D. Castelo

Pretransplantation overweight and obesity: does it really affect kidney transplantation outcomes?

OBJECTIVE The objective of this study was to compare kidney transplant outcomes among pretransplantation overweight and obese patients with those with normal weight. METHODS We performed a retrospective analysis of a sample of 448 kidney transplantations performed between 1984 and 2008 in our institution. We compared of initial graft function, postoperative length of stay, surgical complications, acute and chronic rejection rates, creatinine serum levels, and patient and graft survival, between normal weight, overweight, and obesity groups. RESULTS Overweight was detected on 28.3% of the patients, and obesity on 5.8%. A male predominance was noted among the normal and overweight groups, and the opposite in the obesity group: namely, male:female ratios of 2.17:1, 3.37:1, and 0.37:1, respectively. Mean age was lower in the normal weight group (41.51 years) versus 48.36 and 46.08 years in the overweight and obesity groups, respectively. Compared with the normal weight group, recipient creatinine serum levels between 1 and 6 months were higher among the obese group, but not the overweight one. Both overweight and obese groups showed significantly higher incidences of delayed graft function (26.8% and 26.9%, respectively) versus 16.9% in the normal weight group (P = .028) and longer surgery times, ie, greater than 3 hours in 22.8% and 42.3%, respectively, versus 20.7% of the normal weight patients. Surgical complication rates were higher in both non-normal weight groups (17.3% and 26.9% vs 15.9% in the normal weight group), especially lymphocele formation and wound dehiscence (P = .031 and P < .0005, respectively). However, no differences were detected concerning postoperative length of stay, graft loss, acute or chronic rejection, and graft or patient survival. CONCLUSION Pretransplantation overweight and obesity did not seem to significantly affect kidney transplantation in the medium and long terms. The early posttransplantation period can however be disturbed by an increased incidence of surgical complications and reversible degradation of some graft functional parameters.

Do Intraoperative Hemodynamic Factors of the Recipient Influence Renal Graft Function

PURPOSE To assess the importance of intraoperative management of recipient hemodynamics for immediate versus delayed graft function. METHODS The retrospective study of 1966 consecutive renal transplants performed in our department between June 1980 and December 2009 analyzed several perioperative hemodynamic factors: central venous pressure (CVP), mean arterial pressure (MAP) as well as volumes of fluids, fresh frozen plasma (FFP), albumin, and whole blood transfusions. We examined their influence on renal graft function parameters: immediate diuresis, serum creatinine levels, acute rejection, chronic transplant dysfunction, and graft survival. RESULTS Mean CVP was 9.23 ± 2.65 mm Hg and its variations showed no impact on graft function. We verified a twofold greater risk of chronic allograft dysfunction among patients with CVP ≥ 11 mm Hg (P < .001). Mean MAP was 93.74 ± 13.6 mm Hg; graft survivals among subjects with MAP ≥ 93 mm Hg were greater than those of patients with MAP < 93 mm Hg (P = .04). On average, 2303.6 ± 957.4 mL of saline solutions were infused during surgery. Patients who received whole blood transfusions (48%) showed a greater incidence of acute rejection episodes (ARE) (P = .049) and chronic graft dysfunction (P < .001). Patients who received FFP (55.7%), showed a higher incidence of ARE (P < .001). Only 4.6% of patients (n = 91) received human albumin with a lower incidence of ARE (P = .045) and chronic graft dysfunction (P = .024). Logistic binary regression analysis revealed that plasma administration was an independent risk factor for ARE (P < .001) and chronic dysfunction (P = .028). Volume administration (≥ 2500 mL) was also an independent risk factor for chronic allograft dysfunction (P = .016). Using Cox regression, we verified volume administration ≥ 2500 mL to be the only independent risk factor for graft failure (P < .001). CONCLUSION MAP ≥ 93 mm Hg and perioperative fluid administration <2500 mL were associated with greater graft survival. Albumin infusion seemed to be a protective factor, while CVP ≥ 11 mm Hg, whole blood, and FFP transfusions were associated with higher rates of ARE and chronic graft dysfunction.

Ureteric Stent in Renal Transplantation

INTRODUCTION Several techniques can be used to accomplish the ureteroneocystostomy in kidney transplantation. A ureteral catheter is a prophylactic measure to avoid urological complications (UC) of stenosis and/or fistula. In this study we evaluate the influence of using a ureteral stent upon the rate of UC in renal transplantation. PATIENTS AND METHODS Retrospective review of 2061 kidney transplants (75 living and 1986 cadaveric donors) for 1360 male and 684 female recipients, from July 14, 1991, to January 13, 2012, with a minimum follow-up of 6 months A double J stent (JJ) was used in 1890 an external tumor (ET) catheter in 52 and no catheter (NC) in 119 cases. RESULTS Mean recipient age was 44.66 ± 13.66 years. UC occurred in 5.9% among which ET showed 17.3%, 8.4% for NC, and 5.4% for JJ (P < .0005). Urological complications were more frequent when surgery duration exceeded 3 hours (8.8% vs 5.3% ≤ 3 hours; P = .003), using older donors organs (P = .048) and with higher donor weight (P = .009). No differences were observed related to recipient age, gender, or weight; donor gender; pretransplant dialysis time; cold ischemia time; type of donor (living vs cadaveric); number of HLA matches; or initial immunosuppression (mammalian target of rapamycin inhibitor vs other). On multivariate analysis, donor weight (odds ratio [OR]: 1.023; P = .015), use of a JJ vs ET (OR: 0.280; P = .005), and surgery time exceeding 3 hours (OR: 3.270; P < .0005) were independently associated with UC. CONCLUSIONS Catheterization of the urinary anastomosis with a JJ was associated with fewer UC. This is especially important for grafts from heavier donors. The use of an external catheter which was associated with an high rate of UC, should be avoided.

Does Multiorgan Versus Kidney-Only Cadaveric Organ Procurement Affect Graft Outcomes?

INTRODUCTION The majority of kidney grafts in most European countries still come from deceased donors who provide other organs. We analyzed whether multiorgan procurement portends a worse functional outcome compared with kidney-only harvesting. METHODS We performed a retrospective analysis of 1043 consecutive brain-dead donor kidney transplantations performed at a single academic institution from September 2002 to June 2011. The graft outcomes using kidney-only donors (n = 243) were compared with multiorgan donor grafts (n = 800) analyzing donor age, gender, cause of death, duration of mechanical ventilation, renal function, and cold ischemic interval. We compared delayed graft function and serum creatinine values at 1, 3, 6, and 12 months posttransplantation as well as graft survivals. This methodology was also applied to the subset of expanded criteria donors: 179 kidney-only versus 474 multiorgan. The influence of donor variables on graft survival was also analyzed in a Cox regression model. Immunosuppressive regimens and preservation solutions were similar in both groups. RESULTS Kidney-only donors were older than their multiorgan counterparts (53.1 versus 44.8, P < .0005) and predominantly male (76.5% versus 62.6% male donors, P < .0005). Other donor variables were comparable. Kidney-only donor grafts showed a slightly higher incidence of delayed function (27.2 versus 21.1%, P = .049), but the mean serum creatinine values were similar at all intervals. No differences were observed in 7-year graft survival: 80.7% versus 79.9%. Expanded criteria donor grafts showed overlapping results, except for a higher rate of donor oligoanuria and a lower 1-month mean creatinine among kidney-only donors. Multivariate analysis revealed that the number of harvested organs did not influence graft survival. DISCUSSION Immediate and long-term outcomes of kidney grafts did not correlate with the number of organs harvested from the donor. The longer explantation time associated with multiorgan procurement did not seem to affect graft function.

916 Pretransplant biopsy in expanded criteria donors. Do we really need it

Introduction. Renal transplantation is the best treatment for end-stage renal disease, including when using expanded criteria donors (ECD) kidneys. However, these suboptimal kidneys should be evaluated rigorously to meet their usefulness. Opinions differ about the best way to evaluate them. Materials and Methods. We retrospectively reviewed kidneys from ECD harvested by a single academic institution between January 2008 and September 2013. Needle biopsies were performed at the time of the harvest when considered relevant by the transplant team. Two pathologists where responsible for their analysis; the Remuzzi classification has been used in all cases. Results. We evaluated 560 ECD kidneys. Biopsies were made in 197 (35.2%) organs, 20 of which were considered not usable and 36 good only for double transplantation. Sixty-three kidneys (11.3%) were discarded by the transplant team based on the biopsy result and clinical criteria. Donors who underwent a biopsy were older (P < .001) and had a worse glomerular filtration rate (GFR; P 1⁄4 .001). Comparing donors approved and rejected by the biopsy, the rejected donors were heavier (P 1⁄4 .003) and had a lower GFR (P 1⁄4 .002). Cold ischemia time was longer for the biopsy group (P < .001). Regarding graft function, the biopsy overall score correlated with the transplant outcome in the short and long term. Separately, glomeruli and interstitium scores were correlated with recipient’s GFR in the earlier periods (3 months; P 1⁄4 .025 and .037), and the arteries and tubules correlated with GFR in the longer term (at 3 years P 1⁄4 .004 and .010). Conclusion. The decision on the usability of ECD grafts is complex. At our center, we chose a mixed approach based on donor risk. Low-risk ECD do not require biopsy. In more complex situations, especially older donors or those with a lower GFR, prompted a pretransplant biopsy. The biopsy results proved to be useful as they relate to subsequent transplant outcomes, thereby allowing us to exclude grafts whose function would most probably be less than optimal.

Tratamento da litíase urinária por cálculos de cistina – Análise retrospectiva observacional

Resumo Introducao : Os doentes com cistinuria e litiase urinaria necessitam de multiplos tratamentos, dada a dureza relativa destes calculos e a natureza recidivante da doenca. Materiais e metodos : Os doentes submetidos a tratamento invasivo de calculos urinarios de cistina na nossa instituicao entre janeiro de 2006 e marco de 2013 foram analisados retrospectivamente. Consideraram-se nesta analise os tratamentos medicos e cirurgicos e os resultados relativos a fragmentacao / remocao completa dos calculos e evolucao da funcao renal. Resultados : Entre janeiro de 2006 e marco de 2013, 7 doentes foram submetidos a tratamentos invasivos na nossa instituicao por litiase urinaria cistinurica. Destes doentes, 4 eram do sexo masculino e 3 do sexo feminino, com uma media de idade a data do ultimo seguimento de 39 anos (min = 19; max = 59). A terapeutica medica consistiu em hidratacao oral abundante (nao quantificada), restricao de sodio na dieta e alcalinizacao da urina (todos os 7 doentes), captopril (6 doentes) e penicilamina (1 doente). Estes 7 doentes foram submetidos a um total de 156 procedimentos, com uma media de 22.3 procedimentos por doente no intervalo de tempo considerado. Todos os doentes realizaram litotricia extracorporea, com uma media de 20 tratamentos por doente (min = 8; max = 35). Os procedimentos cirurgicos incluiram ureterorrenoscopia com litotricia de contacto (9 tratamentos em 4 doentes; media = 2; min = 1; max = 4), nefrolitotomia percutânea (3 cirurgias em 3 doentes), pielolitotomia (2 cirurgias em 2 doentes; uma aberta e outra laparoscopica) e uma nefrectomia aberta (doente septico e com rim nao funcionante no momento do diagnostico). Tres doentes mantiveram-se sem litiase residual nos ultimos 12 meses; todos foram submetidos a nefrolitotomia percutânea ou pielolitotomia. Tres doentes foram submetidos a cintigrafias renais seriadas ao longo do periodo em estudo. Apesar das multiplas intervencoes, 2 doentes mantiveram a funcao renal global e diferencial estavel ao longo de 6 anos e 1 doente ao longo de 2 anos de seguimento. Conclusoes : Na nossa serie, foram necessarios procedimentos cirurgicos mais invasivos (nefrolitotomia percutânea ou pielolitotomia) para reducao significativa ou para eliminacao completa da carga litiasica. A terapeutica medica continuada ao longo do tempo e os procedimentos minimamente invasivos seriados, em especial a litotricia extracorporea, foram essenciais para prevencao da recidiva e tratamento da litiase residual. Apesar dos multiplos procedimentos com potencial efeito deleterio para a funcao renal, nos doentes analisados esta nao foi afectada pela doenca ou pelo seu tratamento agressivo ao longo de um intervalo de varios anos.