Andrzej Baranski

Urological complications and their impact on survival after kidney transplantation from deceased cardiac death donors.

Urological complications after kidney transplantation may result in significant morbidity and mortality. However, the incidence of such complications after deceased cardiac death (DCD) donor kidney transplantation and their effect on survival is unknown. Purpose of this study was to estimate the incidence of urological complications after DCD kidney transplantation, and to estimate their impact on survival. Patient records of all 76 DCD kidney transplantations in the period 1997–2004 were reviewed for (urological) complications during the initial hospitalization until 30 days after discharge, and graft survival until the last hospital visit. Urological complications occurred in 32 patients (42.1%), with leakage and/or obstruction occurring in seven patients (9.2%). The latter seems to be comparable with the incidence reported in the literature for deceased heart‐beating (DHB) transplantations (range 2.5–10%). Overall graft survival was 92% at 1 year and 88% at 3 years, comparable to the rates reported in the literature for kidneys from DHB donors, and was not affected by urological complications (χ2 = 0.27, P = 0.61). Only a first warm‐ischaemia time of 30 min or more reduced graft survival (χ2 = 4.38, P < 0.05). We conclude that urological complications occur frequently after DCD kidney transplantation, but do not influence graft survival. The only risk factor for reduced graft survival in DCD transplant recipients was the first warm‐ischaemia time.

Sequence of Abdominal Organ Procurement

Background: Where all organs were accepted and, after inspection, are found to be suitable for transplantation, the following sequence of abdominal organ procurement is recommended: small bowel, pancreas, liver, kidneys. The small bowel is the most sensitive organ for ischemia; therefore, it is retrieved first.

Presence of Hyperemic Islets in Human Donor-Pancreata Results in Reduced Islet Isolation Yield

When studying histological characteristics of human donor-pancreata, a remarkably high number of hyperemic islets (HIs) were encountered. The abnormalities in these HIs ranged from single/multiple dilated vessels to hemorrhages extending into the exocrine tissue. We aimed to determine the relevance of the presence of HIs in human donor-pancreata for isolation outcome and to identify donor and procurement factors associated with the occurrence of HIs. The presence of HIs was scored semi-quantitatively (HI-, HI+) in 102 human donor-pancreata. Islet isolation was performed in 40 cases. Donor and procurement factors were retrospectively analyzed in 94 donors. HIs were found in 54.6% of all donor-pancreata. However, only 4.5% of all islets in the affected pancreata was hyperemic. The affected pancreata contained slightly more endocrine tissue, but produced significantly lower yields. When corrected for other factors known to influence isolation outcome, the presence of HIs and endocrine content were the only factors significantly influencing isolation outcome. Prolonged ICU stay and pre-procurement hypertension were associated with the presence of HIs. This study is a first indication that the presence of HIs in human donor-pancreata are associated with reduced isolation outcomes and suggest an impact of the procurement procedure and pre-procurement hemodynamic status of the donor on the islet quality. It is tempting to speculate that this contributes to the generally experienced difficulties in obtaining sufficient amounts of human islets.

CONTRIBUTION OF DONOR AND RECIPIENT CHARACTERISTICS TO SHORT- AND LONG-TERM PANCREAS GRAFT SURVIVAL: 1741

BACKGROUND Many donor and recipient factors are known to affect pancreas graft survival. However, their relative importance in explaining differences in graft survival is unknown. Purpose of this study was to retrospectively evaluate the impact of donor and recipient factors on pancreas graft survival, and compare their contribution in explaining graft survival differences. MATERIAL/METHODS Patient records of all 170 pancreas transplantations (158 Simultaneous Pancreas-Kidney; 12 Pancreas-after-kidney) in the period 1997-2008 were reviewed retrospectively to assess recipient factors before/during transplantation, and to assess graft survival. Eurotransplant reports were reviewed to assess donor factors. RESULTS Death-censored 1-year graft survival was 88.4% and 82.3% at 3 years. Several factors significantly influenced graft survival: female recipient gender (Hazard Ratio (HR) 2.81[1.10-7.14]), enteric graft drainage (HR 2.85[1.15-7.05]), and donor-recipient match on BMI (HR 2.46[1.01-6.02]). None of the donor factors significantly affected survival. Similar results were found for 1-year survival, except for enteric graft drainage and donor-recipient BMI matching. In total, donor factors explained 3.6% and recipient factors 10.0% of the variance in graft survival. Donor factors were more important for 1-year survival (3.1%), but still less important than recipient factors which explained 6.4%. CONCLUSIONS Recipient factors are more important in explaining differences in pancreas graft survival than donor factors.

The Tool-Kit

Background: The tool-kit plays a very important role during organ harvesting and transplantation. It consists of the arteries and the veins removed during organ procurement. The tool-kit is used for the reconstruction of different vessels for both the retrieved organ as well as for the vessels of the recipient. The quality of the procured tool-kit is very important and has a great influence on organ and recipient survival.

Hepatoduodenal Ligament and Biliary Tree

Background: The hepatoduodenal ligament extends between the liver and the first portion of the duodenum and is continuous with the right border of the hepatogastric ligament. It contains the common bile duct, hepatic artery and portal vein as well as the hepatic plexus and the lymph nodes.

Right-Sided Medial Visceral Rotation: The Cattel–Braasch Manoeuvre

Background: The Cattel–Braasch manoeuvre is based on the anatomical observation that the small mesentery is attached to the posterior abdominal wall along a short oblique line of fusion. The Cattel–Braasch manoeuvre begins at the common bile duct and ends at the ligament of Treitz. It allows you to mobilise the whole duodenum, pancreas head, small bowel and the right colon and bring the two last structures outside the abdomen. Thanks to anatomical knowledge of the avascular planes – the Cattel–Braasch manoeuvre is the one of the quickest mobilisation surgical techniques with minimal blood loss. Extended Kocher’s manoeuvre is a part of Cattel–Braasch manoeuvre and generally consists of full exposition of the inferior vena cava (IVC), renal veins, abdominal aorta, and superior mesenteric artery (SMA).

Infrarenal and Superior Mesenteric Artry Major Vessel Dissection

Background: Superior mesenteric artery (SMA) and infrarenal major vessel dissection is the next step after the Cattel–Braasch manoeuvre, which consists of dissection, in the retroperitonem, of the following vessels and structures: infrarenal aorta, inferior vena cava (IVC), SMA, inferior mesenteric artery (IMA), inferior mesenteric vein (IMV), celiac trunk and plexus and iliac vessels on both sides. Abdominal aorta and IVC are encircled with long, thick ligatures and the left renal vein with the vessel loop. During the retroperitoneum inspection, special attention has to be paid to the quality of the abdominal aorta and any vascular abnormality.

Left Liver Lobe and Supraceliac Aorta

Background: Placing the bowels in the physiological position in the abdomen, mobilisation of the left liver lobe, followed by lesser omentum inspection (left aberrant hepatic artery), abdominal oesophagus dissection and cutting the right crus of the diaphragm are the steps that have to be taken to access the supraceliac abdominal aorta. Freed and marked, the supraceliac aorta will be cross-clamped with a clamp or ligated with ligature during cold perfusion.

Transplant Coordinator–Procurement Team: Bilateral Aid and Understanding, Before and During Abdominal Organ Procurement 1

Background: Organ procurement is the lifeblood of organ transplantation. A tense competitive atmosphere in the operating room and unprofessional communication skills between transplant coordinator and the members of organ retrieval team(s) may lead to inadequate preservation or surgical injury to the organs. At this stage, all mistakes, which have been made, can make an organ unsuitable for transplantation either due to impossible surgical reconstruction or because of damage – leading to serious complications in the recipient.