Oscar K. Serrano

Evolution of Living Donor Nephrectomy at a Single Center: Long-term Outcomes With 4 Different Techniques in Greater Than 4000 Donors Over 50 Years.

Background The development of minimally invasive surgical approaches to donor nephrectomy (DN) has been driven by the potential advantages for the donor, with questions remaining about long-term outcomes. Methods All living DN performed from June 1963 through December 2014 at the University of Minnesota were reviewed. Outcomes were compared among 4 DN techniques. Results We performed 4286 DNs: 2759 open DN (ODNs), 1190 hand-assisted (HA) laparoscopic DNs (LDNs), 203 pure LDN (P-LDNs), and 97 robot-assisted-LDN. Laparoscopic DN was associated with an older (P < 0.001) and heavier (P < 0.001) donor population. Laparoscopic DN was associated with a higher probability of left kidney procurement (P < 0.001). All 3 LDN modalities required a longer operative time (P < 0.001); robot-assisted-LDN took significantly longer than HA-LDN or P-LDN. Laparoscopic DN decreased the need for intraoperative blood transfusion (P < 0.001) and reduced the incidence of intraoperative complications (P < 0.001) and hospital length of stay (P < 0.001). However, LDN led to a significantly higher rate of readmissions, both short-term (<30 day, P < 0.001) and long-term (>30 day, P < 0.001). Undergoing HA-LDN was associated with a higher rate of an incisional hernia compared with all other modalities (P < 0.001). For recipients, LDN seemed to be associated with lower rates of graft failure at 1 year compared with ODN (P = 0.002). The odds of delayed graft function increased for kidneys with multiple arteries procured via P-LDN compared with HA-LDN (OR 3 [1,10]) and ODN (OR 5 [2, 15]). Conclusions In our experience, LDN was associated with decreased donor intraoperative complications and hospital length of stay but higher rates of readmission and long-term complications.

Defining the Tipping Point in Surgical Performance for Laparoscopic Donor Nephrectomy Among Transplant Surgery Fellows: A Risk-Adjusted Cumulative Summation Learning Curve Analysis

The United Network for Organ Sharing recommends that fellowship‐trained surgeons participate in 15 laparoscopic donor nephrectomy (LDN) procedures to be considered proficient. The American Society of Transplant Surgeons (ASTS) mandates 12 LDNs during an abdominal transplant surgery fellowship. We performed a retrospective intraoperative case analysis to create a risk‐adjusted cumulative summation (RACUSUM) model to assess the learning curve of novice transplant surgery fellows (TSFs). Between January 2000 and December 2014, 30 novice TSFs participated in the organ procurement rotation of our ASTS‐approved abdominal transplant surgery fellowship. Measures of surgical performance included intraoperative time, estimated blood loss, and incidence of intraoperative complications. The performance of senior TSFs was used to benchmark novice TSF performance. Scores were tabulated in a learning curve model, adjusting for case complexity and prior TSF case volume. Rates of adverse surgical events were significantly higher for novice TSFs than for senior TSFs. In univariable analysis, multiple renal arteries, high BMI, prior abdominal surgery, male donor, and nephrolithiasis were correlated with higher incidence of adverse surgical events. Based on the RACUSUM model, high intraoperative time is mitigated after 28 procedures, incidence of intraoperative complications tends to diminish after 24 procedures, and improvement in estimated blood loss did not remain consistent. TSFs exhibit a tipping point in LDN performance by 24–28 cases and proficiency by 35–38 cases.

CD4 Count in HIV- Brain Dead Donors: Insight into Donor Risk Assessment for HIV+ donors.

Background The Human Immunodeficiency Virus (HIV) Organ Policy Equity Act allows for transplantation of organs from HIV-infected individuals (HIV+), provided it is performed under a research protocol. The safety assessment of an organ for transplantation is an essential element of the donation process. The risk for HIV-associated opportunistic infections increases as circulating CD4+ lymphocytes decrease to less than 200 cells/&mgr;L; however, the numbers of circulating CD4+ cells in the HIV-negative (HIV−) brain-dead donor (BDD) is not known. Methods Circulating T-lymphocyte subset profiles in conventional HIV− BDD were measured in 20 BDD in a clinical laboratory. Results The mean age of the BDD cohort was 48.7 years, 95% were white and 45% were women. The average body mass index was 29.2 kg/m2. Cerebrovascular accident (40%) was the most prevalent cause of death. Sixteen (80%) subjects had a CD4 count ⩽441 cells/&mgr;L (lower limit of normal) and 11 (55%) had a CD4 count less than 200 cells/&mgr;L; 11 (55%) subjects had a CD8 count ⩽125 cells/&mgr;L (lower limit of normal). CD4/CD8 ratio was below normal in 3 patients (normal, 1.4-2.6). No recipient had a recognized donor-associated adverse event. Conclusions Absolute numbers of CD4 and CD8 T-lymphocytes are commonly reduced after brain death in HIV− individuals. Thus, CD4 absolute numbers are an inconsistent metric for assessing organ donor risk, irrespective of HIV status.

Rapid Discontinuation of Prednisone in Kidney Transplant Recipients: 15-Year Outcomes from the University of Minnesota

Background Short- and intermediate-term results have been reported after rapid discontinuation of prednisone (RDP) in kidney transplant recipients. Yet there has been residual concern about late graft failure in the absence of maintenance prednisone. Methods From October 1, 1999, through June 1, 2015, we performed a total of 1553 adult first and second kidney transplants—1021 with a living donor, 532 with a deceased donor—under our RDP protocol. We analyzed the 15-year actuarial overall patient survival (PS), graft survival (GS), death-censored GS (DCGS), and acute rejection–free survival (ARFS) rates for RDP compared with historical controls on maintenance prednisone. Results For living donor recipients, the actuarial 15-year PS rates were similar between groups. But RDP was associated with increased GS (P = 0.02) and DCGS (P = 0.01). For deceased donor recipients, RDP was associated with significantly better PS (P < 0.01), GS (P < 0.01) and DCGS (P < 0.01). There was no difference between groups in the rate of acute or chronic rejection, or in the mean estimated glomerular filtration rate at 15 years. However, RDP-treated recipients had significantly lower rates of avascular necrosis, cytomegalovirus, cataracts, new-onset diabetes after transplant, and cardiac complications. Importantly, for recipients with GS longer than 5 years, there was no difference between groups in subsequent actuarial PS, GS, and DCGS. Conclusions In summary, at 15 years postkidney transplant, RDP did not lead to decreased in PS or GS, or an increase in graft dysfunction but as associated with reduced complication rates.

Living donor kidney allograft survival ≥ 50 years

The first successful kidney transplant occurred in 1954. Since then, long‐term graft survival has been an elusive idealistic goal of transplantation. Yet 62 years later, we know of only 6 kidney transplant recipients who have achieved ≥ 50‐year graft survival while being on no immunosuppression or a substantially reduced regimen. Herein, we report graft survival ≥ 50 years in 2 living donor recipients who have been maintained on standard‐of‐care immunosuppression the entire time. For our 2 recipients, their living donors altruism altered the course, length, and quality of their life, which by all accounts can be deemed normal: They attended college, held jobs, had successful pregnancies, raised families, and were productive members of society. Both donors are still alive and well, more than 50 years post‐donation; both have an acceptable GFR and normal blood pressure, with hyperlipidemia as their only medical problem. These 2 intertwined stories illustrate the tremendous potential of a successful kidney transplant: long‐term survival with a normal lifestyle and excellent quality of life, even after more than 5 decades on full‐dose immunosuppression.

The Preneoplastic Lesion in a Pancreas Allograft: Dilemma for the Pancreas Transplant Surgeon

Although the relationship between immunosuppression and cancer risk is well-documented, the association between immunosuppression and the development of preneoplastic lesions (PNL) is less clear. PNLs pose a unique clinical conundrum in the transplanted pancreas because their prevalence in the general population is not infrequent. We present the case of a 58-year-old man with a history of diabetes mellitus type 1 who underwent successful pancreas transplantation with bladder drainage. His kidney function failed 13 years after his transplant and he developed recurrent painful hematuria with symptomatic anemia 2 years after initiating hemodialysis. Upon work-up, he was found to have a 4 cm intraductal papillary mucinous neoplasm in his pancreas allograft. At his enteric conversion, the intraductal papillary mucinous neoplasm was removed through a distal pancreatectomy due to concern for its malignant potential. He recovered well from surgery and continues to be insulin-free. With the rising incidence of PNLs from improved detection and the improved survival of pancreas allografts, the implications of PNLs may be more pronounced in the future. This case raises several important considerations for the pancreas transplant surgeon regarding adequate allograft surveillance protocols, treatment, and follow-up.

Logistical considerations for establishing reliable surgical telementoring programs: a report of the SAGES Project 6 Logistics Working Group

Surgical telementoring programs (STMPs) as educational tools have consistently demonstrated success in the training of surgeons in a variety of surgical disciplines. The goal of an STMP is to train and educate practicing surgeons by improving or remediating surgical skills or assisting in the safe adoption of new procedures. STMPs may even have a role in assisting with recertification. In 2015, the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) launched the SAGES Telementoring Initiative at the Project 6 Summit. Herein, we provide a report on the SAGES Project 6 Logistics working group and lay out a plan for the recommended logistical framework to carry out an STMP.

Implications of excess weight on kidney donation: Long-term consequences of donor nephrectomy in obese donors

Background An elevated body mass index (>30 kg/m2) has been a relative contraindication for living kidney donation; however, such donors have become more common. Given the association between obesity and development of diabetes, hypertension, and end‐stage renal disease, there is concern about the long‐term health of obese donors. Methods Donor and recipient demographics, intraoperative parameters, complications, and short‐ and long‐term outcomes were compared between contemporaneous donors—obese donors (body mass index ≥30 kg/m2) versus nonobese donors (body mass index <30 kg/m2). Results Between the years 1975 and 2014, we performed 3,752 donor nephrectomies; 656 (17.5%) were obese donors. On univariate analysis, obese donors were more likely to be older (P < .01) and African American (P < .01) and were less likely to be a smoker at the time of donation (P = .01). Estimated glomerular filtration rate at donation was higher in obese donors (115 ± 36 mL/min/1.73m2) versus nonobese donors (97 ± 22 mL/min/1.73m2; P < .001). There was no difference between groups in intraoperative and postoperative complications; but intraoperative time was longer for obese donors (adjusted P < .001). Adjusted postoperative length of stay (LOS) was longer (adjusted P = .01), but after adjustment for donation year, incision type, age, sex, and race, there were no differences in short‐term (<30 days) and long‐term (>30 days) readmissions. Estimated glomerular filtration rate and rates of end‐stage renal disease were not significantly different between donor groups >20 years after donation (P = .71). However, long‐term development of diabetes mellitus (adjusted hazard ratio (HR) 3.14; P < .001) and hypertension (adjusted hazard ratio (HR) 1.75; P < .001) was greater among obese donors and both occurred earlier (diabetes mellitus: 12 vs 18 years postnephrectomy; hypertension: 11 vs 15 years). Conclusion Obese donors develop diabetes mellitus and hypertension more frequently and earlier than nonobese donors after donation, raising concerns about increased rates of end‐stage renal disease.

Incidence and magnitude of post-transplant cardiovascular disease after pediatric kidney transplantation: Risk factor analysis of 1058 pediatric kidney transplants at the university of Minnesota

KT recipients have increased the risk of CVD. The incidence of post‐transplant CVEs among pediatric recipients has not been well‐characterized.

Clinical significance of pulmonary nodules in the pretransplant evaluation of liver transplant recipients with hepatocellular carcinoma

OBJECTIVES Pulmonary nodules are common in patients with hepatocellular carcinoma who are being evaluated for a possible liver transplant. MATERIALS AND METHODS In this retrospective study, we analyzed the records of liver transplant recipients at our institution with a primary diagnosis of hepatocellular carcinoma who received transplants between 2000 and 2015. All patients had magnetic resonance imaging-confirmed disease within Milan criteria and a concurrent staging chest computed tomography. Patient survival was estimated using Kaplan-Meier methods and compared between pulmonary nodule characteristic groups. A Cox proportional hazards model was constructed for adjusted analysis. RESULTS Of the 197 liver transplant recipients who met our study inclusion criteria (median follow-up, 40 mo), 115 (58.4%) had a total of 231 pulmonary nodules, with 57 (49.6%) having multiple nodules and 108 (93.9%) having nodules ≤ 1 cm. The presence of pulmonary nodules did not negatively affect patient survival, per our univariate and multivariate analysis, nor did their presence affect their number, location, laterality, shape, edge, density, or the presence of calcifications (P ≥.05). However, pulmonary nodules ≥ 1 cm were associated with decreased overall survival. CONCLUSIONS In our pretransplant evaluation of patients with hepatocellular carcinoma, pulmonary nodules ≤ 1 cm did not portend worse patient or graft survival posttransplant.