J Lawen

Extravesical ureteroneocystostomy with and without internalized ureteric stents in pediatric renal transplantation

Abstract: The use of ureteric double‐J stents and the Lich‐Gregoir (extravesical) technique of ureteroneocystotomy have both been shown to decrease the rate of urologic complications in adult kidney transplantation (Tx). There are, however, few studies of the systematic use of stents in pediatric renal Tx. Between 1991 and 1997, 32 consecutive pediatric renal transplant recipients routinely received a 6F‐12 cm indwelling double‐J stent and were studied prospectively. These patients were compared with 32 consecutive pediatric recipients in whom a stent was not used. The latter were transplanted between 1987 and 1991 and formed the control group. All patients had a Lich‐Gregoir ureteroneocystotomy. Stents were removed under general‐anesthetic cystoscopy 2–3 weeks after Tx. Immunosuppression for stented patients was polyclonal antibody induction, delayed (7–10 days) cyclosporin A, azathioprine, and prednisone. The control group received the same triple drug regimen but with no induction in 29 of the 32 patients. All patients were followed‐up with at least one ultrasound evaluation in the first month, and a renal scan and repeat ultrasound were performed if there was any rise in serum creatinine. In the stented group there were two patients with urinary leak and no obstructions. In the non‐stented group there were no leaks and one obstruction. There was no graft loss owing to urologic complications in either group. There were three cases of stent expulsion (all in girls) and one case of stent migration in the posterior urethra (a boy). The 1‐yr graft survival rate was 90.6% in the stented group and 65.6% in the non‐stented group. The prophylactic use of an indwelling ureteral stent in pediatric renal Tx did not reduce the risk of urinary leakage or obstruction. Stent migration is a common phenomenon and, while not a serious complication, is traumatic to children. Furthermore, removal of an internalized double‐J stent requires a general anesthetic. We recommend using a stent for selected patients only.

The impact of vascular anastomosis time on early kidney transplant outcomes

BackgroundMost studies have found cold ischemic time to be an important predictor of delayed graft function in kidney transplantation. Relatively less is known about the warm time associated with vascular anastomosis and early outcomes.MethodsA retrospective cohort of 298 consecutive solitary deceased donor kidney recipients from January 2006 to August 2012 was analyzed to examine the association between anastomosis time and delayed graft function (need for dialysis) and length of hospital stay.ResultsDelayed graft function (DGF) was observed in 56 patients (18.8%). The median anastomosis time was 30 minutes (interquartile range 24, 45 minutes). Anastomosis time was independently associated with DGF in a multivariable, binary logistic regression analysis (odds Ratio (OR) 1.037 per minute, 95% CI 1.016, 1.057, P = 0.001). An anastomosis time >29 minutes was also associated with a 3.5 fold higher (OR 3.5, 95% CI 1.6, 7.3, P = 0.001) risk of DGF. Median days in hospital was 9 (interquartile range 7, 14 days). Every 5 minutes of longer anastomosis time (0.20 days per minute, 95% CI 0.13, 0.27, P <0.001) was associated with 1 extra day in hospital in a multivariable linear regression model. An anastomosis time >29 minutes was associated with 3.8 (95% CI 1.6, 6.0, P <0.001) more days in hospital.ConclusionAnastomosis time may be an underappreciated but modifiable variable in dictating use of hospital resources. The impact of anastomosis time on longer term outcomes deserves further study.

Basiliximab lowers the cyclosporine therapeutic threshold in the early post-kidney transplant period

Abstract:  Early adequate cyclosporine exposure has been shown to predict low acute rejection rate in kidney transplantation. The aim of this study is to determine the importance of exceeding the early cyclosporine therapeutic exposure threshold with basiliximab induction. A retrospective analysis of 166 first cadaveric and non‐identical live donor transplant recipients treated with or without basiliximab induction, Neoral, mycophenolate mofetil and prednisone, was performed. Adequate exposure was defined as a 2‐h post‐Neoral dose cyclosporine level (C2) >1700 ng/mL at day 3. The primary outcome was acute rejection within the first 6 months. In the no basiliximab (control) group (n = 74), rejection occurred in 23% (17 of 74) of recipients and was strongly associated with low cyclosporine exposure on day 3. Acute rejection occurred in 38% (11 of 29) with C2 <1700 ng/mL compared with 13% (six of 45) with C2 ≥1700 ng/mL (p = 0.014). In the basiliximab group (n = 92), rejection occurred in only 11% (10 of 92) of recipients and did not correlate with cyclosporine exposure. Acute rejection occurred in 10% (four of 40) with C2 <1700 ng/mL compared with 12% (six of 52) with C2 ≥1700 ng/mL (p = 0.81). Therefore achieving cyclosporine therapeutic targets by day 3 may not be required when anti‐IL2 receptor antibody induction is used.

Blood transfusion in deceased donor kidney transplantation

BackgroundGiven the unpredictable timing of deceased donor organs and the need for blood transfusion, this study was carried out to determine the rate and risk factors for transfusion in order to identifying a low-risk cohort in the face of a critical blood shortage.MethodsThis retrospective chart review examined 306 consecutive deceased solitary kidney transplant recipients from January 2006 to August 2012.ResultsRecords show that 80 (26.1%) patients were transfused with a total of 300 units (0.98 units/transplant) during their first hospital stay. Transfusions were higher in patients on warfarin (8/14, 57%, 5.1 units/transplant) and antiplatelet agents (46/136, 33.8%, 1.1 unit/transplant) compared to no anticoagulants (74/156, 16.7%, 0.47 units/transplant). In a multivariable logistic regression analysis warfarin (odd ratio (OR) 8.2, 95% confidence interval (CI) 2.5–27, P=0.001), antiplatelet agents (OR 2.9, 95% CI 1.6–5.3, P=0.001), recipient age ≥55 years (OR 2.2, 95% CI 1.2–3.9, P=0.008), recipient male (OR 0.36, 95% CI 0.2–0.64, P=0.001) and preop hemoglobin ≥115 g/L (OR 0.32, 95% CI 0.18–0.57, P<0.001) were independent predictors of blood transfusion. Lower bleeding cohorts with transfusion rates <5% could not be identified.ConclusionThe need for blood is significantly higher in subjects on either warfarin or antiplatelet agents. These patients might be avoided if kidney transplantation is to occur during a critical blood shortage. Unfortunately even patients not on anticoagulation are at some risk.

Kidney transplantation in an adult patient with VACTERL association.

The vertebral, anal, cardiac, tracheoesophageal, renal, and limb birth defects (VACTERL) association is a rare, non-random constellation of congenital abnormalities among which urinary tract anomalies can be included. In the presence of these anomalies, patients are suspected to have a higher rate of renal failure than average. We report a case of a 22-year-old woman with VACTERL association and consequent end stage renal failure. A live-related kidney transplant was carried out successfully and the postoperative course was uncomplicated. The patient had immediate graft function. Risk factors that may complicate kidney transplant surgery in this patient population as well as considerations relevant to peritransplant management are discussed.

Does Pretransplant Obesity Affect The Outcome In Kidney Transplant Recipients

UNLABELLED The effect of obesity on renal transplant outcome remains unclear due to conflicting published studies. The purpose of this study was to assess whether obesity affects the outcome in renal transplant patients. METHODS We retrospectively analyzed 33 obese (BMI >30; mean = 34.1 +/- 3.68; group I) and 35 nonobese (BMI < or = 30; mean = 23.6 +/- 3.18; group II) renal transplants performed at our center between March 1999 to December 2002. These two groups were well matched with respect to age, sex, donor source, hypertension, diabetes, ischemic heart disease, hyperlipidemia, native kidney disease (PCKD, 6 vs 4; diabetic, 5 vs 4; glomerulonephritis, 6 vs 7; FSGS, 2 vs 2 and IgA, 2 vs 7), HLA mismatch and immunosuppressants medications (Neoral, 21 vs 25; tacrolimus, 11 vs 10; Cellcept, 28 vs 31; Prednisone, 33 vs 35; ATG, 7 vs 8; Basiliximab, 14 vs 13 and Rapamycin, 5 vs 2, groups I and II, respectively). Follow-up was from 7 months to 4.4 years. RESULTS Significant differences were noted in operating time, wound infection, perinephric hematoma, lymphocele, and number of hospital days. There were no significant differences between the two groups in the incidence of wound dehiscence, deep vein thrombosis, pulmonary embolism, atelectasis, urine leak, delayed graft function, acute rejection rate, and the following posttransplant variables: diabetes mellitus, myocardial infarction, hyperlipidemia, hypertension, and incisional hernia. We conclude that obesity significantly increases operating time, wound complications, and hospitalizations.