Jeffery D. Punch

Randomized controlled trial of hand-assisted laparoscopic versus open surgical, live donor nephrectomy

BACKGROUND Laparoscopic live donor nephrectomy for renal transplantation is being performed in increasing numbers with the goals of broadening organ supply while minimizing pain and duration of convalescence for donors. Relative advantages in terms of recovery provided by laparoscopy over standard open surgery have not been rigorously assessed. We hypothesized that laparoscopic as compared with open surgical live donor nephrectomy provides briefer, less intense, and more complete convalescence. METHODS Of 105 volunteer, adult, potential living-renal donors interested in the laparoscopic approach, 70 were randomly assigned to undergo either hand-assisted laparoscopic or open surgical live donor nephrectomy at a single referral center. Objective data and subjective recovery information obtained with telephone interviews and validated questionnaires administered 2 weeks, 6 weeks, and 6-12 months postoperatively were compared between the 23 laparoscopic and 27 open surgical patients. RESULTS There was 47% less analgesic use (P=0.004), 35% shorter hospital stay (P=0.0001), 33% more rapid return to nonstrenuous activity (P=0.006), 23% sooner return to work (P=0.037), and 73% less pain 6 weeks postoperatively (P=0.004) in the laparoscopy group. Laparoscopic patients experienced complete recovery sooner (P=0.032) and had fewer long-term residual effects (P=0.0015). CONCLUSIONS Laparoscopic donor nephrectomy is associated with a briefer, less intense, and more complete convalescence compared with the open surgical approach.

Single-center study of technical graft loss in 714 consecutive renal transplants

No series has specifically focused on rates of technical failure in the kidney transplantation operation. We retrospectively examined the incidence of technical graft loss in a single kidney transplant program. A total of 714 transplants were performed, with a mean follow-up of 3.4 years (range 2–5 years). Technical graft loss was defined as graft loss within the first 2 weeks, without evidence of allograft rejection. Fourteen patients (2%) demonstrated technical graft loss, none of whom received kidneys with multiple renal arteries (n=106 with multiple renal arteries). The incidence of technical graft loss was significantly higher in diabetic recipients (4.3% vs. 1.4%, P=0.03). The mean donor age was significantly higher (46.7 vs. 38.1 years, P=0.05) in patients with technical graft loss. We observed that arterial thrombosis seemed to be related to the donor (older donor significant risk P=0.04) and that venous thrombosis seemed to be related to the recipient (four of seven patients with positive hypercoagulable workup).

Single center review of femoral arteriovenous grafts for hemodialysis.

IntroductionIt is unclear how to manage high risk hemodialysis patients who present with an indwelling catheter. The National Kidney Foundation Practice Guidelines urge prompt removal of the catheter, but the guidelines do not specifically address the problem of patients whose only option is a femoral arteriovenous (AV) graft.MethodsThis study was a retrospective review of all patients who underwent femoral AV graft placement for hemodialysis access between January 1, 1996 and January 1, 2003 at the University of Michigan Health System (UMHS). Graft patency is reported according to the standards developed by the Society of Vascular Surgery and the American Association of Vascular Surgeons.ResultsThirty patients were identified who had undergone femoral AV graft placement. The mean follow-up was 23 months (range 1–75 months). The patients had had significant medical co-morbidities and multiple previous access operations (mean 3; interquartile range 1–5). The 1-year secondary graft patency rate was 41%, the 2-year rate was 26%, and the 3-year rate was 21%. Infection was the cause of final graft loss in eight patients (50% of the grafts losses, 27% of the total grafts placed.) Among those who died (n = 14), the mean time from femoral graft placement to death was 31.2 ± 27.5 months. The patient survival was quite low: at 1 year 81%, at 2 years 68%, and at 3 years 54%.ConclusionsThese complex patients who have exhausted their upper extremity hemodialysis options do poorly following femoral AV graft placement. Consideration should be given to long-term catheter-based access in some of these patients.

Salvage of an unstable brain dead donor with prompt extracorporeal support

Maximizing the support of the marginal donor is an approach to optimizing the donor pool. Thirty-two percent of brain dead donors are hemodynamically unstable and 25% of donors under the age of 60 with traumatic brain injuries expire before organs can be procured (1, 2). When standard donor management protocols are insufficient to salvage a potential donor, aggressive attempts to save the organs can be considered. We present a case of an unstable brain dead donor who suffered premature cardiac death and the use of ECMO (extra-corporeal membrane oxygenation) perfusion in the successful salvage of organs for transplantation. Shortly after being declared brain dead, a 25-year-old patient became hypoxic and hemodynamically unstable. The patient’s family strongly desired organ donation. Despite hormonal replacement and three vasopressors, his mean arterial pressure (MAP) was less than 45 mm Hg. The situation was reviewed with the family, who gave consent for ECMO. The ECMO team was called for an emergent cannulation. The patient was placed on venous-arterial ECMO via cannula placement in the common femoral artery, the internal jugular vein, and the common femoral vein. The patient had a significant improvement in hemodynamics and resumed making urine (MAP 60 to 75). Approximately 75 min later and for unclear reasons, the patient had a cardiac arrest. The MAP was maintained at 53 via ECMO support following cessation of cardiac activity. The patient was transported to the operating room. ECMO flow was not interrupted during this transport. Shortly after arriving into the operating room, cold University of Wisconsin solution was infused through the ECMO circuit. The femoral venous cannula was cut and allowed to drain into a waste bucket. The abdomen was opened and cold slush was poured into the abdominal cavity. The perfusate return soon cleared and the kidneys were procured in the standard fashion. The kidneys were placed on pulsatile pump perfusion. Both kidneys were transplanted and functioned immediately. At our center, we have had success with a protocol using extracorporeal support for NHBDs (non-heart beating donors) (3). In our experience with NHBD, balloon aortic occlusion and a mean ECMO flow of 3.0 L/minute provides physiologic flow to the intra-abdominal organs. Failure of physiologic support to prevent early cardiac death was the second most frequent potentially remediable causes of procurement failure (4). Many potential donors who are unstable are not referred to the local organ procurement organization. In addition, patients who have been hemodynamically tenuous are frequently only kidney donors and the other organs are not procured. In this case, the use of ECMO salvaged the kidneys for donation. In addition, the circuit provided an expeditious means to perfuse with cold University of Wisconsin solution. Using ECMO to optimize brain dead donors is a novel strategy to increase the number of donors and the yield of organs per donor. Michael J. Englesbe Derek Woodrum Meelie Debroy Richard Chenault William Miller Judiann Miskulin Fresca Swaniker John C. Magee Juan D. Arenas Jeffery D. Punch Randall S. Sung Department of Surgery Division of Transplant Surgery and Surgical Critical Care University of Michigan Health System Ann Arbor, Michigan

LUNG PHYSIOLOGY DURING ECS RESUSCITATION OF DCD DONORS FOLLOWED BY IN-SITU ASSESSMENT OF LUNG FUNCTION

Extracorporeal cardiopulmonary support (ECS) of donors after cardiac death (DCD) has been shown to improve abdominal organs for transplantation. This study assesses whether pulmonary congestion occurs during ECS with the heart arrested and describes an in vivo method to assess if lungs are suitable for transplantation from DCD donors after ECS resuscitation. Cardiac arrest was induced in 30 kg pigs, followed by 10 min of warm ischemia. Cannulae were placed into the right atrium (RA) and iliac artery, and veno-arterial ECS was initiated for 90 min with lungs inflated, group 1 (n = 5) or deflated, group 2 (n = 3). Left atrial pressures were measured as a marker for pulmonary congestion. After 90 min of ECS, lung function was evaluated. Cannulae were placed into the pulmonary artery (PA) and left ventricle (LV). A second pump was included, and ECS was converted to a bi-ventricular (bi-VAD) system. The RVAD drained from the RA and pumped into the PA, and the LVAD drained the LV and pumped into the iliac. This brought the lungs back into circulation for a 1-hr assessment period. The oxygenator was turned off, and ventilation was restarted. Flows, blood gases, PA and left atrial pressures, and compliance were recorded. In both the groups, LA pressure was <15 mm Hg during ECS. During the lung assessment period, PA flows were 1.4–2.2 L/min. PO2 was >300 mm Hg, with normal PCO2. Extracorporeal cardiopulmonary support resuscitation of DCD donors is feasible and allows for assessment of function before procurement. Extracorporeal cardiopulmonary support does not cause pulmonary congestion, and the lungs retain adequate function for transplantation. Compliance correlated with lung function.

Patient Characteristics and Outcomes Following Establishment of a Living Donor Kidney Transplant Program in Sub-Saharan Africa

Background End-stage renal disease (ESRD) is one of the most common non-communicable causes of death. ESRD’s effects are significantly worse in the economically underprivileged parts of African society where renal replacement therapy such as dialysis or kidney transplantation is not available, as it is both scarce and unaffordable for most patients and families. About 2 years ago, we established Ethiopia’s first living donor kidney transplant program. Herein, we sought to describe the patient characteristics and outcomes of our living donor kidney program. Methods We retrospectively analyzed all ESRD patients who received kidney transplantation at the Ethiopian Ministry of Health National Kidney Transplant Center, located at St. Paul’s Hospital Millennium Medical College in Addis Ababa. All patients underwent living donor kidney engraftment from September 2015 to August 2017. Results After about 3 years of planning prior to human transplants, a total of 52 living donor kidney transplants were performed, of which 20 were performed in the first year. Of these, 40 recipients (76.9%) were male. Recipient age ranged from 16 to 60 years, with a mean of 34.5 years, and a mean BMI of 20.1 (range 15.3-30.6). Geographically, the majority of patients were from Addis Ababa (71.2%). Due to a relative lack of access for pre-transplant biopsy, the cause of ESRD was unknown in many patients (63.5%). All patients received left donor kidneys, and the majority was placed on the recipient’s left external iliac artery (88.5%). The mean operation time and blood loss were 148 minutes and 120 mL, respectively. The mean length of stay was 8.1 days (SD=4.1). There were a total of 9 surgical complications (6 early and 3 late) in 7 patients, with superficial surgical site infection (SSI) being the most common (4). There were no patient deaths during the immediate postoperative period. Conclusions We have successfully established the first kidney transplant center in Ethiopia. While training for faculty and staff are ongoing, our results so far are comparable to other international centers. Key words: ESRD, Kidney Transplant, Outcomes