M. Bieniasz

The Assessment of Residual Kidney Function After Living Donor Nephrectomy

BACKGROUND The number of patients on the waiting list for kidney transplantation is increasing as a result of the cadaveric donor shortage. One way to expand the pool is living donor transplantation. However, only 2% of kidney transplants in Poland come from living-related donors. AIM We sought to assess residual renal function, incidence of hypertension, and proteinuria among living kidney donors. PATIENTS AND METHODS Between 2004 and 2007, we performed 46 living donor open nephrectomies. The mean age of the kidney donor was 39 years (range, 25-57). The donors were predominantly females (61%). Mean hospitalization time was 8 days (range, 4-22). Nine donors did not report for follow-up visits. The observation periods ranged from 1 to 24 months. Physical examination, blood and urine tests, as well as ultrasound scans were performed before nephrectomy and at every follow-up visit (1, 3, 12, and 24 months post operatively). RESULTS Mean creatinine concentration was higher at 3 months after nephrectomy than preoperatively (P < .05). Mean creatinine clearance according to Cockroft-Gault formula and mean creatinine clearance according to abbreviated modification of diet in renal disease equation (aMDRD) decreased after donation by 30% (P < .05). No cases of proteinuria were observed. Hypertension occurred in 1 donor (2.7%). CONCLUSION Living kidney donation resulted in a reduced creatinine clearance in the donor. Follow-up of living kidney donors is essential to determine risk factors for deterioration of residual kidney function.

Preservation of kidneys by machine perfusion influences gene expression and may limit ischemia/reperfusion injury

Context Machine perfusion improves graft survival. Histopathologic analysis reveals a lower incidence of chronic rejection and interstitial fibrosis in kidneys preserved with machine perfusion. Ischemic/reperfusion injury may help to explain these findings. Objective To assess the activation of genes correlated with ischemic/reperfusion injury in kidneys preserved under different conditions before transplant. Design/Patients Between 2005 and 2006, 69 kidney biopsy specimens were collected and patients were followed up for 5 years after that. Intervention Before transplant, kidneys were preserved with machine perfusion or cold storage. Donors from the machine perfusion and cold storage groups did not differ with regard to age, sex, or hemodynamic status. Recipients were divided into 5 groups: expanded criteria donor–machine perfusion (n = 16), standard criteria donor–machine perfusion (n = 10), expanded criteria donor–cold storage (n = 9), and standard criteria donor–cold storage (n = 27); 7 kidneys were retrieved from living related donors. Main Outcome Measures Biopsies were done 30 minutes after reperfusion. Interleukin-1β, vascular endothelial growth factor, heme oxygenase-1, and hypoxia-inducible factor–1 gene expression levels were analyzed. Results Mean expression levels of hypoxia-inducible factor–1α were significantly higher in the cold storage groups, and lower in the machine perfusion and living-related donor groups. Five-year graft survival was significantly (P < .05) lower in the expanded criteria donor–cold storage group (66%) than in the standard criteria donor–machine perfusion group (90%). Machine perfusion influences gene expression related to hypoxia during reperfusion and may improve the long-term results of kidney transplant.

Surgical site infections in the early posttransplant period after simultaneous pancreas-kidney transplantation.

OBJECTIVE Urinary tract infection (UTI) is among the common infection in simultaneous pancreas-kidney transplantation (SPKT). PATIENTS AND METHODS The study included 26 adult patients undergoing SPKT between September 2001 and December 2006. All the patients were followed prospectively for UTI during the first 4 weeks after surgery. Urine samples were investigated for bacteriologic cultures. The micro-organisms were identified in accordance with standard bacteriologic procedures. Susceptibility testing was carried out using Clinical and Laboratory Standards Institute (CLSI) procedures. RESULTS Among 77 urine specimens obtained from all recipients during the first month, there were 30 isolated bacterial strains. The most common were Gram-positive bacteria (53.3%) with predominance of enterococci (75%) associated with high levels of aminoglycoside resistant strains (HLAR; 58.3%) and vancomycin-resistant strains (VRE; 25%). Gram-negative bacteria were detected in 46.7% of positive cultures. CONCLUSIONS In our study, enterococci predominated as 75% of Gram-positive isolates. The increased proportion of multi-drug-resistant bacteria, which can caused severe UTI in patients after SPKT, may be due to the frequent use of prophylaxis of bacterial infections in patients.

Etiologic agents of bacteremia in the early period after simultaneous pancreas-kidney transplantation.

BACKGROUND Bacteremia is among the known complications in simultaneous pancreas-kidney transplantation (SPKT). This study evaluated the frequency of microbial isolates and their susceptibility profiles among cultures of clinical samples obtained from blood and from the tips of blood vessel catheters of 26 SPKT recipients suspected of bacteremia in the early posttransplant period. PATIENTS AND METHODS Data on microbiologic blood cultures of 26 adult patients undergoing SPKT were collected prospectively from 2001 to the end of 2006. The isolation and identification of cultured microorganisms were performed according to standard microbiological procedures and commercially available tests. The susceptibility of the strains to antibacterial agents was established by the Clinical and Laboratory Standards Institute guidelines. RESULTS All patients were followed prospectively for the first 4 weeks after surgery. Among 66 clinical samples, there were 23 microbial isolates from blood samples of 17 recipients and catheter tips of 12 recipients. The most common isolates were Gram-positive bacteria (73.9%) with domination of staphylococci (64.7%) and MRCNS strains (81.8%). Gram-negative bacteria comprised 17.4% of positive cultures, whereas yeast-like fungi, 8.7% with a predominance of Candida glabrata. CONCLUSION Our study showed predominately Gram-positive bacteria in 73.9% of isolates. The increased proportion of multi-drug-resistant bacteria and fungi to antimicrobial agents may be due to the frequent use of these agents for prophylaxis of bacterial infections in patients.

Simultaneous pancreas-kidney transplantation: analysis of donor factors

There are no urgent indications for simultaneous pancreas-kidney transplantation. So our policy is to harvest only a pancreas in good biologic condition. The criteria for acceptance of a pancreas donor are: age 15 to 40 years, ICU stay < 7 days, no clinical signs of infection, negative virologic status, no history of hypotension or cardiac arrest, serum amylase elevation below three times normal values, controllable hyperglycemia, no history of pancreatic disease, no history of abdominal trauma damaging the organ, no history of alcohol addiction, BMI < 25, no functional or anatomical lesions of the kidneys, and expected ischemia time less than 12 hours. The proper selection of a pancreas donor allows one to achieve good insulin secretion immediately after transplantation. In 2000 to 2002 all 20 pancreases transplanted at transplant center displayed immediate secretory function after transplantation.

Serum concentration of vitamin D and parathyroid hormone after living kidney donation.

BACKGROUND Metabolic consequences resulting from loss of renal mass in living kidney donors remain uncertain. There is recent focus on the changes in the active form of vitamin D because it is an agent for cancer regulation. The objective of the study was to measure serum concentrations of 1,25-dihydroxycholecalciferol, parathyroid hormone and insulin-like growth factor-1 (IGF-1) in living donors after kidney donation. PATIENTS AND METHODS Forty living kidney donors reported for follow-up visits. Their mean age was 46.14 years. They were women in 52.5% of cases. The mean observation period was 65.6 months. Serum 1,25(OH)2D3 and IGF-1 concentrations were measured by radioimmunoassay after extraction. Serum intact parathyroid hormone (PTH) was quantified using an enhanced chemiluminescence immunoassay system. RESULTS 1,25-dihydroxycholecalciferol deficiency in 57.5% patients after nephrectomy was the most important change we noted. No correlation was observed between 1,25(OH)2D3 and PTH. A decreased serum IGF-1 concentration was observed in 17.5% of donors. However, decreases in both serum IGF-1 and 1,25(OH)2D3 concentrations were observed in 12.5% of donors. CONCLUSION Prospective studies may be essential to determine metabolic changes after nephrectomy among living kidney donors.

Characteristics of Potential Living Kidney Donors and Recipients: Donor Disqualification Reasons—Experience of a Polish Center

INTRODUCTION Kidney transplantation is efficacious as a renal replacement, particularly pre-emptive living donation. In Poland, the rate of transplantation of living donor kidneys is only 3%. The aim of the study was to identify the most common reasons to disqualify a potential living kidney donor. METHODS We evaluated 124 kidney donor candidates for 111 potential recipients at 1 medical center for genders and ages of donor and recipient; thus relation, donor disqualification reasons, number of potential donors for a particular recipient, prior transplantations, and kidney vasculature. RESULTS The 111 recipients of ages 2-62 years had, 1, 2, or 3 potential donors were tested in 101, 1, and 7, cases respectively. We had 18.9% recipients referred for pre-emptive transplantation; 59.5% were on haemodialysis and 21.6% on peritoneal dialysis. In all, 89% recipients sought first kidney transplantations. Kidneys were procured from 49/124 (39.5%) of the initially evaluated donors. The full examination was completed by 92 potential donors with 68/124 donors disqualified early. Single and multiple renal arteries were detected in 56 and 36 potential donors, respectively. Donor disqualification was due to medical contraindications (39.7%), earlier transplantation from a deceased donor (25%), immunologic constraints (23.5%), donor consent withdrawn (6%) or psychological and social reasons (4.4%). CONCLUSIONS A considerable number of donor candidates are disqualified for medical reasons.

Is Cyctatin C Valuable Marker of Glomerular Filtration Rate in Living Kidney Donors After Uninephrectomy

BACKGROUND The determination of kidney function plays a pivotal role in living donors renal assessment because of the long-term hazards of life with one kidney. Guidelines recommend estimation of glomerular filtration rate (GFR) by the Modification of Renal Disease (MDRD) or Cockroft-Gault equations for people with normal or near-normal renal function. Cystatin C (CysC) has been introduced as an alternative endogenous marker of GFR. OBJECTIVE The objective of the study was to evaluate residual renal function among living kidney donors by comparing serum CysC concentrations and estimated GFR according to the MDRD formula or the Cockroft-Gault equation. PATIENTS AND METHODS Forty living kidney donors showed a mean age of 46.14 years. Their GFR was estimated according to the abbreviated MDRD (aMDRD) and Cockroft-Gault formula adjusted for body surface area. Twenty-two donors underwent diethylenetriaminepentaacetic acid (DTPA) renal studies. Serum CysC concentrations were measured during the last follow-up visit. GFR values according to Cockroft-Gault formula and MDRD formula were correlated with CysC concentrations using Pearsons linear correlation. RESULTS Mean GFR according to the aMDRD formula and Cocroft-Gault formula decreased after nephrectomy. The Cockroft-Gault formula overestimated the DTPA GFR in our study. No significant differences were observed between DTPA GFR and GFR estimated using the aMDRD equation. The rate of GFR decrease was approximately 0.8 mL/min/1.73 m(2) per year. No significant correlation was observed between serum CysC concentration and GFR. Microalbuminuria was observed in one patient after nephrectomy. CONCLUSIONS aMDRD equation to estimate GFR is more precise than Cockroft-Gault formula and cystatin C in living kidney donors after nephrectomy and should be preferred model in these patients.

Do Anatomical Anomalies Affect the Results of Living Donor Kidney Transplantation

BACKGROUND Multiple renal artery kidneys still represent a special challenge for surgeons, during both nephrectomy for organ donation and transplantation. Recognition of anatomical conditions with advanced imaging methods is one of the most important elements of the preoperative evaluation process. AIM The purpose of the current study was to assess if anatomical abnormalities affect the outcomes of living kidney donor transplantation procedures. PATIENTS AND METHODS A retrospective analysis of 60 living kidney donors and their recipients was performed. Patients were assigned to two groups: pairs with a single allograft vessels (group I) and pairs with any anatomical abnormalities of the transplanted organ (group II). The impact of anatomical abnormalities on initial and long-term outcomes of the transplantation were analyzed. RESULTS The analyzed study group consisted of 60 pairs (35 included in group I and 25 in group II). Immediate graft function was observed in 65.7% vs 64% individuals, recpectively (n.s.). Mean serum creatinine concentration was 1.6, 1.46, and 1.44 mg/mL (group I) vs 1.78, 1.78, and 1.65 mg/mL (group II) at 1, 6, and 12 months posttransplant, respectively (n.s.). Glomerular filtration rate (using the Chronic Kindey Disease Epidemiology Collaboration equation) was estimated at 54.3, 59.9, and 61.0 mL/min/1.73 m2 (group I) vs 59.8, 57.6, and 59.8 mL/min/1.73 m2 (group II) at the same time points, respectively (n.s.). CONCLUSIONS Presence of single renal vessels was not a predictor of immediate graft function in living-donor kidney transplantation. Transplantation outcomes for kidneys with anatomical anomalies did not differ when compared to organs with typical anatomy. Multiple renal arteries did not impact initial graft function if precise surgical technique and proper preoperative diagnostics were provided.

Analysis of Factors Influencing on Living Kidney Donors and Deceased Kidney Donors Transplantation Results

Introduction Recognizing factors influencing kidney transplantation results may significantly affect therapeutic decisions made before, during and post transplantation. Aim of the study The aim of the study was to analyse factors influencing kidney graft function. Material and methods The group of 993 patients who received kidney graft from deceased and living donors, at Department of General and Transplantation Surgery, Baby Jesus Clinical Hospital in Warsaw, between January 1996 and August 2010 was analysed regarding factors that may have an influence on kidney transplantation results. Factors contingent from donor, recipient and time of kidney preservation were analysed. Results A multivariate analysis exhibited that time of dialyses prior transplantation is statistically significant factor influencing recipient’s survival (p=0.017). We proved that donor age is a variable that affects both recipient and graft survival. The higher number of mismatches HLA, the lower graft survival (p=0,0028). Cold ischaemia time (CIT) (OR=1.182), HBV infection (OR=1.58) as well as number of mismatch HLA (OR=1.1496), are the factors that influenced on frequency of delayed graft function (DGF) episodes. Moreover, we evidenced that the cause of graft failure affects graft survival. Patients, who suffer from IgA nephropathy, as well as hypertensive nephropathy, have the worst survival ratio after kidney transplantation. Patients who had had received a kidney graft from cadaveric donor with intracranial bleeding had higher creatinine serum concentration up to 5 years post transplantation in comparison with recipients whose kidney had come from donor with cranial trauma (p<0.005). Conclusions Factors that significantly influence on kidney graft function are: time of dialyses prior transplantation, number of mismatch HLA, cause of renal failure, HBV infection and CIT.