Degloving of the renal capsule: a rare complication of laparoscopic live donor nephrectomy.

Laparoscopic live donor nephrectomy is becoming the procedure of choice for kidney procurement. In the course of 172 laparoscopic procurements, degloving of the renal capsule, a rare complication believed to be related to the method of extraction of the kidney, was encountered in 2 patients (1.2%). The complication was noted after revascularization of the kidney. A capsulotomy was performed to evacuate the subcapsular hematoma. No adverse effect was noted in the postoperative period in the transplanted kidneys.

Early pancreas transplant outcomes with histidine-tryptophan-ketoglutarate preservation: a multicenter study.

Little is known about the use of histidine-tryptophan-ketoglutarate (HTK) preservation solution for pancreas preservation. We compared early pancreas graft outcomes at four pancreas transplant programs within the state of Michigan in 2002 and 2003 (University of Wisconsin [UW] era) with those in 2004 (HTK era). The primary endpoint was early graft loss. The UW group (n=41) and the HTK group (n=36) had similar outcomes with respect to: technical graft loss (9.8% vs. 8.3%, P=NS), 90-day graft function (90.2% vs. 86.1%, P=NS), and rate of pancreatic leak/abscess (12.2% vs. 11.1%, P=NS). There were also no significant differences in postoperative amylase and lipase levels between the two groups. The HTK group did have significantly more acute rejection within the first 180 days (25.0% vs. 9.8%, P<0.05). HTK is a suitable substitute for UW in the preservation of pancreas allografts.

Total laparoscopic live donor nephrectomy: a 6-year experience.

BACKGROUND: Since the introduction of the laparoscopic live donor nephrectomy in 1995, attempts have been made to depart from the total laparoscopic approach to the hand-assisted approach to decrease surgical time and complications. We present our 6-year experience with the total laparoscopic approach. METHODS: Between December 1998 and November 2004 there were 168 total laparoscopic live donor nephrectomies performed at our institution. There were 163 left nephrectomies and 5 right nephrectomies. RESULTS: The procedure was performed in a systematic approach. The surgical time deceased from an average of 2:27 hours in the first year to 1:34 hours in the last year of the study. The overall average warm ischemia time was 3.5 minutes. Major bleeding requiring conversion to an open procedure occurred in 2 (1.2%) donors. Minor bleeding that was controlled laparoscopically occurred in 9 (5.4%) donors. Degloving of the renal capsule occurred in 2 (1.2%) donors with no consequences. Minor mesenteric rent occurred in 7 (4.2%) donors. All mesenteric complications were recognized and repaired laparoscopically. No ureteral or bowel injuries occurred. There were no mortalities. Eighty-three percent of donors were discharged the next day. CONCLUSIONS: Total laparoscopic live donor nephrectomy is safe. It was performed successfully in 98.8% of donors with a short surgical time, low morbidity, and 0% mortality.

Accelerated rejection following offspring-to-mother and husband-to-wife transplants.

It has been demonstrated that graft survival rates of offspring-to-mother and husband-to-wife renal transplants are equivalent to those of other living donors. Although the vast majority of these transplants proceed without incident, we have encountered several instances of delayed accelerated rejections that are not predicted by a positive cross-match. The accelerated rejection can result from an anamnestic reaction subsequent to the in utero exposure of the mother to human leukocyte antigen (HLA) antigens of the fetus with sensitization developing during the pregnancy.

A pilot study of calcineurin inhibitors (CNIs) and steroid avoidance immunosuppressive protocol among living donor kidney transplant recipients.

Calcineurin Inhibitors (CNIs) and Corticosteroids have been the main immunosuppressive agents in solid organ transplantation. Many studies have confirmed the positive impacts of withdrawal/avoidance of these agents, separately, on their side effect profiles. A pilot study was performed avoiding both agents among low-immunological-risk living donor kidney transplant recipients at a single center. Seventeen recipients were maintained on the double avoidance protocol during the study period beginning July 2002 through December 2003. Three rejection episodes occurred (out of ten) among related donor kidney recipients and six episodes (out of seven) among unrelated donor kidney recipients. Although most of the rejections were reversed with a short course of corticosteroids, the protocol was revised to exclude the unrelated donor kidney recipients. There were higher incidences of wound complications among recipients who received the initial loading dose of Sirolimus. Double avoidance of CNIs and corticosteroids is possible in living donor kidney transplant recipients with an acceptable incidence of rejection. Proper management of the side effects of Sirolimus could further minimize the incidence of rejection. A multi-center randomized study is recommended in order to recognize the benefits of avoiding CNIs and corticosteroids in renal transplant recipients.

Management of renal allografts with multiple renal arteries resulting from laparoscopic living donor nephrectomy.

Laparoscopic living donor nephrectomy (LLDN) has become an accepted procedure in many transplant centers. The placement of laparoscopic vascular staples can result in multiple short, small-caliber renal arteries that the recipient surgeon must deal with to restore perfusion to all parts of the kidney. The incidence of multiple renal arteries resulting from LLDN, surgical management of multiple renal arteries, and the short- and long-term graft functions were studied in 73 consecutive kidney recipients at a single center. Various techniques used for reconstruction are described, including the use of recipient internal iliac artery for the extension and reconstruction of small-caliber, short renal vessels. Single-artery allografts were compared with those with multiple arteries, with length of renal artery, warm ischemia time, hospital length of stay, operating time, creatinine levels, and 1 yr survival rates not found to be significantly different. The presence of multiple renal arteries should not exclude the possibility of using the left kidney for LLDN.

The effect of pneumoperitoneum on kidney function in laparoscopic donor nephrectomy.

Between June 1999 and November 2001 a prospective study was conducted to evaluate the effects of pneumoperitoneum during laparoscopic donor nephrectomy on kidney function using two different pressure settings (15 and 10 mm Hg). The effects were evaluated in both the donor's remaining kidney and the procured kidney in the recipient. There was no statistical significant difference in donors and recipients in regard to age, gender, and body mass index. In the two donor groups there was no difference in operative time (2.77 +/- 0.51 vs 2.70 +/- 0.52 hours; P = 0.579), intraoperative fluid (16.53 +/- 4.72 vs 19.54 +/- 7.04, P = 0.056), and urine output (1.81 +/- 0.53 vs 1.75 +/- 0.96 mL/kg/hour, P = 0.782) respectively. Donors' preoperative and first-day postoperative serum creatinine concentrations also did not differ for the groups (preoperative 0.87 +/- 0.21 vs 0.88 +/- 0.17 mg/dL; and postoperative 1.44 +/- 0.32 vs 1.38 +/- 0.29 mg dL, respectively; P = 0.696). Recipients' preoperative and postoperative serum creatinine concentrations on days 1, 2, 3, 7, 14, and 30 differed over time (P < 0.001) but not between groups (P = 0.541). We conclude that procurement of kidneys under either 10 or 15 mm Hg abdominal pressure gives equally good intraoperative and postoperative results.