter greater than 10 mm was considered as a brachial artery aneurysm to simplify the detection and evaluation of aneurysms. RESULTS: About 162 patients with AVF after kidney transplantation were examined between 4/2018 and 4/2020. Brachial artery aneurysm was detected in 34 patients (21%) with AVF or AVG, of them 7 had confirmed wall thrombi. AVF flow volume of more than 1500 ml/min increased the risk of BAA development by 4.54x. Eight aneurysms were treated surgically. After this surgery, the primary patency was 87.5% in 12 months. CONCLUSION: Brachial artery aneurysm was relatively frequent in our study compare to the literature. Aneurysm or dilatation of the brachial artery is more frequent in functional AVFs. Surgical correction is necessary in cases of complicated aneurysms to prevent distal embolization.

Smoothie Drinks: Possible Source of Resistant and Biofilm-Forming Microorganisms.

Smoothie drinks are currently very popular drinks sold especially in fast food establishments. However, smoothies are a significant source of microorganisms. The aim of this study was to evaluate the microbiological quality of smoothies purchased in Eastern Bohemia. A higher prevalence of mesophilic aerobic bacteria (5.4-7.2 log CFU/mL), yeast (4.4-5.9 log CFU/mL) and coliform bacteria (3.1-6.0 log CFU/mL) was observed in vegetable smoothies, in which even the occurrence of enterococci (1.6-3.3 log CFU/mL) was observed. However, the occurrence of S. aureus, Salmonella spp. and Listeria spp. was not observed in any samples. Nevertheless, antimicrobial resistance was observed in 71.8% of the isolated strains. The highest level of resistance was found in isolates from smoothie drinks with predominantly vegetable contents (green smoothie drinks). Considerable resistance was observed in Gram-negative rods, especially to amoxicillin (82.2%) and amoxicillin with clavulanic acid (55.6%). Among enterococci, only one vancomycin-resistant strain was detected. The vast majority of isolated strains were able to form biofilms at a significant level, which increases the clinical importance of these microorganisms. The highest biofilm production was found in Pseudomonas aeruginosa, Kocuria kristinae and Klebsiella pneumoniae. Overall, significant biofilm production was also noted among isolates of Candida spp.

Current Status, Prevention and Treatment of BK Virus Nephropathy.

All renal transplant recipients should undergo a regular screening for BK viral (BKV) viremia. Gradual reduction of immunosuppression is recommended in patients with persistent plasma BKV viremia for 3 weeks after the first detection, reflecting the presence of probable or suspected BKV-associated nephropathy. Reduction of immunosuppression is also a primary intervention in biopsy proven nephropathy associated with BKV (BKVN). Thus, allograft biopsy is not required to treat patients with BKV viremia with stabilized graft function. There is a lack of proper randomised clinical trials recommending treatment in the form of switching from tacrolimus to cyclosporin-A, from mycophenolate to mTOR inhibitors or leflunomide, or the additive use of intravenous immunoglobulins, leflunomide or cidofovir. Fluoroquinolones are not recommended for prophylaxis or therapy. There are on-going studies to evaluate the possibility of using a multi-epitope anti-BKV vaccine, administration of BKV-specific T cell immunotherapy, BKV-specific human monoclonal antibody and RNA antisense oligonucleotides. Retransplantation after allograft loss due to BKVN can be successful if BKV viremia is definitively removed, regardless of allograft nephrectomy.

Reduction of arteriovenous access blood flow leads to biventricular unloading in haemodialysis patients.

AIMS: Patients on chronic haemodialysis have a wide range of changes in cardiac function and structure, including left ventricular hypertrophy, dilation and diastolic dysfunction or pulmonary hypertension. All these changes were linked to increased mortality in previous studies. High-flow arteriovenous fistulas (AVF) are supposed to be a factor contributing to their development. This study investigated the early effect of surgical AVF blood flow (Qa) reduction on these changes in patients with or without heart failure changes. METHODS AND RESULTS: Forty-two patients in chronic haemodialysis programme with high-flow AVF (Qa over 1500 mL/min), indicated for surgery for ≥1 of the following indications: 1.manifest heart failure; 2.hand ischemia; 3.advanced structural heart changes detected by echocardiography. The patients underwent echocardiography on selection visit, before blood flow reducing surgery and six weeks thereafter. The Qa reduction led to decrease of left ventricular mass (p = 0.02), end-diastolic volume (p = 0.008), end-diastolic diameter (p = 0.003) and left atrial volume (p = 0.0006). Diastolic function improved. Similarly, right ventricular diameter and right atrial volume decreased (p = 0.000001 and 0.00009, respectively) together with the decrease of estimated pulmonary artery systolic pressure. 81% of patients suffered from pulmonary hypertension prior to surgery, only 36% thereafter. CONCLUSION: The surgical restriction of the hyperkinetic circulation leads to several improvements of heart structure and function, which was linked to higher mortality in other studies. The beneficial effect of Qa reduction is present even in patients without symptoms of heart failure. The contribution of AVF must be considered with structural or functional heart changes.

Creation of arteriovenous fistula for hemodialysis in the older population.

OBJECTIVE: To evaluate the results of arteriovenous fistula (AVF) created for haemodialysis in patients older than 65 years of age. SUBJECTS AND METHODS: A retrospective analysis of patients with AVF or arteriovenous graft (AVG) creation, who were older than 65 years of age and were operated on at the II. Surgical Clinic at the University Hospital in Olomouc from 2014 - 2018 was performed. RESULTS: 212 patients were evaluated and a total of 239 AVF/AVG were created. 194 AVFs (81.18%) and 45 AVGs (18.82%) were created. Primary failure was seen in 19 arteriovenous fistulas (9.8%) and 2 arteriovenous grafts (4.44%). The primary patency of AVF was 69.9%, 62.8% after 12 and 24 months, respectively, and in the case of AVG it was 54.7% and 32.3% after 12 and 24 months, respectively. Primarily assisted patency of AVF was 77.6% and 66.3% after 12 and 24 months, respectively, and in case of AVG it was 69.1% and 39.7% after 12 and 24 months, respectively. Secondary patency of AVF was 77.6% and 66.3% after 12 and 24 months, respectively, and for AVG it was 69.1% and 39.7% after 12 and 24 months, respectively. CONCLUSION: The type of vascular access should be selected based on a thorough, protocol-based examination. In most seniors, AVF is the method of choice. The AVG is a suitable choice for patients with an exhausted venous bed, in acute need of haemodialysis, in the elderly and in females. A "customized" approach should be matter of fact for older generations.

Arteriovenous Grafts' Types of Indications and Their Infection Rate.

BACKGROUND: Arteriovenous graft infection is a well-known and frequent complication. The objective of this study was to compare infection rates of primary and secondary indicated arteriovenous grafts (AVGs). SUBJECTS AND METHODS: Retrospectively, we evaluated the indications for AVGs created at our institution which became infected. One hundred forty AVGs were evaluated. Of these AVGs, 33 (23.6%) were primary and 107 (76.4%) secondary indicated. RESULTS: Infection of a primary AVG was detected in 5 patients (15.2 %). Infection of a secondary AVG was detected in 30 patients (28.0%). Primary and secondary patency were significantly lower in patients with infected AVG (P = 0.006; P = 0.0001). The effect of diabetes mellitus and age on development of infection was not confirmed. CONCLUSIONS: Indications for AVG creation clearly influence the future risk of infection. If the indication to use the AVG is to correct a complicated arteriovenous fistula, the risk of infection is 2 times higher.

The effect of graphene oxide on signalling of xenobiotic receptors involved in biotransformation.

Graphene oxide (GO) is an engineered nanomaterial which was demonstrated to have outstanding capacity for adsorption of organic pollutants such as polycyclic aromatic hydrocarbons (PAHs) and polychlorinated biphenyls (PCBs), the ligands and activators of the aryl hydrocarbon receptor (AhR). Due to the partially overlapping ligand capacity of AhR and pregnane X receptor (PXR), we tested the impact of GO particles on their signalling. While reporter gene assay revealed potentiating effect of GO on ligand-activated AhR-dependent luciferase activity, there was no effect for PXR. However, inducible target genes for AhR (CYP1A1) or PXR (ABCB1) were decreased at mRNA as well as protein levels by the presence of GO in HepG2 (for AhR), LS180 (for PXR) or primary human hepatocytes (both receptors). Moreover, the presence of GO diminished PXR and AhR protein levels in primary cultures of human hepatocytes. This was partially reversed by proteasome inhibitor MG132 for AhR but not for PXR. In conclusion, GO decreases ligand-stimulated activities of AhR and PXR in human cells.

18F-FDG PET/CT and 99mTc-HMPAO-WBC SPECT/CT effectively contribute to early diagnosis of infection of arteriovenous graft for hemodialysis.

OBJECTIVE: An arteriovenous graft (AVG) is indicated in hemodialysis patients with failed arteriovenous access. Early treatment of AVG infection is important because an advanced prosthetic infection leads to the removal of the prosthesis. The aim of this study was to evaluate the benefits of 18F-FDG PET/CT and 99mTc-HMPAO-WBC SPECT/CT in early detection of AVG infections. SUBJECTS AND METHODS: Fifty-one AVGs were evaluated. 18F-FDG PET/CT and 99mTc-HMPAO-WBC SPECT/CT studies were performed at intervals of 10, 20-30, and 40-50 weeks after AVG insertion. Agreement between the imaging methods and reference parameters (i.e. clinical presentation, C-reactive protein and microbiological findings on the hemodialysis cannula extracted after hemodialysis from AVG) was evaluated. RESULTS: The study results showed that focal accumulation of the radiopharmaceuticals can be considered a sign of AVG infection. At 10 weeks after AVG implantation, the focal 18F-FDG findings showed the best agreement with the reference parameters (agreement coefficients AC1 - clinical status: 0.693, CRP: 0.605, cannula microbiology: 0.518, respectively). At 20 to 30 weeks after AVG implantation, the diagnostic value of focal 99mTc-HMPAO-WBC accumulation increased (AC1 coefficients: 0.658, 0.658, 0.408) and was similar to that of focal 18F-FDG uptake (AC1s: 0.656, 0.570, 0.409). Between 40 and 50 weeks since AVG implantation, the diagnostic significance of focal 99mTc-HMPAO-WBC accumulation (AC1 coefficients: 0.771, 0.811, 0.611) slightly exceeded the diagnostic value of focal 18F-FDG accumulation (AC1 coefficients: 0.524, 0.456, 0.569). CONCLUSION: 18F-FDG PET/CT and 99mTc-HMPAO-WBC SPECT/CT can both serve as important tools contributing to early diagnosis of AVG infection.

[Lethal course of complicated vascular prosthesis infections].

Presented are two cases of vascular prosthesis infections complicated by peritonitis with a lethal course. The authors describe complicated antibiotic therapy with findings, exhausted options for surgical therapy and subsequent decision that the condition was untreatable and palliative care was initiated.

Surgical revision vs. stent-graft to treat venous anastomosis stenosis following surgical thrombectomy of hemodialysis grafts.

BACKGROUND: There is no unanimous strategy for treating stenosis of the venous anastomosis (VA) of an occluded arteriovenous graft (AVG) following surgical thrombectomy. In this study, we compared classical surgical treatment and endovascular treatment procedures with the use of stent- graft in a single center study. The aim was to evaluate whether, the VA stenosis of thrombosed AVG treated endovascularly by stent-graft implantation, have as good results as surgical VA treatment, so that it may be considered the method of choice. METHODS: The study included patients who underwent surgical AVG thrombectomy with subsequent angiographically confirmed VA stenosis between 1/2009 and 12/2014. Surgical angioplasty was then performed in 15 patients and 17 patients underwent primary stent-graft implantation. RESULTS: In the surgically treated patients, the postintervention primary patency, primary assisted patency and secondary patency after 12 months were 50.7%, 56.3%, 62.4%, respectively. In the group of patients with occluded AVG who underwent stent-graft implantation, the postintervention primary patency, primary assisted patency and secondary patency after 12 months were 32.8%, 44.1% a 55.6%, respectively. No statistically significant difference in primary patency (P=0.391), primary assisted patency (P=0.605), and secondary patency (P=0.702) was observed between the groups. CONCLUSIONS: Stent-graft implantation into stenotic VA of an occluded AVG showed to be effective and maintained good long-term patency. It is the preferred method due to its minimal invasiveness. The superiority of this method must be confirmed on a larger set of patients.

Effect of hyperbaric air on endotoxin from Bacteroides fragilis strains.

The aim of the project was to determine any effect of hyperbaric air on Bacteroides fragilis strains cultivated under hyperbaric conditions. Previously, it was hypothesized that there was a correlation between the presence of Bacteroides bacteria in patients preferring a meaty diet and cancer of the small intestine, and particularly of the large intestine and rectum. With respect to the fact that Bacteroides fragilis (BAFR) group are important producers of endotoxins, measurement and statistical evaluation of endotoxin production by individual strains of isolated Bacteroides species were used to compare bacteria isolated from various clinical samples from patients with colon and rectum cancer in comparison with strains isolated from other non-cancer diagnoses. Endotoxin production was proven by quantitative detection using the limulus amebocyte lysate (LAL) test in EU/mL. Production of endotoxins in these bacteria cultured under hyperbaric air conditions was higher than those strains cultured under normobaric anaerobic conditions. But these differences in endotoxin production were not statistically significant (t test with log-transformed data, p value = 0.0910). Based on a two-tier t test for lognormal data, it is possible to cautiously conclude that a statistically significant difference was found between endotoxin production by Bacteroides fragilis strains isolated from non-carcinoma diagnoses (strains (1-6) and strains isolated from colorectal carcinoma diagnoses (strains 7-8; Wilcoxon non-parametric test p = 0.0132; t test = 0.1110; t test with log-transformed data, p value = 0.0294).

New hybrid procedures in treating occluded arteriovenous hemodialysis grafts.

BACKROUND: The use of arteriovenous graft is indicated in patients if the subcutaneous venous bed is exhausted or unsuitable for arteriovenous fistula creation. The leading cause of failure of a prosthetic arteriovenous hemodialysis-access graft is venous anastomotic stenosis causing thrombosis of the graft. A number of surgical techniques and endovascular tools have been used to treat this stenosis and thrombosis. None have yet proven to be ideal. This study was designed to evaluate the results of hybrid treatment of arteriovenous graft thrombosis associated with venous anastomotic stenosis. METHODS: Over the period 2013-2014, we treated 16 AVG occlusions. Immediately after the diagnosis of occlusion was made, the patients underwent thrombectomy using a Fogarty catheter. After thrombectomy, a diagnostic fistulogram was performed and if VAG stenosis was confirmed, it was treated with balloon angioplasty and stent graft introduction. Lesions were dilated to reduce the stenosis in the treated area to less than 25%. RESULTS: Primary patency after 12 months was 32.8%. Primary assisted patency was 44.7%, secondary patency was 47.6%. Restenosis of the stent graft was seen in two patients. Recurring AVG occlusion was observed in four patients. The average number of interventions to maintain AVG patency was 1.18 per patient/1 year of dialysis. CONCLUSION: Treatment of AVG thrombosis due to VAG stenosis by hybrid procedure proved to be effective and improved secondary patency.