H.-H. Wang

Sirolimus Used During Pregnancy in a Living Related Renal Transplant Recipient: A Case Report

OBJECTIVES The majority of pregnancies after transplantation reported in the literature occurred in patients treated with a combination of calcineurin inhibitors, prednisolone, and azathioprine. There is little experience with newer drugs. We report a successful pregnancy in a kidney recipient with exposure to sirolimus-based immunosuppression. METHODS We describe a case of successful delivery in a 30-year-old woman who became pregnant 1 year and 8 months after a living related renal transplantation. She received sirolimus, cyclosporine, and prednisolone before conception and during the first and second trimesters of gestation. RESULTS The female recipient received sirolimus in combination with cyclosporine and prednisolone. During follow-up, her serum creatinine values were stable with pregnancy occurring at 1 year and 8 months after transplantation. At 27 gestational weeks, sirolimus was discontinued and she was maintained on cyclosporine and prednisolone. There were no signs or symptoms of graft rejection. A Cesarean section was performed at 39 weeks of gestation to deliver a healthy, 2994-g, Apgar 10, male infant. The renal function of the female recipient continued to be stable after delivery. CONCLUSION To date, pregnancies in renal transplant recipients are still considered high risk. The U.S. National Transplantation Pregnancy Registry (NTPR) has reported increased rates of maternal and fetal complications. There have been no live births reported to the NTPR about female recipients exposed to sirolimus throughout gestation. We report a live birth without a structural defects with successful delivery after sirolimus use during the first and second trimesters of gestation.

BK Virus Infection in Association With Posttransplant Urothelial Carcinoma

OBJECTIVE BK virus infection after transplantation is known to cause graft failure but the association with malignancies is controversial. METHODS BK virus workup was performed for kidney recipients in our center under conditions of hematuria or acute deterioration of graft function. We reviewed the history and reported our treatment and the disease course of three patients with BK virus later diagnosed with urothelial carcinoma. RESULTS All three patients received kidneys from China with immunosuppression using a calcineurin inhibitor and monoclonal antibodies. Synchronous bladder and upper-tract tumors were treated with surgery followed by intravesical chemotherapies. We tapered the immunosuppressants and changed to a sirolimus-based regimen. Intravesical chemotherapy and concurrent chemoradiotherapy were performed to prevent recurrence. All three patients now have functional grafts. CONCLUSION BK virus infection may lead to tumorigenesis. Besides decreasing immunosuppressants, we should be more alert to the detection of malignancies in BK virus-reactivated recipients. Early aggressive treatment may be curative, preserving functional grafts.

Techniques of vascular control in laparoscopic donor nephrectomy.

OBJECTIVES Laparoscopic donor nephrectomy has become the method of choice for removal of living donor kidneys. The ENDO GIA stapler is commonly used for division of the renal vessels, but it can lead to some loss of graft vascular length. Besides, stapler malfunction can occur. In this study, we report our experience using polymer locking clips for vascular control, compared with previous experience using the ENDO GIA stapler. MATERIALS AND METHODS Eleven donors underwent laparoscopic donor nephrectomy from November 2005 to September 2007. Both renal artery and vein were divided after 2 or more polymer locking clips had been applied on the donor side. The operative times, warm ischemia times, graft function, and vascular complications were compared with the previous 33 donors using the ENDO GIA stapler for renal vein control. RESULTS The operative and warm ischemia times were similar. With the polymer locking clip technique, we harvested nearly the entire renal vein length. There were no vascular complications or graft loss with the use of polymer locking clips. In our series, malfunction of the ENDO GIA stapler device occurred in 1 patient requiring the surgery to be converted to an open procedure. Both donor and recipient outcomes were similar no matter whether polymer locking clips or the ENDO GIA stapler was used for vascular control during the laparoscopic donor nephrectomy. CONCLUSION In our series, there were no vascular complications and no device failure during vascular control using polymer locking clips. We believe that polymer locking clips are safe, yielding greater vessel length during laparoscopic donor nephrectomy.

The impact of climate factors on the prevalence of urolithiasis in Northern Taiwan

Background: Urolithiasis is a common disease with high prevalence and recurrence. Its incidence varies in different geographic locations, and there are evidences that meteorological factors also affect urinary stone formation. The aim of this study is to analyze the effects of climate parameters on the numbers of shockwave treatments for urinary stones in our hospital, in order to understand the effects of these parameters on the prevalence of urolithiasis in northern Taiwan. Methods: We retrospectively reviewed the records of extracorporeal shockwave lithotripsy (ESWL) performed in our hospital from December 2006 to November 2011. Repeated ESWL performed in the same patient within 1 month was excluded, and we only counted as one ESWL in our study. Climate data of the corresponding months were collected from Central Weather Bureau. The available monthly meteorological data included highest, lowest, and average temperatures, humidity, rainfall, total rain days, sunshine hours, average atmospheric pressure, and wind speed. Results: Monthly ESWL number was positively correlated to temperature (r = 0.696), sunshine hours (r = 0.515), and wind speed (r = 0.369), while it was negatively correlated to humidity (r = -0.441) and atmospheric pressure (r = -0.568). Average monthly temperature had the strongest correlation to ESWL number (r2 = 0.484). Monthly rainfall and rain days were not significantly correlated to ESWL number. To investigate the climate parameters together, we introduced these correlated factors into the multivariate linear regression model which demonstrated only temperature (ß = 1.438, 95% CI: 3.703-9.144, p < 0.001) and atmospheric pressure (ß = 0.803, 95% CI: 0.790-5.428, p = 0.010) to be independently related to monthly ESWL number. Conclusion: Temperature and atmospheric pressure are associated with monthly ESWL number. Ambient temperature is the most important climate factor affecting the prevalence of urolithiasis in northern Taiwan.

Quality of Life After Laparoscopic Donor Nephrectomy

OBJECTIVES Distinct from cadaveric donor renal transplantation, living donor renal transplantation has many benefits for the recipient, such as a shorter waiting time as well as longer patient and graft survivals. But, there is no potential physical benefit for the donors. Many studies have shown that laparoscopic donor nephrectomy (LDN) resulted in a lower complication rate and shorter hospital stay compared with an open donor nephrectomy. The present study was performed to analyze the quality of life (QoL) among patients who underwent LDN. MATERIALS AND METHODS From November 2005 to December 2008, 14 patients who underwent LDN were enrolled in this study. We assessed the QoL of these patients before versus 3 months after the operation using the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36), which were expressed as a Physical Component Summary and a Mental Component Summary. We analyzed the association between QoL and donor age, gender, relationship to the recipient, and renal function. RESULTS The Physical Component Summaries showed a significant decrease from the values before kidney donation (92.9+/-5.0) to 3 months thereafter (80.4+/-16.6; P=.004). In addition, the Mental Component Summaries were also significantly decreased from 84.2+/-10.2 to 76.8+/-19.2 (P=.012). However, the changes of QoL were not significantly associated with donor age, gender, relationship to the recipient, or renal function after kidney donation. CONCLUSION This study revealed that kidney donation had negative impacts on donor QoL after LDN although renal function was well preserved. The QoL of a potential living donor must be evaluated carefully before transplantation.

Osteoporosis After Kidney Transplantation : Preliminary Report From a Single Center

OBJECTIVE One of the major adverse effects of kidney transplantation is osteoporosis, which is mainly related to steroid use. Only limited data are available on calcitonin therapy for posttransplantation osteoporosis. METHOD From March 2007 to August 2007, 67 kidney recipients agreed to enter this study. Dual energy X-ray absorptiometry (DEXA) was performed to evaluate bone mineral density (BMD) in the lumbar (L) spine and left femoral neck. We prescribed calcitonin nasal spray to osteoporosis patients (DEXA T < -2.5 SD) who agreed with the treatment. A second and a third DEXA were performed at 3-month subsequent intervals later to evaluate the therapeutic effects. RESULTS The incidence of osteoporosis in our kidney recipients was 46.26% (31/67 patients). Osteopenia accounted for 38.81% (26/67 patients) and only 14.93% (10/67 patients) were normal. Calcitonin inhalation seemed to improve the BMD with 61% showing improvement on the second DEXA study in our preliminary data. CONCLUSION Our preliminary data suggested that calcitonin may help to restore bone mass in kidney recipients with osteoporosis. Steroid elimination may prevent the onset of osteoporosis and might even enhance calcitonin efficacy. In the future we need a longer study period to confirm the results and compare it with the outcomes of bisphosphonates therapy.

The dilemma in the diagnosis of acute scrotum: clinical clues for differentiating between testicular torsion and epididymo-orchitis

BACKGROUND Acute painful scrotum is one of the most challenging urological emergencies. Irreversible parenchymal damage will develop if a testicle is twisted. The aim of the study was to determine the importance of different clinical clues to help differentiate the causes of this devastating condition. METHODS The medical charts of teenagers with acute scrotal pain between January 2003 and December 2008 were reviewed retrospectively. RESULTS Seventy-six patients were included in this study, including 47 initially suspected of having testicular torsion and 29 suspected of having epididymo-orchitis. Testicular torsion was confirmed in 39 of the suspected 47 cases after surgical exploration. Twnety-one of these 39 testicular torsion patients underwent orchiectomy, and 18 were rescued and underwent orchiopexy. The mean pain duration was significantly longer in the orchiectomy group than the orchiopexy group (38.05 hours vs 14.14 hours, p = 0.009). In the testicular torsion group, fewer patients had elevated C-reactive protein levels no patients had pyuria, and the pain duration was shorter compared with the epididymo-orchitis group (5/11 vs 13/22 [p = 0.045], 0/28 vs 8/28 [p = 0.004] and 27.0 vs 74.5 hours [p = 0.0003], respectively). The sensitivity of color Dopper ultrasound in diagnosing testicular torsion and epididymo-orchitis was 84.09% vs 92.59%. Logistic regression for multivariate analysis showed that left side manifestation and pain duration were significantly different between testicular torsion and epididymo-orchitis with odds ratios of 4.76, p = 0.020 and 0.98, p = 0.029, respectively. CONCLUSIONS Pain duration and left side manifestation are independent risk factors of testicular torsion. Prompt surgical exploration should be done if testicular torsion is highly suspected.

Change in Renal Function After Laparoscopic Donor Nephrectomy for Kidney Transplantation

BACKGROUND Laparoscopic donor nephrectomy (LDN) has become the method of choice for living-donor kidney transplantation. However, LDN may result in decreased renal function in the donor, and risk of end-stage renal failure has been reported. OBJECTIVE To evaluate changes in renal function after LDN. PATIENTS AND METHODS The study included 51 living donors of renal transplants between March 2002 and December 2008. Before kidney donation, we computed the initial function of the kidney preserved in the donor using 24-hour creatinine clearance (Ccr) and functional ratio as revealed at technetium 99m dimercaptosuccinic acid renal scanning. After kidney donation, serum creatinine concentration (sCr) and Ccr were calculated on postoperative day 2 and every 3 months thereafter. RESULTS After LDN, mean sCr increased immediately, from 0.90 to 1.31, as did Ccr of the kidney preserved in the donor, from 58.2 to 79.6, a 36.9% increase. A greater percent increase in function was observed in younger donors and those with lower initial Ccr of the preserved kidney. Although 9.8% of donors demonstrated slightly decreased renal function of the preserved kidney at last follow-up, renal function was adequately preserved in most donors. CONCLUSION Younger donors and those with lower initial function of the preserved kidney before nephrectomy demonstrate a greater increase in function after nephrectomy. Age might be a risk factor for decreased renal function after LDN. Older potential living donors may need more careful evaluation before kidney donation.

The New Body Mass Index System in Predicting Renal Graft Outcomes

BACKGROUND Obesity has been related to poor renal graft function. The aim of this study was to compare the long-term graft outcomes of living-related kidney recipients regarding donor-to-recipient body mass index (BMI) parameters using the old Quetelet BMI formula and the new Trefethen BMI formula. METHODS From November 2002 to November 2010, 62 consecutive living-related kidney transplantations were reviewed retrospectively. Four donor-to-recipient BMI parameters were used: (1) BMI difference by the old formula, (2) BMI difference by the new formula, (3) BMI ratio by the old formula, and (4) BMI ratio by the new formula. Long-term outcomes, including graft survival (GS) and rejection-free graft survival (RFGS) either overall or at 5 years post-transplantation, were analysed according to these parameters. RESULTS The baseline demography was similar among tertiles according to the four BMI parameters tested. Although there is no significant difference in the long-term survivals by the old and new BMI formula, we found that the area under receiver operating characteristic (ROC) curve is larger using the new formula, either by BMI difference (0.584 vs 0.559 in 5-year GS and 0.658 vs 0.636 in 5-year RFGS) or by BMI ratio (0.584 vs 0.561 in 5-year GS and 0.644 vs 0.626 in 5-year RFGS). The same trend was observed in overall survival outcomes. CONCLUSION The new Trefethen BMI formula seems to predict long-term renal graft outcomes better than the old Quetelet BMI formula.

A Simplified Preputial Covering Technique to Correct Buried Penis

Objective: We report on refinements of a technique for preputial covering to prevent complications of redundant prepuce, possibly caused by inadequate surgery for buried penis. Patients and Methods: From July 2006 to July 2008, 20 consecutive patients (mean age 4.3 years) underwent surgery for buried penis. The surgical techniques consisted of complete unfurling of the penile shaft, fixation of the penile base skin to Buck’s fascia and 1 pedicle flap for skin coverage. Our method for preputial covering is novel in that we create a unique 1-flap covering for the ventral skin defect. Patients were monitored postoperatively at 2 weeks, 1 month and 3 months. Results: All patients had good or excellent outcomes, with fewer postoperative complications. Two patients developed subcutaneous hematomas that resolved in 2 weeks with conservative treatment. The mean increase in length of penile projection after surgery was 1.7 cm, a statistically significant difference. All patients had good cosmetic results, with increased visualization of the penile shaft. Conclusions: The preputial covering technique we devised avoided postoperative bulky prepuce caused by residual redundant prepuce. Repeat surgery was also unnecessary for our patients. Furthermore, parents judged the cosmetic results as excellent.