Christoph Troppmann

Higher surgical wound complication rates with sirolimus immunosuppression after kidney transplantation: A matched-pair pilot study

Sirolimus, a potent new immunosuppressant, has been anecdotally associated with surgical wound complications. We studied postoperative surgical wound complications in 15 kidney recipients receiving sirolimus, prednisone, and tacrolimus or cyclosporine (study group) compared with 15 recipients receiving tacrolimus, prednisone, and mycophenolate mofetil who were pair-matched for surgical wound complication risk factors. Surgical wound complications were defined as any complication related to the surgical transplant wound requiring reintervention. Fifty-three percent of the study group and 7% of the control group experienced more than one surgical wound complication (P =0.014), and the relaparotomy incidence was 33% and 7%, respectively. Four graft losses have occurred since the beginning of the study: one chronic rejection and two deaths with function in the study group, and one death with function in the control group. At 1 year, graft survival for study recipients compared with control recipients was 87% and 93%, respectively; patient survival was 93% in both groups. Recipients receiving sirolimus demonstrated a significantly higher surgical wound complication rate, but graft and patient survival were not affected. Peritransplant immunosuppression with sirolimus and steroids warrants careful consideration, particularly in recipients with surgical complication risk factors.

Laparoscopic (vs open) live donor nephrectomy: a UNOS database analysis of early graft function and survival.

The impact of laparoscopic (lap) live donor nephrectomy on early graft function and survival remains controversial.

Women Surgeons in the New Millennium

BACKGROUND Women are increasingly entering the surgical profession. OBJECTIVE To assess professional and personal/family life situations, perceptions, and challenges for women vs men surgeons. DESIGN National survey of American Board of Surgery-certified surgeons. PARTICIPANTS A questionnaire was mailed to all women and men surgeons who were board certified in 1988, 1992, 1996, 2000, or 2004. Of 3507 surgeons, 895 (25.5%) responded. Among these, 178 (20.3%) were women and 698 (79.7%) were men. RESULTS Most women and men surgeons would choose their profession again (women, 82.5%; men, 77.5%; P = .15). On multivariate analysis, men surgeons (odds ratio [OR], 2.5) and surgeons of a younger generation (certified in 2000 or 2004; OR, 1.3) were less likely to favor part-time work opportunities for surgeons. Most of the surgeons were married (75.6% of women vs 91.7% of men, P < .001). On multivariate analysis, women surgeons (OR, 5.0) and surgeons of a younger generation (OR, 1.9) were less likely to have children. More women than men surgeons had their first child later in life, while already in surgical practice (62.4% vs 32.0%, P < .001). The spouse was the offsprings primary caretaker for 26.9% of women surgeons vs 79.4% of men surgeons (P < .001). More women surgeons than men surgeons thought that maternity leave was important (67.8% vs 30.8%, P < .001) and that child care should be available at work (86.5% vs 69.7%, P < .001). CONCLUSIONS Women considering a surgical career should be aware that most women surgeons would choose their profession again. Strategies to maximize recruitment and retention of women surgeons should include serious consideration of alternative work schedules and optimization of maternity leave and child care opportunities.

Laparoscopic Live Donor Nephrectomy: A Risk Factor for Delayed Function and Rejection in Pediatric Kidney Recipients? A UNOS Analysis

The impact of laparoscopic (vs. open) donor nephrectomy on early graft function and survival in pediatric kidney recipients (≤18 years) is unknown.

Similar Long-Term Outcomes for Laparoscopic Versus Open Live-Donor Nephrectomy Kidney Grafts : An OPTN Database Analysis of 5532 Adult Recipients

Prior studies that included both adult and pediatric recipients suggested slower early graft function for laparoscopically (vs. openly) procured live donor kidney grafts (LD-Ktxs). Any potential long-term impact, however, remains unknown. We compared long-term outcomes of 2685 (49%) laparoscopic vs. 2847 (51%) open LD-Ktxs reported to the Organ Procurement and Transplantation Network performed in adult (≥18 yrs) recipients between November 1999 and December 2000, with follow-up to February 2006. Acute and chronic rejection accounted for 152 laparoscopic (51%) vs. 148 (46%) open graft losses (P=NS). At discharge and at 5 years, graft function was similar for both groups; graft survival at 5 years was 79% (laparoscopic) vs. 80% (open) (P=NS). We conclude that despite prior reports of slower early laparoscopic LD-Ktx function, both laparoscopic and open nephrectomy are equally effective for procurement of kidneys for adult recipients with regard to short- and long-term (>5 years) function and survival. Future studies must investigate whether these findings apply also to pediatric LD-Ktx recipients.

Renal Transplant Wound Complications in the Modern Era of Obesity

BACKGROUND Obesity is a known risk factor for wound complications following kidney transplantation (KTX), and obese transplant candidates are often encouraged to lose weight. The implications of this weight loss for post-KTX wound healing and morbidity have not been examined. Our aim was to study potential risk factors for post-KTX wound complications, with a specific focus on a history of significant weight loss. METHODS Single-center retrospective review of all KTX recipients ≥ 18 y performed 04/2004-03/2009. We studied potential donor-, transplant-, and recipient-related risk factors for wound complications by univariate and multivariate analyses. Graft and patient survival comparisons were done by Kaplan-Meier curves and two-sided log-rank test. RESULTS Overall wound complication incidence among the 487 study recipients was 6.4%. Significant independent risk factors for wound complications were BMI (odds ratio [OR] = 1.14 per 1 kg/m(2) increase), and history of significant weight loss (OR = 13.46), peri-KTX transfusion (OR = 5.42), and desensitization (OR = 60.34). Wound complications had no significant impact on graft and patient survival. CONCLUSIONS Our study demonstrates for the first time that besides BMI, pre-KTX desensitization, and peri-KTX transfusion, a history of significant pre-KTX weight loss is also an independent risk factor for post-KTX wound complications (potentially at least in part due to body contour changes resulting in an unfavorable abdominal panniculus). Further study of KTX candidates who have lost a significant amount of weight is warranted to (1) identify the exact causes for their increased propensity for complications and (2) devise measures to minimize added cost and morbidity. Finally, our findings suggest that the impact of weight loss on the outcomes of non-transplant operations also warrants further investigation.

The transition from laparoscopic to retroperitoneoscopic live donor nephrectomy: a matched pair pilot study.

Background. Retroperitoneoscopic live donor nephrectomy (RetroNeph) offers an intrinsic advantage over conventional transperitoneal laparoscopic nephrectomy (LapNeph) because of the potentially lower risk for early and late intraperitoneal donor complications. RetroNeph, however, is infrequently performed and has not been systematically and directly compared with LapNeph in nonselected donors. Methods. In November 2007, after 10 years of programmatic experience with transperitoneal LapNeph, we implemented RetroNeph at once for all live donor nephrectomies. Donor selection criteria, laparoscopic port positions, and hand-assistance mode were identical for RetroNeph and preceding LapNeph donors. We compared outcomes of retroperitoneoscopically completed cases with those of previous transperitoneal LapNeph cases that were pair matched for donor sex, body mass index, and donor kidney laterality. Results. Of the first 52 donor nephrectomies (48 left, 4 right) consecutively started with the intent to perform a RetroNeph November 2007 to April 2009, 45 (87%) were completed retroperitoneoscopically, and seven (13%) were switched intraoperatively to transperitoneal LapNeph. We observed no conversions to open nephrectomy, donor blood transfusions, readmissions, or reoperations. Matched-pair analysis of the 45 RetroNeph versus 45 LapNeph cases showed no significant differences for warm ischemia time and other donor outcomes, delayed graft function rates, recipient creatinine at 1 week, and 1-year graft survival. Conclusions. Implementation of a RetroNeph program had no adverse impact on donor morbidity and quality of early graft function. Our pilot experience suggests that the RetroNeph learning curve is short. Given the potential advantages of an extraperitoneal approach for the donor, RetroNeph is an attractive alternative to LapNeph, particularly for surgeons with previous LapNeph experience.

Real-time assessment of in vivo renal ischemia using laser autofluorescence imaging

Potentially transplantable kidneys experience warm ischemia, and this injury is difficult to quantify. We investigate optical spectroscopic methods for evaluating, in real time, warm ischemic kidney injury and reperfusion. Vascular pedicles of rat kidneys are clamped unilaterally for 18 or 85 min, followed by 18 or 35 min of reperfusion, respectively. Contralateral, uninjured kidneys serve as controls. Autofluorescence and cross-polarized light scattering images are acquired every 15 s using 335-nm laser excitation (autofluorescence) and 650+/-20-nm linearly polarized illumination (light scattering). We analyze changes of injured-to-normal kidney autofluorescence intensity ratios during ischemia and reperfusion phases. The effect of excitation with 260 nm is also explored. Average injured-to-normal intensity ratios under 335-nm excitation decrease from 1.0 to 0.78 at 18 min of ischemia, with a return to baseline during 18 min of reperfusion. However, during 85 min of warm ischemia, average intensity ratios level off at 0.65 after 50 min, with no significant change during 35 min of reperfusion. 260-nm excitation results in no autofluorescence changes with ischemia. Cross-polarized light scattering images at 650 nm suggest that changes in hemoglobin absorption are not related to observed temporal behavior of the autofluorescence signal. Real-time detection of kidney tissue changes associated with warm ischemia and reperfusion using laser spectroscopy is feasible. Normalizing autofluorescence changes under 335 nm using the autofluorescence measured under 260-nm excitation may eliminate the need for a control kidney.

Pretransplant recipient cytomegalovirus seropositivity and hemodialysis are associated with decreased renal allograft and patient survival

Background. Pretransplant systemic inflammation has been associated with decreased renal allograft survival, and infectious agents such as cytomegalovi-rus (CMV) may play a role. We hypothesized that pretransplant CMV seropositivity is a risk factor for decreased patient and allograft survival after cadaveric renal transplantation and that other factors believed to modulate systemic inflammation, such as dialysis modality, might act synergistically with CMV to decrease patient and allograft survival. Methods. The United Network for Organ Sharing database was reviewed to identify all patients undergoing cadaveric renal transplantation in the United States from 1988 to 1997. Outcomes for CMV seropositive and seronegative recipients of organs from CMV seronegative donors were analyzed. Subgroup analysis was performed to identify any synergistic influence on outcome between CMV serostatus and known determinants of risk, including degree of human leukocyte antigen mismatch, pretransplant dialysis, and cold ischemia time. Results. Of 29,875 patients who underwent transplantation, 12,239 were CMV seronegative and 17,636 were CMV seropositive. Patient survival was decreased by pretransplant seropositivity (relative risk [RR] 1.11, P =0.001). In addition, this group demonstrated worse overall allograft survival (RR 1.05, P =0.029), although this adverse effect disappeared when patients who died with a functioning graft were censored. Decreased allograft survival was most pronounced in patients who were on hemodialysis before transplantation (RR 1.62, P =0.004). Conclusions. Pretransplant CMV seropositivity is associated with decreased patient survival. Pretransplant CMV seropositivity and hemodialysis have a synergistic adverse effect on graft survival, independent of patient mortality. Additional studies are required to define mechanisms by which pretransplant CMV infection and dialysis modality may contribute to decreased allograft survival.

Use of FK506 in pancreas transplantation

Abstract  Until recently, FK 506 was used only for rescue therapy after pancreas transplantation. We report our initial experience with FK 506 for 67 pancreas recipients (treated between 1 May 1993 and 30 April 1995). Of these recipients, 49 (73 %) received FK.506 for induction and maintenance therapy, 12 (18 %) for rescue or antirejection therapy, and 6 (9 %) for reasons other than rescue or antirejection therapy. In our induction and maintenance therapy group, 32 recipients (65 %) underwent a simultaneous pancreas‐kidney transplant (SPK), 8 (16 %) a pancreas transplant alone (PTA), and 9 (19 %) a pancreas after previous kidney transplant (PAK). Quadruple immunosuppression was used for induction; the median FK 506 starting dose was 4 mg/day p. 0. and target levels were 10–20 ng/ ml. The most common side effects were nephrotoxicity (16 %) and neurotoxicity (14 %); transient episodes of hyperglycemia were also noted (12 %), in particular in the presence of concurrent rejection and infection episodes. A matched‐pair analysis was done to compare graft outcome with FK506 versus cyclosporin A (CsA). For SPK recipients, pancreas graft survival at 6 months was 79 % with FK506 versus 65 % with CsA (P= 0.04), for PTA, 100 % versus 63 % (P > 0.35), and for PAK, 88 % versus 33 % (P > 0.01). Pancreas graft loss due to rejection at 6 months posttransplant was lower with FK 506 versus CsA. Two FK506 recipients died from B‐cell lymphomas (Epstein‐Barr virus positive) at 6 and 7 months post‐transplant. In our rescue or anti‐rejection group, 5 recipients underwent SPK, 3 PTA, and 4 PAK. The mean average FK506 dose was 10 mg/day p. o. and the mean average FK506 blood level was 11 ng/ml. The most common side effects were nephrotoxicity (33 %) and neurotoxicity (16 %). Two recipients developed hyperglycemic episodes, of whom 1 has remained on insulin with good exocrine pancreas graft function. Graft survival at 6 months after conversion was 75 % for SPK, 67 % for PTA, and 50 % for PAK. Only one graft was lost due to chronic rejection. Our single‐center experience shows that FK 506 after pancreas transplantation is associated with: (1) a low rate of graft loss due to rejection when used for induction, in particular for solitary pancreas transplants, (2) a high rate of graft salvage when used for rescue, (3) a 1 % rate of new‐onset insulin‐dependent diabetes mellitus, and (4) a 3 % rate of posttransplant lymphoma. Further studies are necessary to analyze the long‐term impact of FK 506 on pancreas transplant outcome.