Ahmed I. Kamal

Toward a Standardized System for Reporting Surgical Outcome of Pediatric and Adolescent Live Donor Renal Allotransplantation

PURPOSE There is a lack of a standardized reporting methodology for surgical complications of pediatric renal transplantation. We applied Martin criteria and the modified Clavien-Dindo classification in pediatric renal transplantation. MATERIALS AND METHODS We retrospectively reviewed the charts of 447 patients 20 years or younger who underwent renal transplantation between March 1976 and January 2011. Martin criteria were fulfilled and complications were graded according to the modified Clavien-Dindo classification. For early complications grades I and II were considered low grade and III to V high grade. A similar grading system was adopted for late complications. RESULTS A total of 84 early complications (18.5%) occurred in 77 transplant recipients (17%). Of grade I complications 37 (8.1%) were asymptomatic lymphoceles. Grade II complications were observed in 2 patients (0.4%). Grade IIIa complications included aspiration of hematoma (1 case), percutaneous nephrostomy fixed for ureteral obstruction (3), percutaneous tube drain for symptomatic lymphoceles (7) and antegrade ureteral stenting for ureteral leakage (6). Grade IIIb complications included exploration for wound dehiscence (1 case), revision of ureterovesical anastomosis (8), marsupialization of lymphoceles (4), hemorrhage (3) and vascular thrombotic accidents (6). Graft nephrectomy (grade IVa) complications occurred in 2 transplant recipients. Among 4 mortalities (grade V) only 1 patient died due to surgical complications. On multivariate analysis delayed graft function was the only predicator of high grade surgical complications (p = 0.005). High grade surgical complications affected recipient but not graft survival. CONCLUSIONS Using a standardized, high quality reporting methodology is feasible in pediatric renal transplantation. However, consensus should be sought regarding medical complications and a grading system should be developed for reporting of late complications.

Long-term outcome of grafts with multiple arteries in live-donor renal allotransplantation: Analysis of 2100 consecutive patients.

Abstract Purpose:To analyse the long-term outcome in relation to multiple graft arteries (MGA) in live-donor renal transplantation, and assess its effect on graft and patient survival. Patients and methods: Between March 1976 and November 2009, a total of 2100 live-donor renal transplants were carried out at our centre. Patients were stratified according to the number of graft arteries into two groups, i.e. MGA (two or more arteries; 237 patients) and single-graft artery (SGA; 1863 patients). Variables assessed included patient demographics, site of vascular anastomosis, ischaemia time, onset of diuresis, delayed graft function, acute tubular necrosis (ATN), acute rejection, vascular and urological complications. Moreover, long-term patient and graft survival were compared among both groups. Patients were followed up for a mean (SD) of 112 (63) months. Results: Grafts with MGA were associated with a prolonged ischaemia time (P = 0.001) and ATN (P =0.005). Vascular thrombosis (arterial and venous) had a higher incidence in MGA (2.5%) than SGA (0.6%) (P = 0.01). Both groups were not significantly different for the onset of diuresis, acute rejection and urological complications (P = 0.16, 0.23 and 0.85, respectively). Graft and patient survival were comparable in both groups. The mean (SD) 1-, 5-, 10- and 20-year graft survival rates (%) for MGA were 96.1 (1.26), 86.6 (2.39), 61.3 (4.42) and 33.8 (7.23), and 97.5 (0.36), 86.8 (0.84), 66.0 (1.35) and 37.3 (2.76) for SGA (P = 0.54). Conclusions: Although there was a higher incidence of prolonged ischaemia time, ATN and vascular thrombosis in live-donor renal transplants with MGA, it did not adversely affect patient or graft survival. The early, intermediate- and long-term follow-up showed an outcome comparable to that in patients with SGA.

Salvage of grafts with vascular thrombosis during live donor renal allotransplantation: a critical analysis of successful outcome.

To report a high‐volume institution experience with salvage techniques for vascular accidents during live donor renal allotransplantation.

Controversies related to living kidney donors.

Abstract Background: Increasing the living-donor pool by accepting donors with an isolated medical abnormality (IMA) can significantly decrease the huge gap between limited supply and rising demand for organs. There is a wide range of variation among different centres in dealing with these categories of donors. We reviewed studies discussing living kidney donors with IMA, including greater age, obesity, hypertension, microscopic haematuria and nephrolithiasis, to highlight the effect of these abnormalities on both donor and recipient sides from medical and surgical perspectives. Methods: We systematically searched MEDLINE, ISI Science Citation Index expanded, and Google scholar, from the inception of each source to January 2011, using the terms ‘kidney transplant’, ‘renal’, ‘graft’, ‘living donor’, ‘old’, ‘obesity’, ‘nephrolithiasis’, ‘haematuria’ and ‘hypertension’. In all, 58 studies were found to be relevant and were reviewed comprehensively. Results: Most of the reviewed studies confirmed the safety of using elderly, moderately obese and well-controlled hypertensive donors. Also, under specific circumstances, donors with nephrolithiasis can be accepted. However, persistent microscopic haematuria should be considered seriously and renal biopsy is indicated to exclude underlying renal disease. Conclusion: Extensive examination and cautious selection with tailored immunosuppressive protocols for these groups can provide a satisfactory short- and medium-term outcome. Highly motivated elderly, obese, controlled hypertensive and the donor with a unilateral small stone (<1.5 cm, with normal metabolic evaluation) could be accepted. Donors with dysmorphic and persistent haematuria should not be accepted. A close follow-up after donation is crucial, especially for obese donors who developed microalbuminuria.

MP74-20 NECESSITY OF PRE-TRANSPLANT BLADDER CYCLING FOR PATIENTS WITH DEFUNCTIONALIZED BLADDER : A PROSPECTIVE RANDOMIZED TRIAL

INTRODUCTION AND OBJECTIVES: Renal transplantation in patients with lower urinary tract (LUT) dysfunction is a unique challenge, as they are at higher risk of urinary tract infection, sepsis, surgical complications, allograft dysfunction and graft loss. We opt to identify the impact of pre-transplant bladder cycling on the urological complications, graft function and lower urinary tract function. METHODS: The study included patients maintained on hemodialysis for more than 12 months with oliguria or anuria, reduced bladder capacity by ascending cystogram, poor compliance by cystometry, no history of lower urinary tract dysfunction and have no evidence of urological cause of renal failure. Patients were randomly allocated into two groups, group I received direct renal transplantation without bladder recycling. Group II received renal transplant after programmed bladder recycling throughbladder instillation of sterilewater in amount equal to the estimated bladder capacity to be gradually increased till patient can withstand filling the bladder with 200 cc for 2 hours. Standard renal transplantation was carried out with stented Leich Gregoir ureteroneocystostomy. Urological complications and graft functions were recorded at 3 months. Patients were assessed by IPSS, Cystogram as well as cystometry. To achieve a difference in mean cystometric capacity of 50 cc in favor of bladder training patients, 16 patients in each group are required to achieve a power of 80% and an a error of 0.05. RESULTS: A total of 22 patients were randomized so far including 11 patients in each group. All the cases underwent right iliac renal allotransplantation. Urinary leakage occurred in 2 cases (18%) in group I that was managed conservatively and subsided with prolongation of the internal stent and one case required percutaneous tube drainage. In group II urinary leakage occurred in one case (9%) that was managed by surgical exploration and redo ureterovesical reimplantation (p1⁄4 0.07 ). At 3 months, mean serum creatinine was 0.9 mg/dl and 1 mg/dl in both groups respectively (p1⁄4 0.4 ). Symptom score was 9 and 11 in both groups respectively (p 1⁄40.09 ). Mean cystometric capacity three months after transplant was 382 cc and 397 cc in both groups respectively (p1⁄4 0.1). CONCLUSIONS: Pretransplant programmed bladder recycling for patients with defunctionalized bladder provide no clinical advantage as regard postoperative urological complications, graft function, lower urinary tract symptoms and cystometric capacity.

Malignancies After Transplantation and Posttransplant Lymphoproliferative Disorder

Renal transplantation is the preferred mode of renal replacement therapy providing the best outcome in terms of patient morbidity and mortality. In 2010, more than 16,000 kidney transplants were performed in the United States. Although short-term outcomes in terms of patient and graft survival are uniformly outstanding, long-term outcomes continue to be less than optimal. The leading cause of late allograft loss is death with a functioning allograft. While the primary cause remains as cardiovascular disease, malignancy is now the second leading cause of death post kidney transplantation. Indeed, cancer has an overall two- to fourfold elevated risk of incidence compared to healthy, non-transplanted individuals. The development of cancer in a transplant recipient substantially increases the risk of death by as much as fourfold, which is further enhanced by older age and male gender. Moreover, the overall immunosuppressive burden may be a critical feature of pathogenesis and another argument for avoidance and minimization protocols. Posttransplant malignancy may be classified into one of three categories: as a recurrence of preexisting disease, as a rare but definable donor-transmitted malignancy, and finally as a de novo malignancy. In this chapter, we will review each of these types of cancers, evaluating pathogenesis and management. The increased risk of incidence accompanied by the substantial risk of early death necessitates a need for careful pre-transplantation screening, early detection of cancer after transplantation, and appropriate management.