Jeff Warren

Acute Page Kidney Following Renal Allograft Biopsy: A Complication Requiring Early Recognition and Treatment

The acute Page kidney phenomenon occurs as a consequence of external compression of the renal parenchyma leading to renal ischemia and hypertension. Between January 2000 and September 2007, 550 kidney transplants and 518 ultrasound‐guided kidney biopsies were performed. During that time, four recipients developed acute oligo‐anuria following ultrasound‐guided allograft biopsy. Emergent doppler‐ultrasounds were performed demonstrating absence of diastolic flow as well as a sub‐capsular hematoma of the kidney. Prompt surgical exploration with allograft capsulotomy was performed in all cases. Immediately after capsulotomy, intraoperative Doppler study demonstrated robust return of diastolic flow. Three patients maintained good graft function, and one kidney was lost due to acute antibody‐mediated rejection. We conclude that postbiopsy anuria associated with a subcapsular hematoma and acute absence of diastolic flow on doppler ultrasound should be considered pathognomonic of APK. All renal transplant specialists should be able to recognize this complication, because immediate surgical decompression can salvage the allograft.

Immunosuppression without calcineurin inhibition: optimization of renal function in expanded criteria donor renal transplantation

Abstract:u2002 Introduction:u2002 To assess the efficacy of calcineurin inhibitor (CNI)‐free immunosuppression vs. calcineurin‐based immunosuppression in patients receiving expanded criteria donor (ECD) kidneys.

Extracapsular versus intracapsular allograft nephrectomy: impact on allosensitization and surgical outcomes

INTRODUCTIONnOur objective was to compare the impact of extra-capsular (ECAN) versus intracapsular allograft nephrectomy (ICAN) on allosensitization and surgical outcomes.nnnMETHODSnBetween 1990 and 2004, 96 allograft nephrectomies were performed at our institution. Of these, 29 procedures were performed within 1 month of the transplant and were therefore omitted from analysis. Overall, the results of 44 ECAN and 23 ICAN were reviewed.nnnRESULTSnThe mean operative times were 110.9 versus 130.4 min for ICAN versus ECAN (p = 0.02) and the estimated blood loss was 226 mL for ICAN versus 483 mL for ECAN (p = 0.004). Intraoperative and postoperative complications were low using either technique and differences were not statistically significant. Overall, the preoperative to postoperative change in the percentage of panel reactive antibody was +2.1% for ICAN versus +1.2% for ECAN (NS) at 3 to 12 months postoperatively, respectively (NS). The percentage of patients relisted was 33.3% versus 54.3% (NS), and the percentage of patients re-transplanted once relisted was also very similar: 63.2% for ECAN versus 66.7% for ICAN (NS), after a mean follow-up of 4.5 and 8.4 years, respectively.nnnCONCLUSIONSnICAN can be performed with shorter operative times and less blood loss versus the extracapsular approach. As well, this operative approach does not appear to affect allosensitization and the ability to re-transplant patients.

Robot-Assisted Pyeloplasty: Follow-Up of First Canadian Experience with Comparison of Outcomes Between Experienced and Trainee Surgeons

BACKGROUND AND PURPOSEnRobot-assisted pyeloplasty (RAP) has been established recently as an option in the management of ureteropelvic junction obstruction (UPJO). We present the first Canadian experience with RAP with respect to operative results and outcomes. We compare the surgical outcomes between experienced and trainee surgeons, with respect to operating room times and success rates.nnnPATIENTS AND METHODSnEighty-eight patients underwent transperitoneal RAP for UPJO using the da Vinci robotic platform. Two surgeons performed Anderson-Hynes dismembered pyeloplasty in 85 cases and YV-plasty in 5 cases. Five patients had RAP for secondary UPJO after failure of other treatments. Diuretic renography was performed at 6 weeks, and 6, 12, 18, 24, and 36 months postpyeloplasty. The mean follow-up was 14.1 ± 8.5 months.nnnRESULTSnThe mean operative time was 167.7 ± 43.2 minutes, and the mean anastomotic time was 41.9 ± 14.1 minutes. The mean operative duration significantly decreased with time (P < 0.05). Ten patients needed simultaneous nephroscopic stone management via the pyelotomy incision. The mean blood loss was 56.6 ± 55.4 mL, and the mean hospital stay was 2.5 ± 0.5 days. There were five major postoperative (stent migration, urinoma) and three minor complications that were associated with the RAP procedures. Postoperative renal scintigraphy demonstrated only four cases with persistent obstruction. Eighty-three (94.3%) patients experienced improvement of symptoms whereas 5 continued to be symptomatic. Two patients needed secondary procedures to relieve persisting obstruction. There were no statistical differences in outcomes between the experienced surgeons and trainees (P = 0.28).nnnCONCLUSIONSnIn the first large case series of RAP from Canada, we demonstrate that RAP can be performed with relatively short operative times and is safe and effective, achieving similar long-term results with standard open repair. We show that robot-assisted surgery can be safely transitioned to surgical trainees. With its cost and availability, its role in the Canadian system needs further study.

Preoperative Cylex assay predicts rejection risk in patients with kidney transplant.

The ImmuKnow assay measures cell‐mediated immunity by quantifying ATP release from CD4+ T‐cells in peripheral blood. Herein, we hypothesized that this assay could predict complications associated with over‐/under‐immunosuppression in patients with kidney transplant (KT).

Should peritoneal dialysis catheters be removed at the time of kidney transplantation

BACKGROUNDn: Delayed graft function (DGF) following transplantation necessitates support in the form of hemodialyis (HD) or peritoneal dialysis (PD). However, post-transplant PD-related complication and failure rates are unknown.nnnMETHODSn: We studies patients who were on PD at the time of kidney transplantation over a 4-year period at two separate institutions.nnnRESULTSn: Of the 137 PD patients, 19 had their catheters removed at the time of transplant. Of the remaining 118 patients, 89% had immediate graft function. PD-related complications in this group included peritonitis (n=5), catheter-related infections (n=2) and emergency laparotomy (n=1). Of the 15 patients requiring post-transplant PD, 33% developed peritonitis and 20% had fluid-leaks necessitating HD. Overall, leaving a PD catheter in situ post- transplantation is associated with 7% rate of peritonitis versus 0% if removed (p < 0.05).nnnCONCLUSIONSn: PD catheter removal should be considered at the time of renal transplantation, as postoperative PD-related failure/complication rates are high.

Outcome of third renal allograft retransplants versus primary transplants from paired donors.

Background. Third kidney retransplants have technical and immunologic hurdles that may preclude success, which is of particular importance in the contemporary context of discrepancy between organ supply and demand. Methods. The outcomes of third renal transplant recipients (TRTR) were compared with those receiving a first transplant from paired donor kidneys to assess transplant success and complication rates. The Ontario-based Trillium Gift of Life Network database was used to identify deceased donors (n=28) who donated one kidney to a TRTR and the mate kidney to a primary renal transplant recipient (PRTR) from June 1977 to August 2006. Results. As anticipated, TRTR were sensitized versus PRTR based on % panel reactive antibodies (24%±34% vs. 7%±14%, P=0.03). Delayed graft function (46% vs. 22%, P=0.05) and biopsy-proven rejection episodes (50% vs. 29%, P=0.01) occurred more frequently with TRTR despite greater frequency of induction therapy (74% vs. 35%, P=0.004). However, 1- and 5-year patient survival were similar at 93%, 83% and 96%, 87% for TRTR and PRTR, respectively. Accordingly, 1- and 5-year allograft survival censored for mortality, were comparable at 78%, 66% and 78%, 75%. Renal function was similar in both groups. Bacterial infections (43% vs. 18%, P=0.001) and wound problems (28% vs. 11%, P=0.09) were the only postoperative complications to occur more frequently in the TRTR. Conclusion. We conclude that third renal transplantation should not be discouraged based on functional outcomes alone.