Influence of Experience Acquired by a Liver Transplantation Center on Extension of Donor Acceptance Criteria.

BACKGROUND: Liver transplantation (LTx) is the only effective treatment for end-stage liver failure. Due to the ongoing lack of organs available for transplantation, there is a tendency to extend liver donor selection criteria. The aim of the study was to determine whether extension of donor acceptance criteria with increasing experience in LTx occurred at our transplant center. METHODS: This retrospective analysis included 288 donors harvested between 2005 and 2016. The donors were divided chronologically into 4 equally sized groups. They were assessed in subsequent groups according to sex, age, height, body mass index (BMI), cause of death, amount of days spent in the intensive care unit, number of episodes of cardiac arrest before organ removal, and results of laboratory and virologic tests. RESULTS: A statistically significant increase in the age of accepted donors was observed between group 2 and group 4 (median 40 vs 45 years, P < .05). There was a significant increase in the acceptance of anti-HBc-positive donors (0% in group 1 vs 7% in group 4). The remaining parameters did not show statistically significant differences. CONCLUSION: Experience acquired by our transplant center during the period of analysis did not lead to extension of liver donor acceptance criteria. Statistically significant differences for liver donor age and virologic profile (anti-HBc) between groups were observed; however, overall analysis did not confirm a clear tendency to extend liver donor acceptance criteria at this center.

Results of Transplantation of Kidneys Procured From Donors After Brain Death Aged 60 Years and Older.

OBJECTIVE: To analyze results of transplantation of kidneys procured from donors after brain death aged 60 years and older (hereafter denoted by "≥60") compared to kidneys procured from donors after brain death aged 40-59 years (hereafter denoted by "40-59") in medium-term follow-up period, and to assess factors that affect recipient and kidney graft survival. MATERIAL AND METHODS: 92 transplant recipients of kidneys procured from donors after brain death ≥60 were enrolled into the study. The control group were 363 recipients of kidneys procured from donors after brain death 40-59. RESULTS: Mean values of serum creatinine were higher in recipients of kidneys procured from donors after brain death ≥60 compared to control after 3 years: 168.2 ± 57.5 (n = 59) vs 147.9 ± 65.7 (n = 294), P < .05; and after 5 years: 196.2 ± 95.3 (n = 38) vs 157.3 ± 80.0 µmol/L (n = 211), P < .01. Restricted mean recipient survival time was 56.4 (95% confidence interval: 55.0-57.8) and 52.0 (48.0-56.1) months, P < .05; and kidney graft survival time was 51.6 (49.6-53.5) and 43.9 (39.0-48.9) months, P < .01 in recipients who received kidneys from donors after brain death 40-59 and from donors after brain death ≥60 respectively. In Cox regression, donor death due to cardiovascular disease proved to be the factor increasing risk of kidney graft loss (hazard ratio 1.553, P < .001). CONCLUSIONS: The survival and function of kidneys procured from donors after brain death ≥60 at medium-term follow-up remain worse compared to kidneys procured from donors after brain death 40-59, and the donor dependent risk factor of kidney graft loss is cardiovascular disease, which caused donor death.

Effect of the Second Warm Ischemia Time and Its Components on Early and Long-term Kidney Graft Function.

BACKGROUND: During kidney transplantation, the total time of organ ischemia consists of first warm ischemia time (WIT1), cold ischemia time (CIT), and a second WIT (WIT2). Rising graft temperature during WIT2, which comprises the creation of vascular anastomoses, increases oxygen demand and tissue damage, especially in the kidney tubular cells. The aim of this study was to analyze the influence of WIT2 on early and long-term kidney graft function. METHODS: We performed a retrospective analysis of 554 consecutive adult recipients, who received their first kidney graft from a deceased donor between 2003 and 2013. RESULTS: Mean WIT2 was 25.2 min. Donors' sex, age, presence of hypertension, body mass index (BMI), and the cause of brain death showed no effect on WIT2. Weak positive correlations were found between the duration of WIT2 and both recipients' age (r = 0.11; P < .01) and BMI (r = 0.14; P < .01). Multivariate regression analysis confirmed the independent influence of age (ß = 0.107 [95% confidence interval, 0.017 to 0.197] per year; P = .02) but not BMI (P = .09). WIT2 influenced early graft function and was significantly longer in patients with primary graft nonfunction than in other recipients (35.3 vs 24.9 min; P < .01). According to receiver-operating characteristic curve analysis, a WIT2 value >26 min was predictive of primary graft nonfunction, with 64% specificity and 58% sensitivity. No correlations were found between WIT2 and estimated glomerular filtration rate in the long-term follow-up period. CONCLUSIONS: This study found that WIT2 may significantly influence the early graft function. We also found that the creation time of vascular anastomoses does not affect the long-term kidney graft excretory function.

Early and Long-Term Outcomes of Kidney Grafts Procured From Multiple-Organ Donors and Kidney-Only Donors.

BACKGROUND: The deceased-donor kidney pool consists of 2 different populations: multiple-organ donors (MOD) and kidney donors alone (KDA). In MOD, more complicated procedure and lowest priority for kidney procurement may affect graft survival. On the other hand, poor donor status and higher comorbidity are more frequent in KDA transplants. The aim of this study was to provide detailed characteristics of the 2 groups of kidney donors (KDA vs MOD) in our center and to analyze the potential influence of the donor type on the early and long-term kidney graft function and recipient outcome. METHODS: We performed a retrospective analysis of 729 first cadaveric kidney transplant recipients: 499 of them received the organ from MOD, 230 from KDA. RESULTS: The frequency of delayed graft function (DGF) was higher in KDA than in MOD transplants (38.7 vs 25.1%; P < .001). Multivariate logistic regression analysis revealed that donor age, KDA, and early acute rejection independently increased the risk of DGF occurrence, whereas recipient age and cold ischemia time increased the risk of primary graft nonfunction. Kidney excretory function was significantly worse in KDA up to 10 years after transplantation. There were no differences in kidney graft and patient survivals, frequency of proteinuria, acute rejection, and cytomegalovirus episodes, and post-transplantation diabetes. CONCLUSIONS: (1) The use of a kidney from KDA negatively affects early and late kidney graft function compared with MOD. (2) The long-term kidney graft and patient survivals are not affected by the type of organ procurement.

Donation and Transplantation of Kidneys Harvested From Deceased Donors Over the Age of 60 Years in the Upper Silesia Region.

BACKGROUND: Population aging and shortage of organs for transplantation result in increasing numbers of kidneys retrieved from elderly donors. The aim of this study was to analyze donation of kidneys from donors after brain death (DBD) over the age of 60 years (≥60), comorbidities that affect decisions on retrieval, and early results of kidney transplantation. METHODS: Ninety-six potential DBD ≥60 and 309 aged 40-59 years (40-59) reported in Upper Silesia, Poland, from 2004 to 2013 were enrolled in the study. RESULTS: DBD >60 presented a higher rate of coexisting hypertension (53% vs 34%), limb ischemia (10% vs 1%), and past stroke (6% vs 1%) compared with DBD 40-59 (P < .05), but no differences were observed in serum creatinine concentration (85 vs 84 µmol/L), coexisting coronary disease (14% vs 6%), or diabetes (10% vs 4%). The decision of withdrawal from retrieval was more frequent in DBD ≥60 (16% vs 7%; P < .05). Twelve months after kidney transplantation, serum creatinine concentration was higher in recipients of kidneys from DBD ≥60 compared with DBD 40-59 (169 vs 138 µmol/L; P < .001). The survivals of recipients (93% vs 95%) and kidney grafts (90% vs 93%) as well as rates of proteinuria >1.0 g/24 h (6% vs 2%) did not differ between the groups. CONCLUSIONS: A higher rate of comorbidities in potential kidney DBD ≥60 results in a lower retrieval rate in these donors. The function of kidneys harvested from DBD ≥60 12 months after transplantation is worse than those from DBD 40-59, but still acceptable.

Past Cardiovascular Episodes Deteriorate Quality of Life of Patients With Type 1 Diabetes and End-stage Kidney Disease After Kidney or Simultaneous Pancreas and Kidney Transplantation.

BACKGROUND: The beneficial influence of kidney (KTx) or simultaneous pancreas and kidney transplantation (SPK) on quality of life (QOL) in patients with end-stage kidney disease caused by type 1 diabetes mellitus was confirmed in many studies. The aim of this study was to identify factors that influence QOL of patients in long-term follow-up after SPK or KTx. METHODS: Twenty-seven SPK and 26 KTx patients with good function of transplanted organs at least 1 year after transplantation were enrolled into the analysis. To estimate QOL of the recipients the Kidney Disease and Quality of Life Short Form was applied. RESULTS: Within the whole analyzed group, the necessity of exogenous insulin administration correlated (P < .05) with symptom/problem list (γ = -0.35), effects of kidney disease (-0.38), cognitive function (-0.47), sleep (-0.42), overall health (-0.47), physical functioning (-0.61), role-physical (-0.32), pain (-0.50), general health (-0.32), emotional well-being (-0.31), role-emotional (-0.36), social function (-0.33), energy/fatigue (-0.44), and the SF-12 physical composite (-0.44). History of cardiovascular episode correlated (P < .05) with symptom/problem list (γ = -0.59), effects of kidney disease (-0.46), burden of kidney disease (-0.56), sleep (-0.54), social support (-0.51), physical functioning (-0.55), role-physical (-0.70), pain (-0.60), general health (-0.57), emotional well-being (-0.45), role-emotional (-0.95), social function (-0.58), energy/fatigue (-0.59), SF-12 physical composite (-0.45), and SF-12 mental composite (-0.83). CONCLUSIONS: Exogenous insulin administration and history of cardiovascular episode are the most important factors influencing QOL in patients after SPK or KTx, particularly worsening its physical components.

Long-Term Outcomes of Kidney and Simultaneous Pancreas-Kidney Transplantation in Recipients With Type 1 Diabetes Mellitus: Silesian Experience.

BACKGROUND: Kidney transplantation (KTx) markedly reduces mortality in patients with end-stage kidney disease (ESKD) caused by type 1 diabetes mellitus (T1DM). The outstanding issue is whether transplantation should be limited only to KTx, with further insulinotherapy, or combined with pancreas transplantation in patients with ESKD/T1DM. The goal of this study was to compare the results of simultaneous pancreas-kidney transplantation (SPKTx) and deceased donor KTx and to identify factors affecting patient and kidney graft survival in patients with ESKD/T1DM. METHODS: Eighty-seven deceased donor KTx and 66 SPKTx operated on in the Silesia region of Poland between 1998 and 2013 were included in the retrospective analysis. RESULTS: During the mean 6.7 ± 3.6 years of follow-up, fewer cardiovascular episodes were observed in SPKTx recipients than in KTx recipients (1.5% vs 12.6%; P < .05). Five-year patient survival (80.7% in SPKTx vs 77.5% in KTx) and kidney graft survival (66.1% in SPKTx vs 70.4% in KTx) did not differ between study groups. There were no differences in patient survival (log-rank test, P = .99) or kidney graft survival (P = .99) based on Kaplan-Meier curves. Multivariable Cox proportional hazard analysis failed to identify factors explaining patient and kidney graft survival. Five-year pancreas graft survival was 58.9%. SPKTx recipients had significantly higher estimated glomerular filtration rates during the 7-year posttransplant period and less frequently developed proteinuria (6.1% vs 23%; P < .01). CONCLUSIONS: Pancreas transplantation reduced cardiovascular risk and prevented the development of proteinuria but did not improve patient and kidney graft survival in recipients with T1DM in the 7-year follow-up period.

Impact of early lymph node procurement to facilitate histocompatibility testing on long-term cadaveric kidney graft survival.

BACKGROUND: Prolonged cold ischemia time (CIT) is a clinically important causes of delayed graft function (DGF) after kidney transplantation. As DGF has been previously shown to have a deleterious influence on long-term graft survival, in the present study we analyzed the impact of early lymph node (LN) procurement on CIT, HLA mismatches, and long-term kidney graft outcome. MATERIALS AND METHODS: We evaluated 394 consecutive cadaveric procedures performed from 2001 to 2006, including 289 recipients, in whom LN were obtained before kidney procurement seeking to shorten the total time for HLA typing and crossmatch procedures. RESULTS: During 58±6 months, 24 patients died (918 [8.3%] in the early and 6 [5.7%] in late procurement group, P=ns) and 52 lost their kidney grafts (31 [10.7%] vs 21 [20%]; P=.025). Early procurement of LN performed in 73.4% of all kidney graft recipients shortened CIT by almost 7 hours (22.9 vs 16.1 hours; P<.001), with a nonsignificantly lower incidence of DGF (32.2% vs 41.0%; P=.13). However, a Cox proportional hazards regression model revealed that early procurement reduced the risk of death-censored kidney graft loss by roughly 40% (log-rank, P=.013). CONCLUSION: Early LN procurement in significantly shorten CIT and subsequently reduced the risk of long-term kidney graft loss.

Evaluation of transplantation procedures acceptance among students of Thai, American, and Polish origin who finished a basic didactic course.

The aim of this paper was to compare acceptance of basic transplantation procedures as displayed among students from Poland, Thailand, and the United States who finished their education in our clinic. The research concerned a group of 110 fifth year students of the medical department, including 42 citizens of Poland (group 1), 41 citizens of Thailand (group 2), and 27 citizens of the United States (group 3). The average age of the respondents was 25.4 years and 58% were women. After completing a number of clinical transplantation classes, we performed an anonymous poll that consisted of 12 questions related to attitudes toward organ donation and transplantation from dead of living donors. Chi-square tests were used to analyze the relationship between expressed opinions and demographic data. The majority of students accepted organ donation from either dead (92% "definitely yes") or living (81%) donors. The smallest percentage (58%) was expressed by group 2. Some insignificant differences were also observed in connection with the question of whether "brain death" is equivalent to death of a person. Students' responses were diverged with regard to consideration of implied consent as a factor to condition organ procurement from dead donors. Amid Thai students, acceptance was definitely lower (23%) than Polish (67%) or American (58%) ones. At the same time, organ donation was mostly dependent on the consent of a deceased person's family. Similar to other groups, the great majority of students declared their consent to both organ procurement after their own death, to donating a kidney to their relatives, or to persons with whom they are emotionally connected. Interestingly, 16% accepted organ donation for money.

Intraoperative resistance index measured with transsonic flowmeter on kidney graft artery can predict early and long-term graft function.

INTRODUCTION: Resistive index (RI) measured by Doppler sonography in the early period after kidney transplantation is a well-known predictor of kidney transplant outcome. The purpose of this study was to analyze the impact of RI values calculated intraoperatively in renal allograft artery using transit time flowmetry (TTF) on both early and long-term kidney graft function. MATERIAL AND METHODS: TTF was performed on 72 patients who received kidney grafts fed by a single artery. TTF was performed before wound closure. We excluded patients with an early acute rejection (n=8), an early graft loss (n=2), or primary graft nonfunction (n=1). Recipients were divided into RI tertile groups. The initial kidney graft function was defined as immediate (IGF), slow or delayed. Kidney graft estimated glomerular filtration rate (eGFR) was analyzed upon long-term follow-up. RESULTS: Patients with a low RI (<0.57) showed the highest incidence of immediate graft function (65% versus 5.3%), whereas the high RI group (>0.70). Show the most frequent rate of delayed graft function (52.6% versus 15%). Recipients with low RI values displayed significantly better eGFR (by at least 12 mL/min/1.73 m2) than those with medium or high RI values at all analyzed times; subjects with medium or high RI showed similar eGFR at 48-months. CONCLUSION: An high RI value measured intraoperatively was a valuable predictor of inferior early and long-term kidney graft function.

Risk factors for early hemorrhagic and thrombotic complications after kidney transplantation.

INTRODUCTION: Clotting disturbances resulting from chronic renal failure do not remit immediately after successful kidney transplantation (KTx). Hemorrhagic and thrombotic complications after KTx increase the risk of transplanted kidney loss. The aim of the study was to analyze the influence of clotting system disturbances and applied antithrombotic prophylaxis on the development of hemorrhagic and thrombotic complications among KTx patients in the early postoperative period. MATERIALS AND METHODS: Sixty seven KTx patients underwent measurement of plasma activated partial thromboplastin time (APTT); international normalized ratio; fibrinogen and D-dimer concentration; activity of antitrombin III; protein C and S, VIII, IX; and von Willebrand factors, as well as platelet counts. RESULTS: A perigraft hematoma developed in 25.4% patients, of whom 4.5% required reoperation. Lower antithrombin III activity (96.2±27.6 vs 112.3±17.4, P=.02) on postoperative day (POD) 7 and higher fibrinogen concentration (4.41±2.03 vs 3.35±0.87, P=.01) and platelet count (269.8±117.5 vs 215.8±64.8, P=.03) on POD 14 were noted in recipients with a hematoma compared to those free of this complication. A perigraft hematoma developed in 57.9% patients undergoing antithrombotic prophylaxis and in 12.5% without this treatment (P=.0002). Among patients receiving unfractionated heparin, we observed extension of APTT on POD 1 (45.9±53.2 vs 30.9±7.5 seconds, P=.04), higher von Willebrand factor activity on POD 7 (348.8±122.2 vs 218.5±125.5, P=.02), and higher D-dimer concentrations POD 7 and 14 (1662±894 vs 757±708, P=.002 and 1614±1372 vs 672±532, P=.003, respectively). No significant differences were observed as regards to analyzed parameters between patients receiving low-molecular-weight heparin versus those not receiving antithrombotic prophylaxis. CONCLUSIONS: Disturbances in analyzed parameters of hemostasis did not increase the risk of hemorrhagic and thrombotic complications in the early period after KTx. Antithrombotic prophylaxis increases the risk of hemorrhagic complications and should be introduced only for selected renal transplant recipients.

Biliary complications after orthotopic liver transplantation: a 5-year experience.

INTRODUCTION: Biliary complications, particularly bile duct stenosis or leak, remain the "Achilles' heel" of orthotopic liver transplantation (OLT), significantly increasing the risk of graft loss and recipient death. The aim of the study was to retrospectively analyze biliary complications over a 5-year experience seeking to identify risk factors for these complications. MATERIAL AND METHODS: Eighty-seven OLT performed in 84 recipients were included in the analysis. In all cases but one, we performed an end-to-end hepatic duct anastomosis with a 7-0 running suture under 2.5× magnification. RESULTS: Biliary complications developed after 17.2% OLT: anastomosis site stenosis (10.3%), multiple stenoses (5.7%), or bile duct necrosis (1.1%). A bile leak was not observed. Two recipients died from biliary sepsis. Among the patients with biliary complications, there was an higher rate of hepatic artery problems (33.3% vs 2.7%; P<.01), and a longer anhepatic phase (85 vs 72 minutes; P<.01). We performed endoscopic treatment in 73% and percutaneous drainage in 6.6% of recipients. Good treatment results were achieved in 36.4% of cases with biliary complications whereas they were satisfactory in 27.3%. Five patients with biliary complications required re-transplantation. CONCLUSIONS: A bile duct anastomosis performed end-to-end with a running suture under magnification decreased the risk of bile leakage after OLT. A prolonged anhepatic phase or an hepatic artery thrombosis or stenosis increased the risk of biliary complications after OLT.

Donor-dependent risk factors for early surgical complications after simultaneous pancreas-kidney transplantation.

INTRODUCTION: The success of simultaneous pancreas-kidney transplantation (SPK) depends in a large degree on avoidance of surgical complications in the early postoperative period. The aim of the study was to analyze the Pre-procurement Pancreas Allocation Suitability Score (P-PASS) and the deceased donor parameters included within it as risk factors for early surgical complications after SPK. MATERIAL AND METHODS: Forty-six consecutive donors whose kidney and pancreas were simultaneously transplanted were included in the study. RESULTS: Donor age was older among recipients who lost their pancreatic grafts: 30.4±6.9 versus 24.1±6.9 years. Donor age was also older among recipients who lost their pancreatic grafts or died compared with those discharged with a functioning graft: 29.3±5.7 versus 24.0±6.9 years. Donor body mass index (BMI) was higher among patients who died compared with those who were discharged: 25.3±1.1 versus 23.2±2.5 kg/m2. P-PASS was higher in patients who lost their pancreatic grafts (17.6±2.1 vs 15.2±1.8) or died (15.3±1.9 vs 17.2±1.9), or lost pancreatic graft or died (15.2±1.8 vs 17.0±2.2) or with intra-abdominal infections (IAI; 17.1±1.7 vs 15.0±1.8). The incidence of donors≥30 years old was higher among recipients with IAI (45.4% vs 14.3%; P=.04). An higher rate of donors with P-PASS>16 was revealed among patients who lost their pancreatic grafts (26.7% vs 3.2%), died (26.7% vs 3.2%), lost the pancreatic graft or died (33.3% vs 6.4%), or experienced IAI (46.7% vs 9.7%). Multivariate logistic regression analysis revealed P-PASS (odds ratio 2.57; P=.014) and serum sodium (odds ration, 0.91; P=.048) to be important predictors of IAI development. CONCLUSION: Older age and higher BMI among deceased donors increased the risk of IAI, pancreatic graft loss, or recipient death after SPK. Transplantation of a pancreas from a donor with a low P-PASS score was associated with a lower risk of surgical complications after SPK.

Does simultaneously transplanted pancreas improve long-term outcome of kidney transplantation in type 1 diabetic recipients?

INTRODUCTION: Simultaneous pancreas-kidney transplantation (SPK) is an alternative to kidney transplantation (KTx) for type 1 diabetic patients with end-stage kidney disease. However, a fair comparison of SPK and KTx is difficult because of significant differences in donor, recipient, and transplantation procedure parameters. The aim of this study was to compare the early and long-term outcomes of SPK versus KTx in southwest Poland. MATERIAL AND METHODS: Thirty-five diabetic dialysis patients who had SPK and 64 patients who had KTx were included in the analysis. RESULTS: SPK recipients were younger (38±6 years versus 42±9 years) and received organs from younger donors (25±7 versus 43±12 years) compared to the KTx group. They had shorter kidney cold ischemia time (9±2 hours versus 22±7 hours) but worse HLA class II mismatches (1.4±0.6 versus 1.0±0.5). In the early postoperative period, three patients died from the SPK group and one patient died from the KTx group. Additionally, two SPK patients lost their pancreatic grafts, and five KTx patients lost their kidney grafts. One-year patient survival rates for the SPK and KTx groups were 88% and 98%, respectively, and 5-year, 81% and 93%, respectively. One-year kidney graft survivals rates for the SPK and KTx groups were 100% and 89%, respectively, and 5-years, 89% and 81%, respectively. One-year insulin-free survival among SPK patients was 90% and the 5-year survival rate was 76%. Excretory function of the transplanted kidneys was better among SPK group; however, the difference reached statistical significance only in posttransplant years 2 and 3: 63.5±20.1 versus 50.3±19.7 and 64.9±12.9 versus 51.6±21.8 mL/min/1.73 m2 for SPK and KTx, respectively. CONCLUSIONS: Normoglycemia in SPK recipients did not improve patient survival at 5 years. The worse HLA compatibility in the SPK group did not lead to impaired kidney graft survival compared to KTx. Better kidney graft function among SPK recipients probably resulted from a more restrictive donor selection.

Impact of pancreas transplantation on the quality of life of diabetic renal transplant recipients.

UNLABELLED: Simultaneous pancreas and kidney transplantation (SPKT) is considered to be the best method of treatment for patients with chronic renal failure (CRF) resulting from insulin-dependent diabetes mellitus (IDDM). The aim of the study was to compare the quality of life (QOL) of patients with IDDM and CRF subjected to SPK or kidney transplantation alone (KTA). MATERIALS AND METHODS: We analyzed 21 patients after SPKT with good function of both grafts. The results were compared with 17 patients with functioning kidney grafts. Minimal observation time was 6 months. QOL was evaluated using Kidney Disease and Quality of Life Short Form (KDQOL-SF), which was sent to recipients by post. Results were presented as medians and interquartile ranges of calculated scored KDQOL-SF points. RESULTS: Observation time was 30 months (range, 6-85). Analyzed groups did not differ as regards patient age at transplantation or duration of diabetes and dialysis treatment before transplantation. After SPKT patients reported higher QOL compared with KTA as regards symptom/problem list, 90.91 (86.36-95.46) versus 84.09 (75.00-90.91; P = .04), effects of kidney disease, 90.63 (84.38-93.75) versus 81.25 (68.75-82.14; P = .001); cognitive function, 93.33 (86.67-100.00) versus 80.00 (73.33-93.33; P = .03); overall health, 80.00 (70.00-90.00) versus 50.00 (50.00-70.00; P = .001); physical functioning, 90.00 (75.00-100.00) versus 80.00 (55.00-85.00; P = .03); and pain, 100.00 (90.00-100.00) versus 67.50 (45.00-90.00; P = .005), respectively. CONCLUSION: SPKT had a positive impact on selected parameters of QOL among patients with IDDM and CRF compared to KTA.

Did volume of lymphocele after kidney transplantation determine the choice of treatment modality?

INTRODUCTION: Lymphocele is a lymph collection that forms after surgery following injury to lymph nodes and vessels. The aim of the study was to perform a retrospective analysis of different treatment modalities of lymphocele in patients after kidney transplantation. MATERIAL AND METHODS: A lymphocele located in renal graft area was observed in 25 of 386 transplanted patients (6.5%). Mean patient age was 45 (95% confidence interval [CI], 40 to 50) years. Mean observation time was 35 (95% CI, 27 to 43) months. RESULTS: Mean time from transplantation to diagnosis of lymphocele was 29 days (range, 4 to 127). In 13 patients (54.2%), the lymphocele was symptomatic, requiring initial treatment by repeated needle aspirations or percutaneous drainage. Among 7 patients with persistence of the lesion treatment by sclerotherapy with doxycycline, povidone-iodine, and/or ethanol was successful in 4 cases who showed maximal lymphocele volume of 500 mL. Three other patients, namely, volumes of 120, 874, and 2298 mL were referred for surgery; in two cases, internal marsupialization was performed and in one case external drainage was necessary due to abscess formation. Mean time from the diagnosis to recovery in patients requiring surgical treatment was 15 (range, 8 to 24) weeks. Eleven patients with asymptomatic lymphoceles (mean volume 45 mL; range, 8 to 140) were monitored to resolution after a mean of 4 (range, 1 to 11) weeks. CONCLUSION: All lymphoceles with the maximal volume exceeding 140 mL were clinically symptomatic. Initial percutaneous drainage with or without sclerotherapy was an effective method of treatment. Punctures, drainage, and sclerotherapy were not effective in patients with lymphoceles (>500 mL).

Analysis of coagulation parameters in the early period after kidney transplantation.

BACKGROUND: Hemorrhagic diatheses observed in patients with chronic renal failure result from platelet defects, vessel wall damage, and deficiency of II, VII, IX, and X clotting factors. In contrast, increased levels of fibrinogen and von Willebrand factor, as well as decreased plasma fibrinolytic activity, may lead to thrombotic complications in nephrotic syndrome. Successful kidney transplantation may reverse these disturbances. The aim of the study was to analyze plasma coagulation parameters in the early postoperative period. MATERIALS AND METHODS: We studied 40 patients who received cadaveric kidney grafts in 2005 and 2006 for activated partial thromboplastin time (APTT), prothrombin time (PT), fibrinogen, and D-dimer concentrations as well as antithrombin III and protein C and S activities. Blood was collected before surgery and on postoperative days 1, 7, and 14. RESULTS: The APTT, PT, and fibrinogen values did not differ before and after transplantation. The activity of antithrombin III pretransplantation was 80.9% +/- 19.3%, increasing to 114.2% +/- 25.5% on postoperative day 14. The activities of protein C and S pretransplantation were 115.1% +/- 32.2% and 120.2% +/- 51.6%, respectively, increasing to 150.2% +/- 56.6% and 139.5% +/- 35.4%, respectively, on postoperative day 14. D-dimer concentrations increased from 252.3 +/- 312.0 ng/mL before transplantation to 951.5 +/- 1170.8 and 739.1 +/- 1049.8 ng/mL on postoperative days 7 and 14, respectively. CONCLUSIONS: Kidney transplantation increased plasma clotting inhibitor activity in the early postoperative period. The high level of D-dimer observed postoperatively suggested increased thrombotic processes in these patients.

Simultaneous transabdominal bilateral nephrectomy in potential kidney transplant recipients.

BACKGROUND: Bilateral nephrectomy of potential kidney graft recipients is indicated for patients with recurrent infections in the polycystic kidneys or chronic pyelonephritis resulting from vesicoureteric reflux. The aim of this study was to analyze the frequency of complications after simultaneous bilateral transperitoneal nephrectomy. PATIENTS AND METHODS: Twenty hemodialysis patients (age 28 to 55 years) were referred for simultaneous bilateral nephrectomy between 1996 and 2004. Among the 18 patients with autosomal-dominant polycystic kidney disease, 11 experienced recurrent cysts or urinary tract infections and two, episodes of disabling flank pain. Five patients with extremely enlarged kidneys were asymptomatic. Two patients presented vesicoureteric reflux with chronic pyelonephritis. In all cases the kidneys were removed transperitoneally via a transverse or midline incision. RESULTS: Although no fatal outcome was recorded, three patients required brief hospitalizations in the intensive care unit. The only intraoperative complication was spleen injury in five patients. Surgical postoperative complications developed in nine patients (45%) including: extended drainage and delayed wound healing (n = 4), postoperative hernia (n = 3), prolonged abdominal pain (n = 3), perihepatic hematoma (n = 2), stress duodenal ulceration (n = 1), and subileus (n = 1). Five patients displayed thrombosis of their dialysis access, probably as a consequence of low blood pressure. After surgery 15 patients were placed on the waiting list and 10, successfully transplanted. CONCLUSION: Simultaneous transabdominal bilateral nephrectomy was associated with a high risk of postoperative complications, but may save the suffering associated with a repeated operation in potential kidney graft recipients who have an indication for bilateral nephrectomy.

Early donor lymph node procurement and local HLA typing reduce cold ischemia time and risk of acute tubular necrosis in cadaveric kidney transplantation.

Prolonged cold ischemia time (CIT) is one of the most common causes of acute tubular necrosis (ATN) with consequent delayed graft function after kidney transplantation. The aim of the study was to analyze the impact of early donor lymph nodes (LN) procurement in combination with local or central HLA typing on CIT, on donor-recipient HLA mismatches, and on the early results of grafts. Two hundred six cadaveric procedures were performed from 2001 to 2004 including 86 cases out of 119 recipients who were matched locally and 60 cases out of 87 recipients who were matched centrally, wherein LN were obtained before kidney harvest. CIT was significantly shorter when LN were obtained before kidney harvesting both in local (13.6 vs 20.6 hours) and central (20.1 vs 27.7 hours) matching (both P < .001). ATN frequency was significantly lower in patients with LN obtained earlier (27.9%) when matched locally versus (35.0%) when matched centrally. Kidney graft function estimated at 12 months was similar in both groups. CIT longer than 19.5 hours predicted ATN occurrence with 57.7% sensitivity and 66.4% specificity. Local matching resulted in shortening CIT compared to central matching (15.5 vs 22.4 hours); however, the mismatch in HLA class I and HLA class II were significantly worse (HLA A + B 2.76 vs 2.45, HLA DR 1.21 vs 0.82). These discrepancies did not significantly influence the frequency of ATN (36.1% vs 40.0%) or the kidney graft function at 12 months.

The intrarenal vascular resistance parameters measured by duplex Doppler ultrasound shortly after kidney transplantation in patients with immediate, slow, and delayed graft function.

BACKGROUND: Evaluation of pulsatility (PI) and resistive (RI) indexes by duplex Doppler ultrasound shortly after kidney transplantation reflects the exacerbation of interstitial edema. The aim of study was to characterize factors that influence PI and RI in patients with immediate (IGF), slow (SGF), or delayed (DGF) kidney graft function. PATIENTS AND METHODS: PI and RI were measured in 200 transplanted patients at 2 to 4 days postoperatively. We excluded patients with acute rejection episodes within the first month. IGF, which was defined as serum creatinine <264 micromol/L at 3 days, SGF, which was defined as creatinine >264 micromol/L by day 3 with a maximum of one dialysis, and DGF, which was defined as more than 1 dialysis were observed in 33.3%, 41.5%, and 25.2% of patients, respectively. The examined donor parameters were age, hypotensive episodes, catecholamine infusion, central venous pressure, and glomerular filtration rate. The recipient factors were age, history of hypertension, diabetes mellitus, ischemic heart disease, and stroke. Additionally cold ischemia time (CIT), HLA mismatch, and PRA were analyzed. RESULTS: The lowest PI and RI values were observed among patients with IGF (PI 1.37 [1.28 to 1.46]; RI 0.72 [0.69 to 0.74]); moderate values in SGF (PI 1.65 [1.52 to 1.78]; RI 0.78 [0.76 to 0.80]) and the highest values in DGF (PI 2.09 [1.83 to 2.35]; RI 0.83 [0.80 to 0.86]) differences that were highly significant. Hypotensive episodes and catecholamine infusion in the preharvest period had essential impacts on PI or RI values in the early posttransplant period. There was no significant correlation between PI or RI values and CIT. A slower ATN resolution was observed in DGF patients with higher PI values. CONCLUSION: Ischemic injury, which occurred mainly prior to organ harvesting, played a dominant role determining intrarenal resistance in the early posttransplant period.