James W. Lim

Laparoscopic versus open donor nephrectomy: comparing ureteral complications in the recipients and improving the laparoscopic technique.

BACKGROUND Laparoscopic live donor nephrectomy (LDN) is a recently developed procedure, the performance of which needs to be studied. Given the reported advantages in the donors, this study looks at graft outcome and ureteral complications in recipients of kidneys procured by open donor nephrectomy (ODN) versus LDN. METHODS The LDN recipients consisted of 193 patients since 3/27/96. A total of 168 ODN recipients from 1991 to 1998 served as controls. Immunosuppression protocols were similar for both groups. RESULTS Two-year graft survival for LDN and ODN was 98% and 96%, respectively. Two-year patient survival for LDN and ODN was 98% and 97%, respectively. The incidence of delayed graft function and mean serum creatinine at 3 and 12 months was similar in both groups. However, the number of ureteral complications that required operative repair was significantly higher for LDN recipients compared to ODN recipients, 7.7% (n=15) vs. 0.6% (n=1) respectively (P=0.03). Ureteral stenting was required in an additional 3.1% (n=6) of LDN and 2.4% (n=4) of ODN (P=NS). There was, however, a learning curve with time. For the first 130 LDN patients, a total of 20 ureteral complications were recorded, whereas only one occurred in the more recent 63 patients (P=0.03). CONCLUSIONS The higher ureteral complication rate in LDN recipients has improved over time as technical causes have been identified. We have noted significant improvement in ureteral viability by using the endogastrointestinal anastomosis instrument on the ureter and peri-ureteral tissue. LDN is therefore an excellent alternative to ODN. Identification of hazards unique to this technique is critical before its broader application.

Successful use of chronic epoprostenol as a bridge to liver transplantation in severe portopulmonary hypertension

BACKGROUND Portopulmonary hypertension, defined as mean pulmonary artery pressure >25 mmHg in the presence of a normal pulmonary capillary wedge pressure and portal hypertension, is a known complication of end-stage liver disease that has been associated with high morbidity and mortality at the time of liver transplantation. We have recently reported the successful treatment of portopulmonary hypertension with chronic intravenous epoprostenol and now report the first patient with severe portopulmonary hypertension successfully treated with epoprostenol who subsequently underwent successful liver transplantation. METHODS A patient with severe portopulmonary hypertension was treated with intravenous epoprostenol, 23 ng/kg/min, for a 4-month period, after which the portopulmonary hypertension resolved and the patient underwent successful liver transplantation. RESULTS The patient was discharged, continues to do well, and at 3 months is off epoprostenol with near normal pulmonary artery pressures. CONCLUSIONS Chronic epoprostenol, in conjunction with a multidisciplinary, well-planned perioperative evaluation and treatment plan, may be the answer to a heretofore untreatable disease.

Mycophenolate mofetil reduces the risk of acute rejection less in African-American than in Caucasian kidney recipients

BACKGROUND Multicenter clinical trials have shown that mycophenolate mofetil (MMF) reduces the risk of acute rejection, but it is unknown whether African-Americans constitute a subgroup of recipients less likely to benefit from MMF. METHODS This study compared the acute rejection rates within 6 months of kidney transplantation in MMF-treated transplant patients with those on azathioprine (AZA) at a single center. The study population consisted of 353 consecutive recipients of cadaver or living donor kidney transplants. African-Americans constituted 43% of the patients on AZA and 49% of the patients on MMF. Variables used in a Cox regression analysis included MMF immunosuppression, recipient race, type of transplant, delayed graft function, postoperative immune induction, average cyclosporine trough level, and HLA mismatch. RESULTS Significantly fewer patients on MMF experienced a biopsy-proven rejection episode than those treated with AZA (24% vs. 42%, respectively; relative risk [RR]=0.57, P=0.001). This decrease in risk was greater in Caucasian transplant recipients (MMF vs. AZA: 16% vs. 46%, RR=0.35, P < 0.001) than in African-American patients (32% vs. 36%, RR=0.88, P=0.6). Within each race stratum, the mean cyclosporine trough levels averaged over 2-week intervals were nearly identical for AZA- compared with MMF-treated patients. In the regression model, the effect of MMF on the incidence of rejection was again less in African-American than in Caucasian patients. CONCLUSIONS Kidney recipients treated with MMF have a significantly lower risk of acute rejection within 6 months of transplantation than those given AZA. This reduction in risk is significantly less in African-American recipients than Caucasians.

Outcome After Splenic Vein Thrombosis In The Pancreas Allograft

The outcome and management of isolated splenic vein thrombosis in the pancreas transplant is unknown. We retrospectively reviewed the records of 76 simultaneous pancreas-kidney transplantations (SPK) and 56 solitary pancreas transplantations (SPT) performed at the University of Maryland from January 1995 to December 1996. A total of 24 patients were identified (9 SPK and 15 SPT recipients). All were systemically anticoagulated for a period of 6-8 weeks after diagnosis. In the SPK thrombosis group, anticoagulation resulted in 1-year graft survival that was equivalent to that of SPK controls (86.1% vs. 95.3%). In contrast, in SPT, thrombosis and subsequent anticoagulation were associated with decreased graft survival compared with SPT controls (26.8% vs. 78.3%; P<0.01). Although the outcome of splenic vein thrombosis in the absence of anticoagulation is unknown, these data suggest that (1) in SPK, anticoagulation for splenic vein thrombosis maintains graft survival, and (2) in SPT, anticoagulation does not alter the ultimate progression of splenic vein thrombosis to complete graft thrombosis.

Selective bowel decontamination in hospitalized patients awaiting liver transplantation

BACKGROUND Infection remains a major contributor to morbidity and mortality following orthotopic liver transplantation (OLT). Selective bowel decontamination (SBD) in hospitalized patients is one strategy for prophylaxis. METHODS A retrospective case-control study was performed using 18 consecutive hospitalized patients receiving SBD prior to OLT during the period September 1995 to September 1996. Eighteen consecutive hospitalized patients without SBD transplanted during the period March 1995 to September 1995 served as a historical control group. RESULTS Selective bowel decontamination was associated with a significantly decreased prevalence of positive cultures for gram-negative bacteria and fungi and reduced overall hospital charges. CONCLUSION In hospitalized patients awaiting OLT, SBD is an effective prophylactic measure against infectious morbidity associated with gram-negative bacteria and fungi.

Double adult renal allografts

D espite renewed efforts l’ocused on education of the public on the great disparity between the number of organ donors relative to the number of patients awaiting organ transplantation in the United States, the gap continues to increase. Currently, there are over 50,000 patient registrations on the United Network for Organ Sharing (UNOS) waiting list. Thirty-four thousand seven hundred sixty-six patients are awaiting kidney transplantation. It is estimated that 10 patients die each day awaiting transplantation. In 1996, there were 5,411 cadaveric organ donors. Although the waiting list size has increased approximately 20% per year, the cadaveric organ donor pool has only increased 4% per year. Median waiting times have nearly doubled for all organs in the last 6 years. From 1988 to 1995, cadaveric donors in the 18-34 age group decreased from 41% to 29%. During the same time period, the percentage of older donors (50 years) doubled from 12% to 24% and likely will continue to increase in prevalence as the population ages. Innovative strategies to compensate for this major constraint to kidney transplantation provided the impetus to conduct a protocol for the use of kidneys from older donors with suboptimal nephron mass, kidneys that otherwise might not have been used for transplantation. The protocol was initiated in 1994 and entailed the simultaneous transplantation of both kidneys from a single donor into a recipient. The background for this novel approach was based on several elegant