Trasplante cardiorenal combinado en la enfermedad cardíaca y renal avanzada / Combined cardiorenal transplant in heart and advanced renal disease

Introducción: la insuficiencia renal (IR) es predictor de morbimortalidad postrasplante cardíaco (TxC). El trasplante cardiorenal (TxCR) combinado en candidatos a TxC con enfermedad renal severa, es una opción terapéutica. Nuestro objetivo es evaluar los resultados y seguimiento del TxCR en un único Centro. Material y métodos: Entre febrero de 1993 y diciembre de 2014 se realizaron 442 TxC. Desde el año 2006 se efectuaron TxCR con único donante en 20 pacientes (p). Los criterios de selección fueron: IR con ClCr ≤ 40 mil/min o requerimiento de diálisis en candidatos a TxC. Todos los p recibieron timoglobulina e inmunosupresión con tacrolimus, micofenolato mofetil y esteroides. La mediana de seguimiento fue 46 meses (7-96). Resultados: Edad media 58±7 años y 85% eran hombres. La creatinina (Cr) media 3,1+-2,5 mg/ dl y ClCr 27,5+10 mil/min. Requirieron diálisis 3p en el período pre trasplante y 4p se encontraban en diálisis crónica. Etiología de miocardiopatías dilatadas: coronaria 10p, no coronaria 9p y reTxC 1p; nefropatías: nefroangioesclerosis 5p, síndrome cardiorenal 10p, diabetes 2p, glomerulopatía 1p, poliquistosis 1p y nefritis tóxica 1p. La Cr a 30 días y a 1 año del TxCR fue 1,2+-0,4 mm/dl y 1,1+-0,2 mg/dl respectivamente. La mortalidad hospitalaria fue de 3/20p (15%), 2p por sepsis y 1p por falla del injerto cardíaco. Mortalidad alejada 5/17p (29%), 4p por sepsis y 1p por sarcoma hepatocelular. La supervivencia a 1 y 3 años fue del 76 y 72%. Conclusiones: En nuestra serie el TxCR fue un tratamiento seguro y eficaz en candidatos a TxC y con ClCr < 40 mil/min.

Introduction: renal failure (RF) is a post cardiac transplantation predictor of morbimortality. The combined cardiorenal transplant (CCRTx) in cardiac transplantation (CTx) candidates with chronic renal disease is a therapeutic option. Our aim was to evaluate the CCRTx follow up outcomes in a single Centre. Methods: Between 2/1993 and 12/2014 we performed 442 CTx. Since 2006, 20 patients (p) underwent CCRTx using allografts from the same donor. The inclusion criteria were: RF with CrCl ≤ 40 mil/min or dialysis requirement in CTx candidates. All p received Thymoglobulin and immunosuppression with tacrolimus, mycophenolate mofetil and steroids.Median follow up: 46 months (7-96). Results: Mean age: 58±7 years, 85% were male. Mean Creatinine (Cr): 3,1+-2,5 mg/dl and ClCr 27,5+10 mil/min. Three p required dialysis during the pre-transplantation phase and 4 p were under chronic dialysis. Etiologies: cardiomyopathies: coronary 10 p, noncoronary 9 p and re CTx, 1 p; nephropathies: nephroangiosclerosis 5 p, cardiorenal syndrome 10 p, diabetes 2 p, glomerulopathy 1 p, polycystosis 1 p and toxic nephritis 1 p. At 30 days and 1 year post CCRTx, Cr was 1,2+-0,4 mg/dl and 1,1+-0,2 mg/dl respectively. In-hospital mortality was 3/20 p (15%), 2 p due to sepsis and 1 p due to cardiac graft failure. Late mortality 5/17 p (29 %), 4p due to sepsis and 1 p due to liver sarcoma. Survival at 1 and 3 years was 76 and 72%, respectively. Conclusions: In our series CCRTx was a safe and effective treatment for CTx candidates with CrCl < 40 ml/min.

Cumulative incidence, indications, morbidity and mortality of transplant nephrectomy and the most appropriate time for graft removal: only nonfunctioning transplants that cause intractable complications should be excised.

PURPOSE: We assessed the cumulative incidence of transplant nephrectomy in our population of patients who underwent transplantation and those in whom the transplant failed due to immunological causes. Transplant nephrectomy indications, morbidity and mortality were analyzed to establish the most appropriate time for graft removal. MATERIALS AND METHODS: We included all patients who underwent transplantation and graft removal at our institution from January 1, 1970 through January 1, 2000. We estimated the noncumulative incidence of transplant nephrectomy, morbidity and mortality. The cumulative incidence of transplant nephrectomy was estimated by Kaplan-Meier curves. RESULTS: Of the 631 renal transplants performed in 598 patients we studied a total of 91 transplant nephrectomies in 85 patients. The cumulative incidence of transplant nephrectomy 15 years after the date of transplantation was 25% (95% CI 14 to 40). The cumulative incidence of transplant nephrectomy at 10 years after the date of return to dialysis was 74% (95% CI 49 to 90). The main indication for transplant nephrectomy was graft related complications associated with chronic rejection in 58.2% of cases. The morbidity rate was 48.3% (95% CI 37.7 to 59). Hemorrhagic events were the chief complication. In 7 patients there was a total of 10 reoperations (10.9%, 95% CI 5.3 to 19.2). The mortality rate was 7% (95% CI 2.6 to 14.7). These patients died of sepsis. Urgent transplant nephrectomies had statistically higher morbidity and mortality (p <0.01 and 0.002, respectively). CONCLUSIONS: Most transplant nephrectomies were performed within 2 years of the transplant date and almost half were done within year 1 after the return to dialysis. The advent of cyclosporine significantly decreased the transplant nephrectomy rate at the expense of fewer graft failures but not at the expense of a lower amount of graft related symptoms after patients returned to dialysis. Bleeding was the leading cause of morbidity and infection was the main cause of mortality. Considering the high morbidity and mortality of transplant nephrectomy, and the potential benefits of leaving nonfunctioning grafts in situ our current policy is to remove the graft only in cases of failed transplants that cause intractable complications.

Comparing Taguchi and Lich-Gregoir ureterovesical reimplantation techniques for kidney transplants.

PURPOSE: We compared the incidence of urological and anastomotic complications, and the duration of ureteral reimplantation for the Taguchi and Lich-Gregoir techniques. MATERIALS AND METHODS: We recorded all urological and anastomotic complications that developed from the date of transplantation through December 31, 2001. The cutoff date for transplantation was August 30, 2000. The urological complications evaluated included complicated hematuria, urinary fistula, ureteral stenosis, symptomatic vesicoureteral reflux and operative time. The chi-square test was done to compare the proportion of complications in the groups and the Mann Whitney test was used to compare the duration of ureteral reimplantation. RESULTS: Of the 575 transplants evaluated 416 and 159 were performed via the Lich-Gregoir and Taguchi techniques, respectively. The incidence of anastomotic complications was 10.7%. Complications in the Lich-Gregoir group included fistula in 4.7% of cases, stenosis in 4.1%, symptomatic vesicoureteral reflux in 1.9% and complicated hematuria in 0.5%. Complications in the Taguchi group included urinary fistula in 6.3% of cases, stenosis in 2.5% and complicated hematuria in 2.5%. Symptomatic reflux was not observed in this group. There was a higher proportion of hematuria at the limit of statistical significance in the Taguchi group (p = 0.05). There were a higher number of urological complications in transplants from live donors in the Lich-Gregoir group (p = 0.01), mostly involving fistula (p = 0.05). There were no significant differences in the groups in overall complications. Average operative time for the Taguchi and Lich-Gregoir techniques was 14.2 and 29 minutes, respectively. This difference was significant (p = 0.02). CONCLUSIONS: In the sample studied Taguchi ureterocystoneostomy proved to be a more rapid method without increasing the incidence of urological or anastomotic complications. There were no cases of symptomatic reflux in the Taguchi group and select fistula cases could be managed conservatively. The Lich-Gregoir cohort was at greater risk for the urological complications of live donor transplantation. The Taguchi method has become the ureterovesical reimplantation technique of choice in our setting.

[Value of gray scale ultrasonography in the early diagnosis of urologic complications of renal transplantation]. / Valor de la ultrasonografía en escala de grises en el diagnóstico precoz de las complicaciones urológicas del trasplante renal.

OBJECTIVE: To determine the significance of gray scale ultrasound as a tool for diagnosis, follow-up and treatment of urological complications of renal transplantation based on the experience of our institution. METHODS: A retrospective, longitudinal and observational study was carried out. We reviewed the patients' perioperative ultrasound scans and their respective urological complications from January 1, 1982 to January 1, 2000. The patients were consecutively taken from the kidney transplant registry of the Urology and Nephrology and Transplant Departments. We describe the ultrasound findings of normal functioning grafts as well as those with urological complications, such as fluid collections (lymphocele, hematoma, urinoma and abscess), uronephrosis and its possible causes, and symptomatic vesicourethral reflux. RESULTS/CONCLUSIONS: Diagnostic and therapeutic algorithms in kidney transplant patients have been changed since the advent of ultrasound in our country in 1981. Rapid diagnosis and better therapeutic options have been the hallmarks of ultrasound. Added advantages are: it is low-cost, non-invasive, not time consuming. It can be performed regardless of kidney function, can be repeated as many times as required, subsequent scans can be compared. It can be carried out in special care units. The superficial location of the graft makes it highly sensitive. Its disadvantages are low specificity to identify either the nature of the fluid collections or the precise site of urinary tract obstruction, apart from depending on the skill of the operator. Specialists should be familiar with the surgical anatomy of the kidney graft and its variations in order to utilize completely its diagnostic and therapeutic potentials.