J. Domínguez

Cost-benefit estimation of cadaveric kidney transplantation: the case of a developing country.

BACKGROUND In this paper we have estimated the cost savings for the health care system and quality-of-life improvement for patients from an increased number of kidney transplants in Chile. We compared the present value of dialysis and transplantation costs and quality of life over a 20-year horizon. METHODS We used Markov models and introduced some degree of uncertainty in the value of some of the parameters that built the model. Using Monte Carlo simulations, we estimated the confidence intervals for our results. RESULTS Our estimates suggested that a kidney transplant showed an expected savings value of US

Factors That Predict Duration of Delayed Graft Function in Cadaveric Kidney Transplantation

28,000 for the health care system. If the quality-of-life improvement was also considered, the expected savings rise to US

Renal Vein Extension Using Gonadal Vein: A Useful Strategy for Right Kidney Living Donor Harvested Using Laparoscopy

102,000. These results imply that increasing donation rate by 1 donor per million population would achieve an estimated cost saving of US

Effects of Immunosuppressive Drugs on Rat Renal Ischemia Reperfusion Injury

827,000 per year, or near US

Effectiveness of Different Kidney Exchange Mechanisms to Improve Living Donor Transplantation in Chile

3 million per year considering the effect on the quality of life. CONCLUSION These results demonstrated that kidney transplantation along with a better quality of life for patients are a cost-saving decision for developing countries.

A New Kidney Allocation Policy in Chile: Computer-Based Simulations

INTRODUCTION We have previously shown that the duration of delayed graft function (DGF) is a significant predictor of serum creatinine concentration at 1 year posttransplantation, which may be a surrogate marker for kidney survival after renal transplantation. OBJECTIVE To identify donor and recipient characteristics that influence the duration of DGF in a 2-center study. PATIENTS AND METHODS This retrospective analysis of 212 consecutive cadaveric renal transplant procedures examined the following variables: donor and recipient age and sex, cause of death (cerebrovascular accident or trauma), donor creatinine and sodium concentrations, multiorgan or kidney-only donor use, type of vasoactive drugs, cold ischemia time, percent reactive antibodies, and HLA mismatch. RESULTS Overall, 30.5% of recipients experienced DGF with a mean (SD) duration of 4.4 (8) days. At univariate analysis, the use of norepinephrine in the donor and increased cold ischemia time were associated with longer DGF duration. However, at multivariate analysis, none of the factors studied was significant. CONCLUSIONS The duration of DGF may be associated with longer cold ischemia time, which emphasizes the need to shorten this period insofar as possible to improve long-term results. The association of use of norepinephrine and prolonged DGF should be observed carefully because it may be that use of this drug is related to worse hemodynamics in the donor and not to deleterious effects of the drug per se.

Association of a single-nucleotide polymorphism from chromosome 17q12 with the aggressiveness of prostate cancer in a Hispanic population

INTRODUCTION Vascular management of the right renal vein during laparoscopic living donor nephrectomy is still an unsolved problem. This short vessel has limited the use of right kidneys. However, the right kidney should be harvested in some instances. Based on experience in open donor nephrectomy, our unit has used the donor gonadal vein to obtain a longer renal vein in this setting. METHODS Four consecutive living related donors with the indication for laparoscopic right nephrectomy underwent this procedure. Three donors were females and the overall average age was 48.5 years. The renal vein was controlled with a 30-mm stapler and we included 5-6 cm of the ipsilateral gonadal vein during the harvest. The donor kidney was perfused and renal vessels prepared under cold conditions. The gonadal vein was opened longitudinally and sutured to the donor right renal vein as a wide tube in 3 cases and as a spiral tube in 1 case with 6-0 monofilament suture. RESULTS This procedure extended the bench work between 25 to 40 minutes permitting an 2.5- to 3.5-cm extension of the donor vein. The transplantations were performed in the usual mode and the vein enlargement enormously facilitated the implantation surgery. All recipients displayed immediate graft function; no complications were observed with this strategy. CONCLUSIONS Vein extension with the gonadal vein was a simple, safe method to enlarge the renal vein among right living donor kidneys procured using laparoscopy.

Cost-Effectiveness of Policies Aimed at Increasing Organ Donation: The Case of Chile

INTRODUCTION Recent evidence has demonstrated that the immune response and, more specifically, lymphocytes (T and B) and dendritic cells participate as mediators of renal ischemia reperfusion injury (IRI). The aim of this study was, therefore, to evaluate the effect of various immunosuppressive drugs with known activity to prevent IRI among rats undergoing a scheme that is potentially applicable in the clinic. METHODS Male Sprague-Dawley rats (200-300 g) underwent 60 minutes of ischemia by renal artery clamping and contralateral nephrectomy. The experimental groups (n = 6-7) were as follows: I, Sham; II, Control; III, Rapamycin (R; 1 mg/kg); IV, Methylprednisolone (M; 15 mg/kg); V, Vitamin D3 (VD3; 2 microg/kg); VI, VD3 (1 microg/kg); and VII, M (15 mg/kg) + R (1 mg/kg). Each drug was administered in 2 doses at 6 hours and 1 hour before surgery. Creatinine (Cr) was determined on days 0.1, 2, 3, 5, and 7, and Cr clearance was determined on days 3 and 7. At 7 days nephrectomy was performed to obtain samples for histology to evaluate the degree of acute tubular necrosis. RESULTS Mortality from renal insufficiency was between 0 and 33%, except in group V (66%; 4/6; P = .01). Kidney function was similar to controls in all groups except for creatinine at 7 days between group VI (VD3) and control (1.05 vs 0.65; P < .05) but no difference in Cr clearance. Histologically moderate to severe renal damage was greater in groups V and VI (VD3) than controls (P = .04). CONCLUSION We observed that none of the drugs conferred protection against IRI in a time setting relevant to kidney transplantation. Controversy exists regarding R, because some prior studies have shown a deleterious effect on IRI injury, although we did not observe any deleterious effect.

Obtención de cultivos primarios de estroma prostático benigno y tumoral mediante explantes de tejido desde biopsias por punción

INTRODUCTION Chile has a low cadaveric organ donation rate; at the same time, living donor transplantation activity is also low. The purpose of this study was to analyze the impact on the number and quality of transplants using various mechanisms for kidney exchange from living donors to patients on Chiles waiting list. METHODS A computerized model was developed to simulate five options for living kidney donation: (1) direct donation; (2) direct donation plus pairwise and three-way exchanges; (3) pairwise exchange; (4) three-way exchange; and (5) allocation of donors based on the top trading cycles (TTC) mechanism. We calculated the projected number of transplantations, adjusting for the risk of a positive crossmatch, as well as the average quality in terms of the human leukocyte antigen (HLA) match. RESULTS If all patients on the waiting list have a willing direct donor, 47.7% of patients will receive a transplant. Allowing for incompatible pairs or pairs with a positive crossmatch an exchange of kidneys, can increase the number to 51.8%. This figure rises to 60% or 61% for pairwise or three-way exchanges, respectively. Although TTC ensures that 55% of the patients could be transplanted, the graft quality is better with an average HLA match of 3.5 versus 1.25. CONCLUSIONS These results showed that kidney exchange mechanisms can increase the number of living donor transplantations by 4% and 13%.

OBTENCIÓN DE CULTIVOS PRIMARIOS DE ESTROMA PROSTÁTICO BENIGNO Y TUMORAL MEDIANTE EXPLANTES DE TEJIDO DESDE BIOPSIAS POR PUNCIÓN OBTAINING PRIMARY CULTURES OF BENIGN AND TUMORAL PROSTATIC STROMAL TISSUE THROUGH EXPLANTS FROM NEEDLE BIOPSIAS

INTRODUCTION Kidney allocation should reach a balance between equity and efficiency. In Chile kidneys are allocated based on ABO matching, first to medical priorities and then according to a point scheme considering human leukocyte antigen (HLA) match (60%), waiting list time (20%), and panel-reactive antibodies (PRA; 20%); pediatric recipients receive extra points. A new policy maintains ABO matching and medical priorities as the first step, but incorporates other successive steps: previous living donors donors, 0 mismatch, pediatric recipients, and finally all other recipients according to a point scheme incorporating recipient age, HLA match, PRA, and time on waiting list with similar proportions. We compared the resulting transplantations using the new versus the older allocation policy. METHODS We analyzed computer-generated simulations using actual patients (N = 1176) on the Chilean waiting list in 2011 with the 300 donors over the previous 3 years. RESULTS The new policy a significantly decreased recipient age from 43 ± 0.3 years to 41 ± 0.3 and increased the number of 0-mismatched transplantations from 3% to 4%. The mean HLA mismatch increased from 2.8 ± 0.1 to 3.6 ± 0.1. Waiting time increased from a mean of 38 ± 1 months to 40 ± 1 months, but patients remaining on the waiting list had less waiting time with the new rule. CONCLUSIONS With the proposed changes younger patients are being privileged and the importance of compatibility is diminished (except for 0-mismatched transplantations). The chance of a good match is directly related to the size of the recipient pool, thus an allocation policy that privileges HLA matching in a restricted recipient pool is especially unfavorable for younger patients. Including age of the recipient as a continuum can help to compensate for this lack of equity. Computer-generated simulations can help discern which policies are best suited for each country based on their local characteristics.