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.

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

Objetivo: Establecer el valor de la ecografía en escala de grises para el diagnóstico, seguimiento y eventual tratamiento de las complicaciones urológicas del trasplante renal basado en la experiencia de nuestro centro. Métodos: Se revisaron los informes ecográficos y las complicaciones urológicas de los pacientes trasplantados desde el 1 de enero de 1982 hasta el 1 de enero del 2000. El muestreo fue consecutivo, no probabilístico en base a los registros documentados en la sección Urología y en el Servicio de Nefrología y Trasplante de la Institución. El diseño fue retrospectivo, longitudinal y observacional. Resultados: Se describen los hallazgos ecográficos de injertos con buen funcionamiento y aquellos con complicaciones urológicas, a saber: colecciones (linfoceles, hematomas, urinomas y abscesos), uronefrosis con sus posibles causas y reflujo sintomático. Conclusiones: Desde el advenimiento de la ecografía en nuestro país en 1981 se han modificado tanto los algorritmos diagnósticos como los tiempos terapéuticos en esta población de pacientes. Se ha ganado en precocidad diagnóstica y mayor serenidad al momento de decidir por un tratamiento, dado por un sin fin de ventajas: bajo costo, no invasividad, rápida realización, no altera ni perjudica la función del injerto, puede repetirse cuantas veces sea necesario lo que hace que los sucesivos estudios sean comparables entre sí, al ser portátil puede llevarse a cabo dentro de las áreas especiales para pacientes inmunosuprimidos y la localización superficial del injerto contribuye a hacer de este un procedimiento altamente sensible. Sus desventajas son su baja especificidad para distinguir el contenido de las colecciones o el nivel exacto de las obstrucciones, y el hecho de ser un procedimiento operador dependiente. El buen especialista debe estar profundamente familiarizado con la anatomía quirúrgica del trasplante y sus variantes a los efectos de obtener de la ecografía el 100 por ciento de su potencial diagnóstico y terapéutico (AU)