RESUMO
The quality assurance provided by preimplantation biopsy quantification of chronic damage may allow greater use of kidneys from expanded criteria donors, and thereby expand the deceased donor pool. Preimplantation biopsy may, however, identify additional acute or chronic pathologies not considered in the scoring of chronic damage, and these may influence the decision to implant or discard the kidney. This single-centre retrospective cohort study of a contemporary UK donor population systematically characterised the nature of additional findings in 1,046 preimplantation and implantation biopsies over an eight-year period. A diverse range of findings were identified in 111/1,046 (11%) organs; most frequently diabetic glomerulopathy, focal segmental glomerulosclerosis, (micro)thrombi, neutrophil casts, and immunoglobulin/complement staining. Seventy (63%) of these were transplanted, with subsequent biopsy in 41 (58%) cases confirming that 80% of the initial acute changes had spontaneously resolved, while there was no progression of diabetic glomerulopathy, and the lesions of focal segmental glomerulosclerosis were not identified. Over 75% of assessable grafts with additional histological findings at the time of transplant showed adequate function at one-year following transplant. In conclusion, most histological abnormalities that may be identified in addition to chronic scarring in preimplantation kidney biopsies would not preclude transplantation nor predict poor graft function.
Assuntos
Transplante de Rim , Rim , Humanos , Estudos Retrospectivos , Biópsia , Feminino , Masculino , Adulto , Pessoa de Meia-Idade , Rim/patologia , Incidência , Glomerulosclerose Segmentar e Focal/patologia , Reino Unido/epidemiologia , Idoso , Doadores de Tecidos , Nefropatias Diabéticas/patologiaRESUMO
During a kidney transplant, a plastic tube (stent) is placed in the ureter, connecting the new kidney to the bladder, in order to keep the new join open during the initial phase of transplantation. The stent is then removed after a few weeks via a camera procedure (cystoscopy), as it is no longer needed. The present study compared performing this in the operating theatre or in clinic for transplanted patients using a new single-use type of camera with an integrated grasper system. The results have shown that it is safe and cost-effective to do this in clinic, despite patients being susceptible to infection after transplantation.
Assuntos
Procedimentos Cirúrgicos Ambulatórios/métodos , Cistoscopia/métodos , Remoção de Dispositivo/métodos , Transplante de Rim , Stents , Ureter , Adolescente , Adulto , Idoso , Procedimentos Cirúrgicos Ambulatórios/efeitos adversos , Procedimentos Cirúrgicos Ambulatórios/economia , Análise Custo-Benefício , Cistoscopia/efeitos adversos , Cistoscopia/economia , Remoção de Dispositivo/efeitos adversos , Remoção de Dispositivo/economia , Estudos de Viabilidade , Feminino , Custos Hospitalares , Humanos , Masculino , Pessoa de Meia-Idade , Salas Cirúrgicas/economia , Cuidados Pós-Operatórios/efeitos adversos , Cuidados Pós-Operatórios/economia , Cuidados Pós-Operatórios/métodos , Complicações Pós-Operatórias , Estudos Retrospectivos , Adulto JovemRESUMO
In the United Kingdom, donation after circulatory death (DCD) kidney transplant activity has increased rapidly, but marked regional variation persists. We report how increased DCD kidney transplant activity influenced waitlisted outcomes for a single center. Between 2002-2003 and 2011-2012, 430 (54%) DCD and 361 (46%) donation after brain death (DBD) kidney-only transplants were performed at the Cambridge Transplant Centre, with a higher proportion of DCD donors fulfilling expanded criteria status (41% DCD vs. 32% DBD; p = 0.01). Compared with U.K. outcomes, for which the proportion of DCD:DBD kidney transplants performed is lower (25%; p < 0.0001), listed patients at our center waited less time for transplantation (645 vs. 1045 days; p < 0.0001), and our center had higher transplantation rates and lower numbers of waiting list deaths. This was most apparent for older patients (aged >65 years; waiting time 730 vs. 1357 days nationally; p < 0.001), who received predominantly DCD kidneys from older donors (mean donor age 64 years), whereas younger recipients received equal proportions of living donor, DBD and DCD kidney transplants. Death-censored kidney graft survival was nevertheless comparable for younger and older recipients, although transplantation conferred a survival benefit from listing for only younger recipients. Local expansion in DCD kidney transplant activity improves survival outcomes for younger patients and addresses inequity of access to transplantation for older recipients.
Assuntos
Morte Encefálica , Acessibilidade aos Serviços de Saúde , Disparidades em Assistência à Saúde , Transplante de Rim , Doadores de Tecidos , Obtenção de Tecidos e Órgãos/métodos , Listas de Espera , Idoso , Cadáver , Feminino , Sobrevivência de Enxerto , Humanos , Masculino , Pessoa de Meia-Idade , Taxa de Sobrevida , Resultado do Tratamento , Reino UnidoRESUMO
AIM: To examine the usage and value of computed tomography (CT) following simultaneous pancreas and kidney (SPK) transplantation. MATERIALS AND METHODS: Indications for postoperative CT, key findings, and their influence on management were determined by retrospective analysis. RESULTS: Ninety-eight patients underwent 313 CT examinations. Common indications for the examinations included suspected intra-abdominal collection (31.1%) and elevated serum amylase/lipase (24.1%). CT findings most frequently showed non-specific mild inflammation (27.6%), a normal scan (17.1%) and fluid collections (16.3%). High capillary blood glucose (CBG) was associated with resultant CT demonstration of graft vascular abnormalities, but otherwise, particular clinical indications were not associated with specific CT findings. CONCLUSION: Clinical findings in patients with SPK transplants are non-specific. The pattern of abnormalities encountered is significantly different to those seen in native pancreatic disease and demands a tailored protocol. CT enables accurate depiction of vascular abnormalities and fluid collections, thus reducing the number of surgical interventions that might otherwise be required. Elevated CBG should prompt urgent CT to exclude potentially reversible vascular complications.
Assuntos
Transplante de Pâncreas/métodos , Pâncreas/diagnóstico por imagem , Adulto , Aloenxertos/diagnóstico por imagem , Glicemia/metabolismo , Feminino , Sobrevivência de Enxerto , Humanos , Estimativa de Kaplan-Meier , Transplante de Rim/métodos , Masculino , Cuidados Pós-Operatórios/métodos , Complicações Pós-Operatórias/diagnóstico por imagem , Estudos Retrospectivos , Tomografia Computadorizada por Raios X , Transplante Homólogo/métodosRESUMO
Most kidneys from potential elderly circulatory death (DCD) donors are declined. We report single center outcomes for kidneys transplanted from DCD donors over 70 years old, using preimplantation biopsy Remuzzi grading to inform implantation as single or dual transplants. Between 2009 and 2012, 43 single transplants and 12 dual transplants were performed from elderly DCD donors. Remuzzi scores were higher for dual than single implants (4.4 vs. 3.4, p < 0.001), indicating more severe baseline injury. Donor and recipient characteristics for both groups were otherwise similar. Early graft loss from renal vein thrombosis occurred in two singly implanted kidneys, and in one dual-implanted kidney; its pair continued to function satisfactorily. Death-censored graft survival at 3 years was comparable for the two groups (single 94%; dual 100%), as was 1 year eGFR. Delayed graft function occurred less frequently in the dual-implant group (25% vs. 65%, p = 0.010). Using this approach, we performed proportionally more kidney transplants from elderly DCD donors (23.4%) than the rest of the United Kingdom (7.3%, p < 0.001), with graft outcomes comparable to those achieved nationally for all deceased-donor kidney transplants. Preimplantation biopsy analysis is associated with acceptable transplant outcomes for elderly DCD kidneys and may increase transplant numbers from an underutilized donor pool.
Assuntos
Doenças Cardiovasculares/mortalidade , Função Retardada do Enxerto/epidemiologia , Transplante de Rim/métodos , Doadores de Tecidos/estatística & dados numéricos , Obtenção de Tecidos e Órgãos/métodos , Fatores Etários , Idoso , Biópsia por Agulha , Estudos de Coortes , Função Retardada do Enxerto/patologia , Feminino , Rejeição de Enxerto/epidemiologia , Sobrevivência de Enxerto , Humanos , Imuno-Histoquímica , Cuidados Intraoperatórios/métodos , Estimativa de Kaplan-Meier , Transplante de Rim/efeitos adversos , Masculino , Prognóstico , Sistema de Registros , Estudos Retrospectivos , Estatísticas não Paramétricas , Taxa de Sobrevida , Transplantados/estatística & dados numéricos , Resultado do Tratamento , Reino UnidoRESUMO
A significant number of pancreases procured for transplantation are deemed unsuitable due to concerns about graft quality and the associated risk of complications. However, this decision is subjective and some declined grafts may be suitable for transplantation. Ex vivo normothermic perfusion (EVNP) prior to transplantation may allow a more objective assessment of graft quality and reduce discard rates. We report ex vivo normothermic perfusion of human pancreases procured but declined for transplantation, with ABO-compatible warm oxygenated packed red blood cells for 1-2 h. Five declined human pancreases were assessed using this technique after a median cold ischemia time of 13 h 19 min. One pancreas, with cold ischemia over 30 h, did not appear viable and was excluded. In the remaining pancreases, blood flow and pH were maintained throughout perfusion. Insulin secretion was observed in all four pancreases, but was lowest in an older donation after cardiac death pancreas. Amylase levels were highest in a gland with significant fat infiltration. This is the first study to assess the perfusion, injury, as measured by amylase, and exocrine function of human pancreases using EVNP and demonstrates the feasibility of the approach, although further refinements are required.
Assuntos
Tomada de Decisão Clínica , Função Retardada do Enxerto/prevenção & controle , Seleção do Doador , Preservação de Órgãos , Transplante de Pâncreas , Perfusão/métodos , Coleta de Tecidos e Órgãos , Adolescente , Adulto , Amilases/metabolismo , Função Retardada do Enxerto/diagnóstico , Função Retardada do Enxerto/metabolismo , Feminino , Seguimentos , Sobrevivência de Enxerto , Humanos , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde , TemperaturaRESUMO
Histological assessment of baseline chronic kidney injury may discriminate kidneys that are suitable for transplantation, but has not been validated for appraisal of donation after circulatory death (DCD) kidneys. 'Time-zero' biopsies for 371 consecutive, solitary, deceased-donor kidneys transplanted at our center between 2006 and 2010 (65.5% DCD, 34.5% donation after brain death [DBD]) were reviewed and baseline chronic degenerative injury scored using Remuzzi's classification. High scores correlated with donor age and extended criteria donors (42% of donors), but the spectrum of scores was similar for DCD and DBD kidneys. Transplant outcomes for kidneys scoring from 0 to 4 were comparable (1 and 3 year graft survival 95% and 92%), but were much poorer for kidneys scoring ≥5, with 1 year graft survival only 73%, and 12.5% suffering primary nonfunction. Critically, high Remuzzi scores conferred the same survival disadvantage for DCD and DBD kidneys. On multi-variable regression analysis, time-zero biopsy score was the only independent predictor for graft survival, whereas one-year graft estimated glomerular filtration rate (eGFR) correlated with donor age and biopsy score. In conclusion, the relationship between severity of chronic kidney injury and transplant outcome is similar for DCD and DBD kidneys. Kidneys with Remuzzi scores of ≤4 can be implanted singly with acceptable results.
Assuntos
Transplante de Rim , Rim/lesões , Doadores de Tecidos , Adulto , Doença Crônica , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Análise de SobrevidaAssuntos
Causas de Morte , Transplante de Pâncreas , Choque , Doadores de Tecidos , Feminino , Humanos , MasculinoRESUMO
PURPOSE: Controlled donation after circulatory death (DCD) donors make an important contribution to organ transplantation but there is considerable scope for further increasing the conversion of potential to actual DCD organ donors. The period between withdrawal of life-supporting treatment and death (the withdrawal period) is a major determinant of whether organ donation proceeds and it is therefore timely to review recent relevant studies in this area. RECENT FINDINGS: The duration and haemodynamic nature of the withdrawal period is extremely variable, and clinical guidelines for management of the potential donor during this period differ widely. Recent evidence suggests that kidneys from DCD donors with a prolonged withdrawal period can be used to increase the number of transplants performed and provide satisfactory graft function, suggesting that it is not the duration but the haemodynamic profile of the donor during this phase that are important. This suggestion questions the relevance of clinical indices predicting death within 1âh of treatment withdrawal. SUMMARY: Future studies should aim to define clinical and physiological variables during the withdrawal period that can be used to maximize well tolerated use of organs from potential DCD donors; these thresholds are likely to differ according to organ type.
Assuntos
Morte , Parada Cardíaca/etiologia , Obtenção de Tecidos e Órgãos , Suspensão de Tratamento , Seleção do Doador , Humanos , Transplante de Órgãos , Fatores de Tempo , Doadores de TecidosRESUMO
BACKGROUND: Adult whole-organ donation after circulatory death (DCD) and 'split' extended right lobe donation after brain death (ERL-DBD) liver transplants are considered marginal, but direct comparison of outcomes has rarely been performed. Such a comparison may rationalize the use of DCD livers, which varies widely between UK centres. METHODS: Outcomes for adult ERL-DBD livers and 'controlled' DCD liver transplantations performed at the Cambridge Transplant Centre between January 2004 and December 2010 were compared retrospectively. RESULTS: None of the 32 patients in the DCD cohort suffered early graft failure, compared with five of 17 in the ERL-DBD cohort. Reasons for graft failure were hepatic artery thrombosis (3), progressive cholestasis (1) and small-for-size syndrome (1). Early allograft dysfunction occurred in a further five patients in each group. In the DCD group, ischaemic cholangiopathy developed in six patients, resulting in graft failure within the first year in two; the others remained stable. The incidence of biliary anastomotic complications was similar in both groups. Kaplan-Meier survival analysis confirmed superior graft survival in the DCD liver group (93 per cent at 3 years versus 71 per cent in the ERL-DBD cohort; P = 0·047), comparable to that of contemporaneous whole DBD liver transplants (93 per cent at 3 years). Patient survival was similar in all groups. CONCLUSION: Graft outcomes of DCD liver transplants were better than those of ERL-DBD liver transplants. Redefining DCD liver criteria and refining donor-recipient selection for ERL-DBD transplants should be further explored.
Assuntos
Transplante de Fígado/métodos , Choque , Obtenção de Tecidos e Órgãos/métodos , Adolescente , Adulto , Idoso , Morte Encefálica , Seleção do Doador , Doença Hepática Terminal , Feminino , Sobrevivência de Enxerto , Parada Cardíaca , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Cuidados Pós-Operatórios/métodos , Resultado do Tratamento , Isquemia Quente/métodos , Adulto JovemRESUMO
BACKGROUND: Organ scarcity has prompted increased use of organs from donation after circulatory death (DCD) donors. An early single-centre experience of simultaneous pancreas-kidney (SPK) transplantation from controlled DCD donors is described here. METHODS: Outcomes of SPK transplants from DCD and donation after brain death (DBD) donors between August 2008 and January 2011 were reviewed retrospectively. RESULTS: SPK transplants from 20 DCD and 40 DBD donors were carried out. Donor and recipient characteristics were similar for both groups, although pancreas cold ischaemia times were shorter in DCD recipients: median (range) 8·2 (5·9-10·5) versus 9·5 (3·8-12·5) h respectively (P = 0·004). Median time from treatment withdrawal to cold perfusion was 24 (range 16-110) min for DCD donors. There were no episodes of delayed pancreatic graft function in either group; the graft thrombosis rates were both 5 per cent. Similarly, there were no differences in haemoglobin A1c level at 12 months: median (range) 5·4 (4·9-7·7) per cent in DCD group versus 5·4 (4·1-6·2) per cent in DBD group (P = 0·910). Pancreas graft survival rates were not significantly different, with Kaplan-Meier 1-year survival estimates of 84 and 95 per cent respectively (P = 0·181). CONCLUSION: DCD SPK grafts had comparable short-term outcomes to DBD grafts, even when procured from selected donors with a prolonged agonal phase.
Assuntos
Morte Encefálica , Transplante de Rim/métodos , Transplante de Pâncreas/métodos , Choque , Obtenção de Tecidos e Órgãos/métodos , Adolescente , Adulto , Função Retardada do Enxerto , Seleção do Doador , Feminino , Sobrevivência de Enxerto , Humanos , Estimativa de Kaplan-Meier , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Cuidados Pós-Operatórios/métodos , Estudos Prospectivos , Resultado do Tratamento , Isquemia Quente/métodos , Adulto JovemRESUMO
Donation after Cardiac Death (DCD) is an increasingly important source of kidney transplants, but because of concerns of ischemic injury during the agonal phase, many centers abandon donation if cardiorespiratory arrest has not occurred within 1 h of controlled withdrawal of life-supporting treatment (WLST). We report the impact on donor numbers and transplant function using instead a minimum 'cut-off' time of 4 h. The agonal phase of 173 potential DCD donors was characterized according to the presence or absence of: acidemia; lactic acidosis; prolonged (>30 min) hypotension, hypoxia or oliguria, and the impact of these characteristics on 3- and 12-month transplant outcome evaluated by multivariable regression analysis. Of the 117 referrals who became donors, 27 (23.1%) arrested more than 1 h after WLST. Longer agonal-phase times were associated with greater donor instability, but surprisingly neither agonal-phase instability nor its duration influenced transplant outcome. In contrast, 3- and 12-month eGFR in the 190 transplanted kidneys was influenced independently by donor age, and 3-month eGFR by cold ischemic time. DCD kidney numbers are increased by 30%, without compromising transplant outcome, by lengthening the minimum waiting time after WLST from 1 to 4 h.
Assuntos
Morte , Parada Cardíaca , Transplante de Rim/métodos , Obtenção de Tecidos e Órgãos/métodos , Adolescente , Adulto , Idoso , Feminino , Taxa de Filtração Glomerular , Humanos , Isquemia , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Análise de Regressão , Fatores de Tempo , Doadores de TecidosRESUMO
BACKGROUND: Although outcomes of kidney transplants following donation after cardiac death (DCD) and donation after brainstem death (DBD) are similar, generally only optimal younger DCD donors are considered. This study examined the impact of pre-existing donor kidney disease on the outcome of DCD transplants. METHODS: This retrospective study compared the outcome of all DCD kidney transplants performed during 1996-2006 with contemporaneous kidney transplants from DBD donors. Implantation biopsies were scored for glomerular, tubular, parenchymal and vascular disease (global histology score). There were 104 DCD and 104 DBD kidney transplants. RESULTS: Delayed graft function (DGF) occurred more frequently in DCD than DBD kidneys (64.4 versus 28.8 per cent; P < 0.001). Long-term graft outcome was similar. The only donor factor that influenced outcome was baseline kidney disease, which was similar in both groups, even though DCD donors were younger, with a higher predonation estimated glomerular filtration rate. The global histology score predicted DGF (odds ratio 1.85 per unit; P = 0.006) and graft failure (relative risk 1.55 per unit; P = 0.001), although there was no difference for DCD and DBD kidneys. CONCLUSION: Transplant outcomes for DCD and DBD kidneys are comparable. Baseline donor kidney disease influences DGF and graft survival but the impact is no greater for DCD kidneys.
Assuntos
Morte , Nefropatias/cirurgia , Transplante de Rim/métodos , Doadores de Tecidos , Adolescente , Adulto , Idoso , Morte Encefálica , Criança , Função Retardada do Enxerto , Feminino , Humanos , Nefropatias/fisiopatologia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Obtenção de Tecidos e Órgãos , Resultado do TratamentoRESUMO
Orthotopic liver transplant (OLTx) has evolved to a successful surgical management for end-stage liver diseases. Awareness and information about OLTx is an important tool in assisting OLTx recipients and people supporting them, including non-transplant clinicians. The study aimed to investigate the nature and quality of liver transplant-related patient information on the World Wide Web. Four common search engines were used to explore the Internet by using the key words 'Liver transplant'. The URL (unique resource locator) of the top 50 returns was chosen as it was judged unlikely that the average user would search beyond the first 50 sites returned by a given search. Each Web site was assessed on the following categories: origin, language, accessibility and extent of the information. A weighted Information Score (IS) was created to assess the quality of clinical and educational value of each Web site and was scored independently by three transplant clinicians. The Internet search performed with the aid of the four search engines yielded a total of 2,255,244 Web sites. Of the 200 possible sites, only 58 Web sites were assessed because of repetition of the same Web sites and non-accessible links. The overall median weighted IS was 22 (IQR 1 - 42). Of the 58 Web sites analysed, 45 (77%) belonged to USA, six (10%) were European, and seven (12%) were from the rest of the world. The median weighted IS of publications originating from Europe and USA was 40 (IQR = 22 - 60) and 23 (IQR = 6 - 38), respectively. Although European Web sites produced a higher weighted IS [40 (IQR = 22 - 60)] as compared with the USA publications [23 (IQR = 6 - 38)], this was not statistically significant (p = 0.07). Web sites belonging to the academic institutions and the professional organizations scored significantly higher with a median weighted IS of 28 (IQR = 16 - 44) and 24(12 - 35), respectively, as compared with the commercial Web sites (median = 6 with IQR of 0 - 14, p = .001). There was an Intraclass Correlation Coefficient (ICC) of 0.89 and an associated 95% CI (0.83, 0.93) for the three observers on the 58 Web sites. The study highlights the need for a significant improvement in the information available on the World Wide Web about OLTx. It concludes that the educational material currently available on the World Wide Web about liver transplant is of poor quality and requires rigorous input from health care professionals. The authors suggest that clinicians should pay more attention to take the necessary steps to improve the standard of information available on their relevant Web sites and must take an active role in helping their patients find Web sites that provide the best and accurate information specifically applicable to the loco-regional circumstances.
Assuntos
Internet , Transplante de Fígado/métodos , Informática Médica , Humanos , Educação de Pacientes como Assunto , Reino UnidoRESUMO
BACKGROUND: Despite increasing use of recombinant factor VIIa (rFVIIa) in non-haemophiliac patients, it is unclear when rFVIIa might be effective. METHODS: A single centre review of consecutive non-haemophiliac patients receiving rFVIIa for the management of severe haemorrhage. Treatments with rFVIIa were at a dose of 90 mug kg(-1) repeated at three hourly intervals at the clinicians' discretion. RESULTS: Eighteen patients received rFVIIa. Six patients survived to discharge and 12 patients died in hospital. The median (range) Sequential Organ Failure Assessment (SOFA) score at the time of administration of rFVIIa for the group that survived was 8.0 (5-12) compared with the group that died 12.0 (7.0-14.0) (P=0.03). One of the patients who survived (17%) had organ failure at the time of rFVIIa administration compared with 11 of those who died (92%) (P=0.004). Fifteen patients survived long enough to consider a second dose of rFVIIa, one patient who survived to discharge needed more than one dose (1/6, 17%), compared with seven of those who later died in hospital (7/9, 78%) (P=0.04). The survivors had a significant reduction in blood product requirements after rFVIIa, while patients who died did not. Neither the prothrombin time nor the activated partial thromboplastin time before or after rFVIIa predicted survival. CONCLUSIONS: High SOFA score and failure to respond to one adequate dose of rFVIIa appear to identify patients with poor prognosis. These observations may help in determining when rFVIIa treatment is likely to be futile.
Assuntos
Fator VII/uso terapêutico , Hemorragia/tratamento farmacológico , Hemostáticos/uso terapêutico , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Esquema de Medicação , Fator VIIa , Feminino , Hemorragia/sangue , Hemorragia/complicações , Mortalidade Hospitalar , Humanos , Masculino , Futilidade Médica , Pessoa de Meia-Idade , Insuficiência de Múltiplos Órgãos/complicações , Tempo de Tromboplastina Parcial , Seleção de Pacientes , Hemorragia Pós-Operatória/sangue , Hemorragia Pós-Operatória/complicações , Hemorragia Pós-Operatória/tratamento farmacológico , Prognóstico , Tempo de Protrombina , Proteínas Recombinantes/uso terapêutico , Estudos Retrospectivos , Índice de Gravidade de Doença , Resultado do TratamentoRESUMO
BACKGROUND: Use of routine preoperative ultrasonography to determine the optimum site for haemodialysis access surgery increases the number of distal arteriovenous fistulas formed and improves overall patency rates. Nevertheless its use in all patients is time consuming and costly. This study examined whether clinical parameters could be used to determine the requirement for preoperative ultrasonography. METHODS: Between March 2002 and October 2003, 145 consecutive patients were reviewed in the vascular access clinic. Patients were first assessed clinically, a site for vascular access surgery was proposed, and the need for radiological mapping studies recorded. A second, blinded, clinician determined the site for vascular access surgery using ultrasonography. The correlation between clinical and ultrasonographic findings was then examined. RESULTS: Ultrasonography was considered unnecessary using clinical criteria in 106 patients. Subsequent ultrasonographic mapping altered the management of only one patient. In contrast, the management of 18 of the 39 patients in whom ultrasonography was thought necessary was influenced by radiological imaging. A 1-year primary patency rate of 77.0 per cent was achieved following vascular access surgery on the study population. CONCLUSION: Clinical parameters could be used to determine the need for preoperative vascular ultrasonographic mapping; imaging was not required in the majority of patients.
Assuntos
Vasos Sanguíneos/diagnóstico por imagem , Cateteres de Demora , Diálise Renal/instrumentação , Ultrassonografia de Intervenção/métodos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Cuidados Pré-Operatórios/métodos , Grau de Desobstrução VascularRESUMO
Human immunodeficiency virus (HIV)-based lentiviral vectors expressing viral interleukin-10 (vIL-10) were used to transduce rat cardiac allografts with the aim of extending graft survival. vIL-10 expression was first shown, by RT-PCR, to persist in transduced heart isografts for at least 28 days after transduction. Cardiac transplants were performed in a fully allogeneic rat strain combination (Lewis to DA); allografts transduced by vectors expressing vIL-10 showed significantly prolonged survival (14.5 vs 7.5 days median survival time). Mixed lymphocyte reactions (MLRs) were used to determine the influence, in vitro, of vIL-10 on alloantigen-induced T-cell proliferation. Bioactive vIL-10, produced by DA rat aortic endothelial cells transduced with HIV-PGK-vIL-10, was added to MLRs at different time points and lymphocyte proliferation was assessed by uptake of [3H]thymidine. T-cell proliferation was inhibited by >80% when vIL-10 was added to the MLR at day 1, 2 or 3 of coculture. The inhibitory effect was significantly decreased when addition of vIL-10 was delayed until day 4 or 5 (47 and 35% inhibition, respectively). The extended graft survival time is comparable to that using adenoviral vectors delivering vIL-10 in a similar rat strain combination. The limited improvement in survival may be due to lack of inhibition of the early phase of the alloimmune response as suggested by in vitro studies confirming that maximum suppression of the MLR by vIL-10 can only be achieved if the cytokine is present at the initiation of alloimmune recognition. The delay in expression of vIL-10 from the lentiviral vector means that protocols must be developed to suppress the early stages of alloimmune stimulation before vIL-10 is produced.