Prophylactic Ureteric Stents in Renal Transplant Recipients: A Multicenter Randomized Controlled Trial of Early Versus Late Removal.

Prophylactic ureteric stenting in renal transplantation reduces major urological complications; however, morbidity is related to the indwelling duration of a stent. We aimed to determine the optimal duration for stents in this clinical setting. Patients (aged 2-75 years) from six UK hospitals who were undergoing renal transplantation were recruited and randomly assigned to either early stent removal at 5 days (without cystoscopy) or late removal at 6 weeks after transplantation (with cystoscopy). The primary outcome was a composite of stent-related complications defined as pain, visible hematuria, migration, fragmentation, and urinary tract infections (UTIs) within 3 mo of transplantation. Between May 2010 and Nov 2013, we randomly assigned 227 participants, with 205 included in the final analysis of the primary outcome. Stent-related complications were significantly higher in the late versus early stent removal groups (36 of 126 [28.6%] vs. 6 of 79 [7.6%]; p < 0.001). The majority of stent complications consisted of UTIs, with an incidence of 31 of 126 (24.6%) in the late group compared with 6 of 79 (7.6%) in the early group (p = 0.004). We found early stent removal on day 5 significantly reduced stent-related complications and improved quality of life in the first 3 mo after transplantation (ISRCTN09184595).

TCC in Transplant Ureter--When and When Not to Preserve the Transplant Kidney.

We present four cases of transitional cell carcinoma of the transplant ureter (TCCtu). In three cases, localized tumor resection and a variety of reconstructive techniques were possible. Transplant nephrectomy with cystectomy was performed as a secondary treatment in one locally excised case. Transplant nephroureterectomy was performed as primary treatment in one case. The role of oncogenic viruses and genetic fingerprinting to determine the origin of TCCtu are described. Our cases and a systematic literature review illustrate the surgical, nephrological, and oncological challenges of this uncommon but important condition.

Reversible acute anuric kidney injury after surgical evacuation of perinephric hematomas as a complication of renal transplant biopsies.

Percutaneous renal transplant biopsy is the gold standard investigation to diagnose the cause of renal allograft dysfunction. There are inherent risks to this investigation, despite the procedure becoming safer due to the increased utilization of ultrasound-guided techniques. These biopsy risks can be increased when there is acute rejection present with a swollen transplanted kidney. Subcapsular hematomas are not uncommon after percutaneous renal transplant biopsies, but we describe two cases of post-biopsy subcapsular hematoma which were associated with acute renal allograft dysfunction in pediatric renal transplant recipients who did not have acute rejection.

Native nephrectomy in transplant patients with autosomal dominant polycystic kidney disease.

INTRODUCTION: This study examined the clinical indications and timing for native nephrectomy (NN), together with the associated pathological findings in transplant patients with autosomal dominant polycystic kidney disease (ADPKD) at our institute over a period of 20 years. METHODS: A retrospective review was performed of ADPKD patients who had undergone both kidney transplantation and NN. Patients were identified from the kidney transplant database between 1988 and 2008 at Guy's and St Thomas' Hospital and the notes reviewed. All NN specimens were re-reviewed and reported according to current guidelines. RESULTS: There were 157 kidney transplants performed for ADPKD (114 cadaveric and 43 living donor). Of these, 31 required NN (28 bilateral). The timing of NN was pre-transplant in 10 cases, at the time of the transplant in 1 case and post-transplant in 20 cases. The indications for NN were urinary tract infection (n=14, 45%), pain (n=12, 39%), tumour suspicion (n=3, 10%), haematuria (n=1, 3%) and space (n=1, 3%). Mortality in this NN series was 3%, with a 65% surgical morbidity rate. The length of hospital stay post-NN was significantly longer with open compared with laparoscopic techniques (p=0.003). There were two renal cell carcinomas (RCCs) in this series. Both patients presented with macroscopic haematuria (bilateral pT1a papillary RCCs in one case and a pT3b clear cell RCC in the other case). The incidence of RCC in this series of ADPKD transplant patients was 1.3%. CONCLUSIONS: We have demonstrated that the majority of ADPKD patients do not require NN, with only 20% of our series undergoing this procedure. The timing of NN is variable and dictated by indication. NN was only required to make space for transplantation in one case (combined kidney and pancreas transplant). The main indications for NN were recurrent infection and pain, where NN can provide a successful outcome. Laparoscopic NN can be performed safely in patients with ADPKD. Haematuria in such patients should not be assumed to be of benign origin and requires exclusion of urinary tract malignancy as the incidence of RCC in this population is at least as common as in the general population.

Influence of number of retransplants on renal graft outcome.

BACKGROUND: To assess the influence of number of transplants on the renal graft outcome. METHODS: Retrospective analysis of various factors that could influence the outcome of kidney retransplantation in patients receiving more than one allograft between 1993 and 2005 at our center. RESULTS: During the 12-year period (1993-2005), 196 patients received more than one renal transplant. Of these, 163 had two (group 1) and 33 had more than two transplants (group II). In group II, 24 patients had three, eight had four, and one had five consecutive allografts. The control group comprised of 100 randomly selected patients receiving a first graft during the same period. In group I, 53 (32.5%) grafts failed. Eighteen (11.0%) patients died with functioning grafts. In group II, 14 (41.2%) grafts failed while four patients (11.8%) died with functioning grafts. In group I, actuarial graft survival rates at 1, 2, 3, and 4 years were 82.3%, 67.3%, 55.97%, and 42.14%, respectively. In group II, the respective figures were 84.85%, 66.67%, 60.61%, and 51.52%. The difference was not statistically significant (P = .96). In the control group, 1-, 2-, 3-, and 4-year survival rates were 92%, 84, 74%, and 60%, respectively. The difference between the control and study groups was statistically significant (P = .0002). CONCLUSION: Graft survival after retransplantation is relatively inferior when compared to the primary graft but still remains fairly high. Therefore, previous graft failure should not be considered as a relative contraindication for retransplantation.

Interpreting regulatory authority guidance on immunosuppressive therapy for renal transplantation: a response to the UK's National Institute for Clinical Excellence (NICE).

AIMS: A group of UK consultant transplant physicians and surgeons (the Consensus Group) met to consider the implications and interpretation of the National Institute for Clinical Excellence's (NICE) Technology Appraisal No. 85 on the use of immunosuppressive therapy for renal transplantation in adults. METHODS: This group considered what the implications of these guidelines might be for clinical practice and consensus was developed on those areas which were potentially open to different interpretations. A wider survey of nephrologists and transplant surgeons throughout the UK was also performed to gauge the impact of the NICE recommendations. RESULTS AND CONCLUSIONS: The outcome of the discussions of the Consensus Group are presented with particular reference to the recommendations of how to respond to calcineurin inhibitor (CNI) intolerance. The survey suggested that the publication of this NICE guidance has resulted in relatively few changes in prescribing practice: UK transplant centers continue to use a wide range of locally developed protocols for immunosuppressive therapy. These include the use of agents such as mycophenolate mofetil (MMF) and sirolimus, despite the fact that both drugs appeared to receive only conditional acceptance in the NICE Guidelines.

Transplantation of kidneys from deceased adult polycystic donors.

Renal transplantation is the best treatment for end-stage renal disease. The discrepancy between donor organ supply and demand continues to widen. Maximum efforts should be made to make use of donor kidneys and we suggest that polycystic kidneys can be suitable marginal donor organs. Five polycystic cadaveric donor kidneys were transplanted in four recipients at our institution between year 2000 and 2004. The donor kidneys were either of normal size or moderately enlarged (less than 15 x 10 cm). Donor ages were 24, 46 and 55 years. All donors had normal serum creatinine at the time of organ retrieval. Recipients gave informed consent to be transplanted with the polycystic kidneys. Three of four recipients had primary graft function. The patient with primary nonfunction required graft nephrectomy 8 weeks post-transplantation. One patient died due to cardiovascular causes with a functioning graft 18 months after transplantation. Two patients remain well, 26 and 58 months after transplantation, with normal graft function. Our experience and the limited evidence from the literature suggest that, with careful selection of both donor and recipient, transplantation of cadaveric polycystic donor kidneys should be considered given the current organ shortage.

Transmission of syphilis by solid organ transplantation.

Two organ recipients developed serologic evidence of syphilis infection after renal transplantation from a common deceased donor with a history of treated syphilis. Testing of donor serum for syphilis, which occurred after transplantation, gave results interpreted as consistent with past infection. However, subsequent serologic results in the recipients suggested transmission of infection at transplantation due to active infection of the donor. This may be explained by recent donor re-infection in view of the current syphilis epidemic in the United Kingdom. An initial error in the treatment of recipients further served to highlight unfamiliarity in managing this resurgent infection in the context of organ transplantation.

Follow-up of polytetrafluoroethylene arteriovenous fistulae for haemodialysis.

The polytetrafluoroethylene (PTFE) arteriovenous fistula allows vascular access for haemodialysis where a primary fistula or brachio-basilic vein transposition is not possible. We report patency rates and complications associated with these prosthetic grafts. Fifty-nine upper limb PTFE grafts in 48 patients were evaluated with a mean follow-up of 19 months (range 2-54 months). Three grafts (5%) were never used. The primary patency rate at 6 weeks was 90%. Cumulative secondary patency rates were 66% at 6 months, 36% at 12 months, 17% at 18 months, 3% at 24 months and 2% at 30 months. None of the grafts had remained patent at 3 years. Forty-six percent of the grafts studied thrombosed at least once and 32% became infected. Although the initial primary patency rate achieved compares favourably with that reported for brachio-basilic transposition fistulae, this study confirms that the use of prosthetic material is associated with a poor overall patency rate and high risk of complications. All options using autologous vein should be exhausted before considering prosthetic material.

Long-term outcomes of brachiobasilic transposition fistula for haemodialysis.

OBJECTIVES: The transposed basilic vein to brachial artery arteriovenous fistula provides secondary vascular access for haemodialysis. The long-term results of such fistula are assessed in this retrospective series. MATERIAL AND METHODS: Over a 5-year period 75 brachiobasilic transposition fistulae were performed in 74 patients. There was a median follow up of 14 months. RESULTS: Primary patency was achieved in 69 (92%) of the fistulae, and secondary patency in 74 (99%) of the fistulae. Successful interventions included angioplasties in four, and saphenous vein interposition in one, whilst three patients had failed thrombectomies. Dialysis was performed using 69 (92%) of the fistulae while 6 (8%) were never used. Of the 75 fistulae 47 (63%) were patent at follow up. Cumulative secondary patency was 66% at 1 year, 52% at 2 years, and 43% at 3 years. Complications developed in 41 (55%), and included thrombosis, infection, stenosis, arm oedema, bleeding, steal syndrome and microaneurysm formation. CONCLUSIONS: Brachiobasilic transposition fistulae have good long-term patency rates. The complication rate, although high, is lower than that reported for PTFE grafts. Brachiobasilic fistulae should be used in preference to PTFE grafts for secondary access.

Atypical post-renal transplantation hyperparathyroidism--further support for "removing all enlarged glands".

Hyperparathyroidism is an important sequela of chronic renal failure, remains a considerable challenge to nephrologists, and can be seen as inevitable in patients undergoing long-term renal replacement therapy. As time with renal disease increases then so does the cumulative risk of hyperparathyroidism, and the eventual need for surgical parathyroidectomy when hyperparathyroidism becomes refractory to medical intervention. Parathyroidectomy before dialysis treatment has started, or after successful renal transplantation, is much less commonly performed than when the patient is receiving dialysis. Increasingly the propensity for residual parathyroid tissue left behind (by design or accident) at an initial parathyroidectomy to undergo progressive hyperplasia under the constant stimulus of uremia, and by so doing result in the need for a second, more complex, neck exploration, has increased support for initial total parathyroidectomy for patients on dialysis. The optimal operative procedure for autonomous hyperparathyroidism after successful renal engraftment is however less clearly established. We discuss two very unusual but instructive cases of post renal transplantation autonomous hyperparathyroidism requiring surgical parathyroidectomy. Using these cases as examples we discuss the various surgical options, and discuss the contentious issue of the place for autografting parathyroid tissue.

Pilot study using high-frequency diagnostic ultrasound to assess surgical wounds in renal transplant patients.

BACKGROUND: The majority of renal transplant patients will sustain at least one acute rejection episode during the first 4 months, following transplantation. Clinical rejection is rarely an all-or-nothing reaction, and the first episode seldom progresses to complete renal destruction. The functional changes induced by rejection appear to be in large part reversible; therefore the recognition and treatment of the rejection episode, before the development of severe renal damage, are of extreme importance. METHODS: This pilot study describes a technique of non-invasive wound assessment used to monitor 14 transplant patients, over a 3 week post-operative period. The technique involved the use of 20 MHz diagnostic ultrasound, in conjunction with fractal image analysis. Ultrasound scans of both wounded and adjacent uninjured tissue were taken 5, 7, 11, 14 and 21 days post-surgery. RESULTS: When patients were divided into those who experienced allograft rejection and those who did not, a distinct trend appeared. In those who did not reject, the fractal signature of the wound progressed towards that of normal tissue in a linear fashion. In patients that did reject, the fractal signature initially progressed towards normal until day 11, then changed direction moving away from normal, between days 11 and 14. The patients experiencing allograft rejection were clinically diagnosed around a mean time of 14 days post-surgery. It is therefore possible that this shift in fractal signature may correlate with graft rejection. CONCLUSION: The results of this pilot study indicate that high frequency diagnostic ultrasound, coupled with appropriate image analysis, may be a useful adjunct to renal function assessment.

Mid-aortic syndrome presenting in childhood.

Mid-aortic syndrome (MAS) is an uncommon condition characterized by segmental narrowing of the proximal abdominal aorta and ostial stenosis of its major branches. It is usually diagnosed in young adults, but may present in childhood as a challenging problem. Over the past 20 years 13 patients with MAS have presented to this institution. All had hypertension, four had associated neurofibromatosis, three persistent eosinophilia and three had Williams syndrome. In all cases arteriography showed a smooth segmental narrowing of the abdominal aorta with concomitant stenosis at the origins of the renal arteries. Six children were successfully treated with antihypertensive medication alone. Percutaneous transluminal angioplasty was attempted in two cases with poor result. Surgery was indicated in seven children with refractory hypertension and progressive renal impairment. Techniques used to revascularize the kidneys included thoracoabdominal to infrarenal aortic bypass with renal artery reimplantation, splenorenal bypass, gastroduodenal to renal bypass, aortorenal bypass and autotransplantation.

Recurrence of focal segmental glomerulosclerosis in transplanted kidneys: analysis of incidence and risk factors in 59 allografts.

Fifty-nine allografts were placed in 43 patients with renal failure from focal segmental glomerulosclerosis (FSGS): 27 allografts were put into 16 children aged less than 15 years, and 32 allografts into 27 adolescents and adults. Recurrence of FSGS was noted histologically in 13 allografts, 10 in 8 children and 3 in adults. None of the 9 children and 24 adults who never developed an allograft nephrotic syndrome showed FSGS in their allograft biopsies. The age of onset was a strong risk factor for recurrence: recurrent FSGS developed in 8 of 16 children (50%) but only in 11% of adolescents and adults (3 of 27 patients). Although the time from apparent onset to renal replacement treatment was shorter in those with recurrence than those without in the children, there was no difference in the time spent on dialysis prior to transplantation. Mesangial prominence was observed in the original biopsy in 12 of 13 patients with recurrence, and recurrence rate was similar in living and cadaver donor allografts; class I MHC matching was similar in those with and without recurrence. Three allografts treated with cyclosporin A as well as 9 with azathioprine showed recurrence. Of 9 second or subsequent allografts placed in those with recurrence in the first allograft, only 3 showed further recurrence. In 3 re-grafted after 13, 11 and 5 years, normal function was seen.

The relevance of induced class II HLA antigens and macrophage infiltration in early renal allograft biopsies.

Using a panel of monoclonal antibodies, immunohistological analysis was performed on frozen sections taken from 14 peritransplant renal biopsies and 42 biopsies taken 6 +/- 2 days posttransplantation. The following parameters were examined: tubular expression of HLA-DR, DP, and DQ and infiltration with T lymphocytes and macrophages. Of the 42 posttransplant biopsies, 26 were diagnosed as rejecting and 16 as nonrejecting according to clinical and histopathological criteria. HLA-DR antigens were strongly expressed on 8 of 14 peritransplant biopsies, 23 of 26 rejecting biopsies and 13 of 16 nonrejecting biopsies. Tubular expression of HLA-DP and DQ was weak or absent. In the rejecting biopsies there was a significantly increased infiltrate of T lymphocytes of all phenotypes and of macrophages when compared with the nonrejecting biopsies. Graft outcome was invariably favorable in the nonrejecting group, with no graft losses in the first posttransplant year. There were 4 graft losses in the rejecting group, all due to rejection, and further analysis revealed that all 4 had macrophage-dominated infiltrates in their early allograft biopsies. We conclude that immunohistological analysis of early allograft biopsies provides an accurate prognosis of subsequent graft acceptance or rejection and that early macrophage infiltration is a poor prognostic sign.

Calcific stenosis of a mitral valve xenograft in a patient in chronic renal failure.

A 61 year old man presented with mitral regurgitation and glomerulonephritis caused by suspected infective endocarditis. His glomerulonephritis remitted on immunosuppression but mitral valve replacement with a Carpentier-Edwards porcine xenograft later proved necessary. The patient became dialysis dependent and cadaveric renal allografting was complicated by delayed graft function and refractory pulmonary oedema. Cardiac catheterisation showed severe calcification and stenosis of the xenograft with a transvalvar gradient of 23 mm Hg and despite emergency valve replacement the patient died. The valve had been in place less than five years. The rapid calcification and stenosis of a bioprosthetic heart valve calls into question the use of such prostheses in patients with chronic renal failure.