P. J. Goldsmith

Boari flap vesicocalycostomy: a salvage drainage procedure for complete ureteric stricture and pyelocalyceal fistula

Abstract:  To increase the working knowledge on how to drain a transplanted kidney via the use of a Boari flap as a salvage procedure. A female with a transplant kidney had complete obstruction at the ureteropelvic junction and multiple strictures of the ureter causing deterioration of the graft function. Surgery was the only way to successfully drain the obstructed kidney, but conventional methods were not possible due to dense fibrosis around the kidney. A Boari flap to the lower pole calyx of the transplant kidney was therefore employed. A Boari flap vesicocalycostomy is a potential method available to the transplant surgeon to successfully restore graft function in a case where the transplant or native ureter is unsalvageable.

The Impact of Postoperative Infection on Long-Term Outcomes in Liver Transplantation

INTRODUCTION Postoperative infection (POI) prolongs inpatient stay, delays return to normal activity, and may be detrimental to long-term survival after cancer resections. This study sought to identify the impact of postoperative infection on liver transplantation outcomes. METHODS We analyzed our prospective database of 910 adult patients who underwent liver transplantation between 2000 and 2010 in a single UK center. POI was defined as pyrexia plus positive cultures from blood, sputum, urine, wound, or ascitic fluid. Patient demographic features and perioperative variables were analyzed for their effects on POI. The impacts of POI on overall survival (OS) and graft survival were analyzed using Kaplan-Meier curves with log-rank tests for significance, before entry into a multivariate regression analysis. We analyzed the effects of POI on the length of hospital stay (LOS) and the incidence of acute rejection episodes and readmissions within 1 year as secondary outcomes. RESULTS Patients who developed a postoperative chest or wound infection showed poorer OS at a mean of 7.0 versus 8.8 years (P = .009) and 7.0 versus 8.8 years (P = .003), respectively. Infection in blood, ascitic fluid, or urine showed no significant impact on survival. LOS was significantly increased among patients with a wound (median 21 vs 17 days, P = .011), a sputum (median 24 vs 17 days, P < .001), or a blood infection (median 32 vs 17 days, P < .001). Higher rates of intraoperative blood transfusion were observed among subjects who developed a chest or a wound infection. There was no difference in other variables between those who did versus did not develop an infection. Upon multivariate analysis, wound infection was the strongest independent predictor of OS (P = .007). CONCLUSION We demonstrated that wound or chest infections were associated with poorer OS. More aggressive prophylactic and/or therapeutic interventions targeting specific sites of infection may represent a simple and cost-effective measure to reduce hospital stay and improve OS.

Comparable Outcomes in Donation after Cardiac Death and Donation after Brainstem Death: A Matched Analysis of Renal Transplants

Donation after cardiac death (DCD) donors provide a valuable source of grafts for renal transplantation. They are exposed to an initial warm ischemic insult, which can affect early function. We sought to compare our initial DCD experience in renal transplantation with a case-matched donation after brain death (DBD) cohort from the same period. We included all DCD transplantations in the first 5 years of the program. A control DBD group was matched with a variety of donor and recipient factors. We demonstrated a significantly increased early dysfunction (DGF and primary nonfunction). DCD graft function was poorer than the DBD equivalent at 1- and 3-years. However, medium-term recipient and graft outcomes were comparable. DCD grafts continue to play a vital role in renal transplantation despite evidence of early graft dysfunction.

Optimal reaction coordinate as a biomarker for the dynamics of recovery from kidney transplant.

The evolution of disease or the progress of recovery of a patient is a complex process, which depends on many factors. A quantitative description of this process in real-time by a single, clinically measurable parameter (biomarker) would be helpful for early, informed and targeted treatment. Organ transplantation is an eminent case in which the evolution of the post-operative clinical condition is highly dependent on the individual case. The quality of management and monitoring of patients after kidney transplant often determines the long-term outcome of the graft. Using NMR spectra of blood samples, taken at different time points from just before to a week after surgery, we have shown that a biomarker can be found that quantitatively monitors the evolution of a clinical condition. We demonstrate that this is possible if the dynamics of the process is considered explicitly: the biomarker is defined and determined as an optimal reaction coordinate that provides a quantitatively accurate description of the stochastic recovery dynamics. The method, originally developed for the analysis of protein folding dynamics, is rigorous, robust and general, i.e., it can be applied in principle to analyze any type of biological dynamics. Such predictive biomarkers will promote improvement of long-term graft survival after renal transplantation, and have potentially unlimited applications as diagnostic tools.

Sequential transplant of paired kidneys following donation after cardiac death: impact of longer cold ischemia time on the second kidney on graft and patient outcome.

The United Kingdom has no national sharing scheme for kidneys received from donation after cardiac death (DCD). Therefore, both kidneys retrieved by a transplant team are implanted at a single unit, often sequentially. This study analyzes the impact of a prolonged cold ischaemia time on the second transplanted kidney and the effects on short-term and long-term outcomes in all our DCD renal implants from 2002 to 2009. Cold ischaemia time was significantly longer with the second kidney (P = .04) as was delayed graft function (P = .02). Acute rejection was increased in the first transplanted kidney (P < .001). Five-year patient survival was comparable between groups, but 5-year graft survival was higher in the second transplanted group (P = .04). The results confirm that, provided recipient centers are willing to accept higher initial rates of delayed graft function, it is acceptable to transplant DCD grafts sequentially without jeopardizing long-term graft or recipient outcome.

Predicting Donor Asystole Following Withdrawal of Treatment in Donation After Cardiac Death

Donation after cardiac death donation allows donor pool expansion. The period between withdrawal of treatment and donor a systole is extremely variable; its prolongation often results in unsuccessful organ procurement. We sought to assess a variety of donor variables to determine whether they predicted successful organ retrieval. We included all Donation after Cardiac Death (DCD) retrievals between 2002 and 2009, which were grouped as successful (n = 104) versus unsuccessful (n = 42). Factors that predicted unsuccessful organ procurement included older donor age, donor history of hypertension, higher at withdrawal, and absence of inotropic support. On multivariate analysis, mean arterial pressure retained its significance. Prediction of withdrawal-to-asystole time is complex, but our analysis suggested that donor blood pressure at withdrawal is an important predictor of whether retrieval would be successful.

Kidney transplantation using the inferior epigastric vessels for multiple anastomoses from a pelvic kidney.

D T b p d m elvic kidney is a rare congenital malformation of renal scent during development. Such kidneys may be dysplasic, with suboptimal renal function. They are also known to ave multiple aberrant vessels and are associated with an ncreased risk of nephrolithiasis. If functionally normal, elvic kidney can be used for living donor kidney translantation. There are only six case reports in the transplanation literature of successful live donor renal transplantaion using pelvic kidneys in adults and one report in the ediatric setting. We report successful live donor translantation of a pelvic kidney with multiple blood vessels till functioning 4 years postoperatively, with the unique se of the inferior epigastric artery and vein to aid the nastomosis.

Impact of Cold Ischemia on Renal Transplant Outcomes Following Donation After Cardiac Death

Donation after cardiac death (DCD) provides grafts in renal transplantation but is associated with increased early graft dysfunction. Cold ischemia time (CIT) is a factor that is thought to affect outcomes in renal transplantation. We sought to assess the impact of the length of CIT among our DCD cohort of renal transplants performed between April 2002 and December 2009. Since the median CIT was 15.5 hours, we formed two groups CIT < 15.5 (n = 100) and CIT > 15.5 hr (n = 98). We demonstrated an increased incidence of DGF among the extended CIT group, but the long outcomes and the mean graft function were otherwise comparable. In conclusion, CIT affects early graft function; every effort should be made to minimize it in renal transplantation using DCD kidneys.

Successful outcome of paediatric en bloc kidney transplantation from the youngest donation-after-cardiac-death donor in the United Kingdom

We wish to highlight the successful outcome of en bloc kidney transplantation from the youngest donation after cardiac death (DCD) donor into a paediatric recipient in the United Kingdom. The donor (Maastricht Category III) was 2 years old and 12 kg male subject who died of drowning. Only kidneys were accepted for transplantation for a single recipient and were retrieved en bloc with aorta and vena cava. The recipient was a 15-year-old female subject weighing 40 kg, with end-stage renal failure secondary to familial nephritis and had a previous failed transplant caused by renal vein thrombosis. The en bloc allograft was implanted extraperitoneally in the left iliac fossa using a modification of the previously described Newcastle technique for graft implantation [1]. In their technique, the infrarenal portions of the aorta and cava are transposed to a ‘suprarenal’ position to facilitate lowering of kidneys in the pelvis and implantation of ureters of shorter length. However, as the liver was not retrieved in this case, and also as sufficient suprarenal aorta and inferior vena cava (IVC) were provided, vascular reconstruction was not required. At the back table, the aorta and IVC below the renal vessels, together with the origins of the coeliac and superior mesenteric arteries were over-sewn using 6.0 Prolene suture (Fig. 1). Graft implantation was to the external iliac vein and artery using continuous 6.0 Prolene suture. The ureters were implanted separately onto the bladder using ‘on-lay’ technique over pigtail stent using PDS sutures (Fig. 2). The first warm-, coldand second ischeamia times were 11 min, 11.5 h and 32 min respectively. Primary function was observed and postoperative recovery was uneventful. Immunosuppression consisted of tacrolimus, azathioprine and prednisolone. The patient remains well to date and 3-month creatinine was 84 lmol/l (0.95 mg/dl). The practice of transplanting paediatric en bloc kidneys is not universally accepted. Reports of increased organ discard rates, technical complications, graft thrombosis, rejection, decreased functional nephron reserve, and claims of suboptimal patient and graft survival have all contributed to the reluctance of many centres to transplant kidneys from the very young donors [2–4]. Vascular damage is not uncommon in these small kidneys and a leading cause for discard, particularly within a multiorgan procurement setting [5]. Furthermore, variable periods of first warm ischaemia, higher incidence of delayed graft function and impact on long-term graft survival associated with DCD donors mean that utilization of this source may be questioned. More recently, reports of successful outcomes of paediatric en bloc kidney transplantation into adult recipients has provided evidence of its efficacy [6–8] but its role in paediatric recipients and in the DCD setting remains controversial and little reported. Since 1988, there have been only 39 paediatric heartbeating en bloc donor kidney transplants in the United Kingdom and all into adult recipients. The mean donorand recipient ages for heart-beating en bloc donors were 3 (range 0–6 years) and 37 (range 15–72 years) years Figure 1 Graft preparation utilising a modified Newcastle technique [1]. Exclusion of the infra renal portion of the aorta and vena cava (dashed arrow) and origins of coeliac trunk and superior mesenteric artery (arrows).

Pleural myxoid liposarcoma: features of 2 cases and associated literature review

Primary pleural myxoid liposarcoma is a rare entity and no agreed treatment options have been formulated once diagnosis has been made. We report two cases with subsequent management and make recommendations for treatment pathways in these rare cases.