R. Bertelli

Urological Complications After Kidney Transplantation: Experience of More Than 1000 Transplantations

OBJECTIVE Urinary fistulas and stenoses are the most common complications that may require surgical revision after kidney transplantation. The aim of this study was to retrospectively assess the incidence of and risk factors for early (within 30 days) or late major urological complications (stenoses and fistulas) after kidney transplantation. PATIENTS AND METHODS The study population comprised 1142 consecutive patients who underwent kidney transplantation between January 1990 and September 2007. Endpoints were early and late urological complications (stenoses and fistulas). The variables considered upon multivariate and univariate analyses were: recipient age, sex, etiology of renal failure, number (first/second) and type (single/double/combined with other organs) of kidney transplantations, cold ischemia time, type of urinary reconstruction, stent positioning, as well as donor cause of death, sex, age, and serum creatinine and clearance. We also examined the presence of graft polar arteries, acute rejection episodes, and postoperative graft function. RESULTS Among 1142 transplantation performed at our center, 100 patients (8.7%) experienced 107 urological complications: 85 (79.4%) were early (56 fistulas, 29 stenoses) and 22 (20.5%) late (7 fistulas and 15 stenoses). Multivariate analysis for all complications revealed significant associations with male recipient sex (P = .00, HR = 2), while first kidney transplantation was protective (P = .00, HR = .4). Male gender both of the recipient and of the donor was significantly associated with early fistulas (P = .01, HR = 2.5 and P = .02, HR = 2, respectively). First (versus second) kidney transplantation had a protective effect on early stenoses (P = .01, HR = .27). Late fistulas were associated with anastomotic stenting (P = .03) in univariate but not multivariate analysis. Multivariate analysis for late stenoses did not demonstrate any significant association with the considered variables; however, the late stenosis cases showed significantly higher recipient and donor ages (P < .05) and a lower donor creatinine clearance (P < .05). The type of urinary anastomosis, stenting, cold ischemia time, presence of polar arterial branches, and type of transplantation did not influence the incidence of urinary fistulas or stenoses. CONCLUSIONS Our data confirmed that older recipients and organs from older donors, especially of male gender, and retransplantations are to be considered risk factors for urological complications. The present analysis cannot suggest any modification of the actual surgical strategy that would prevent urological complications in kidney transplantation.

Analysis of 80 dual-kidney transplantations: a multicenter experience.

INTRODUCTION The use of kidneys from expanded criteria donors (ECD) is an attractive strategy to enlarge the pool of organs available for transplantation. Considering the fact that ECD organs have a reduced nephron mass, they are preferentially allocated for dual-kidney transplantation (DKT). Authors have reported excellent results of DKT when pretransplant ECD organs are evaluated for histological scores. The aim of this study was to evaluate DKT donor and recipient characteristics for comparison with DKT posttransplant outcomes versus those of recipients of single-kidney transplantations from expanded criteria (edSKT) and ideal donors (idSKT). We analyzed the potential prognostic factors involved in DKT among a population derived from three transplant centers. MATERIALS AND METHODS Between 2001 and 2007, DKT (n = 80) were performed based upon the ECD kidney allocation assessed by biopsy. RESULTS The average donor ages for the DKT, edSKT, and idSKT groups were 68.8 ± 7.8, 65.3 ± 7.2, and 40.1 ± 13.8 years, respectively (P < .001). The number of human leukocyte antigen mismatches was greater in the DKT group (3.1 ± 1.2, P < .05). Patient and graft 5-year survival rates were similar among DKT, edSKT, and idSKT recipients, namely, 97.5% versus 95.8% versus 96.9% and 93.7% versus 87.4% versus 86.9%, respectively. Mean serum creatinine values at discharge were lower in the DKT and idSKT recipients (1.5 ± 0.9 and 1.6 ± 0.7 mg/dL; P < .05) compared with the edSKT group (1.9 ± 0.7 mg/dL). Correlations between supposed prognostic factors and survival among the DKT group noted worse outcomes in reoperation cases (P < .05). CONCLUSION We confirmed that DKT produced successful outcomes. An accurate surgical procedure is particularly important to try to avoid reoperations. In our experience, the use of a biopsy as an absolute criterion to allocate ECD kidneys may be too protective.

Gastrointestinal Perforations Following Kidney Transplantation

This study reports major gastrointestinal (GI) complications among a group of 1611 patients following kidney transplantation. The immunosuppressive regimen changed somewhat during the course of the study but included azathioprine, prednisolone, antilymphocyte globulin, cyclosporine, tacrolimus, mycophenolate mofetil, and sirolimus. Perforations occurred in the colon (n=21), small bowel (n=15), duodenum (n=6), and stomach (n=4). Nearly 50% of the complications occurred while patients were being given high-dose immunosuppression to manage either the early postoperative period or acute rejection episodes. Of the 46 patients affected, 11 (24%) died as a direct result of the GI complication. This high mortality appeared to be related to the effects of the immunosuppression and the associated response to sepsis. Reduction of these complications may be achieved by improved surgical management, preventive measures, prompt diagnosis, and a reduced immunosuppressive protocol.

Aortoiliac surgery concomitant with kidney transplantation: a single center experience

Abstract:  Introduction:  Aortoiliac pathology in kidney allograft recipients is not rare but treatment timing is controversial. As most publications on this topic are case reports it’s difficult to evaluate long‐term outcomes of those clinical challenges. Herein we report long‐term results of these procedures.

Multicenter study on double kidney transplantation.

BACKGROUND Marginal organs not suitable for single kidney transplantation are considered for double kidney transplantation (DKT). Herein we have reviewed short and long-term outcomes of DKT over a 7-year experience. PATIENTS AND METHODS Between 2001 and 2007, 80 DKT were performed in the transplant centers of Bologna, Parma, and Modena, Italy. Recipient mean age was 61+/-5 years. The main indications were glomerular nephropathy (n=33) and hypertensive nephroangiosclerosis (n=14). Mean HLA A, B, and DR mismatches were 3.1+/-1.2. Donor mean age was 69+/-8 years and mean creatinine clearance was 75+/-27 mL/min. Almost all kidneys were perfused with Celsior solution. Mean cold ischemia time was 17+/-4 hours and mean warm ischemia time was 41+/-17 minutes. Mean biopsy score was 4.4. Immunosuppression was based on tacrolimus (n=52) or cyclosporine (n=26). RESULTS Fifty (62.5%) patients displayed good postoperative renal function. Thirty (37.5%) experienced acute tubular necrosis and required postoperative dialysis treatment; 8 acute rejections occurred. Urinary complications were 13.7% with 8/11 requiring surgical revision. There were 6 surgical reexplorations: intestinal perforation (n=2), bleeding (n=3), and lymphocele (n=1). Two patients lost both grafts due to vascular and infectious complications at 7 or 58 days after transplantation. Two patients underwent intraoperative transplantectomy due to massive vascular thrombosis. Four (5%) patients underwent transplantectomy of a single graft due to vascular complications (n=2), bleeding (n=1), or infectious complications (n=1). Graft and patient survivals were 95% and 100% versus 93% and 97% at 3 versus 36 months, respectively. CONCLUSIONS DKT is a safe approach for organ shortage. The score used in this study is useful to determine whether a kidney should be refused or accepted.

Extracorporeal Portal Vein Oxygenation Improves Outcome of Acute Liver Failure in Swine

BACKGROUND Portal vein arterialization (PVA) has shown efficacy to treat acute liver failure (ALF) in preclinical studies. The next step is to perform large animal studies that propose a clinically acceptable method of PVA. In this study, we assessed the efficacy of PVA using an extracorporeal device to treat 2 ALF models in swine. MATERIALS AND METHODS The 2 ALF swine models were carbon tetrachloride toxic ALF and subtotal hepatectomy using 8 animals per group. PVA was performed with an extracorporeal device that may be suitable for future clinical studies. Arterial blood was drawn from the iliac artery and delivered into the portal vein for a 6-hour treatment. We analyzed biochemical, blood gas, and histological parameters as well as 1-week survival rates. RESULTS In both models, ALF was successfully achieved. Control group animals deteriorated biochemically, dropping their prothrombin times and increasing the liver enzymes. In contrast, treated animals improved with a survival rate of 75% at 7 days compared with 0% for the former group. CONCLUSIONS PVA using an extracorporeal device was feasible and effective to treat both toxic and resective ALF in swine.

Endolymphatic immunotherapy in inoperable hepatocellular carcinoma.

INTRODUCTION We report the preliminary results of endolymphatic immunotherapy in patients with inoperable hepatocellular carcinoma (HCC). METHODS From 2003 to 2005 we enrolled 31 patients with inoperable HCC. The patients underwent monthly endolymphatic injections of 15-30 x 10(6) interleukin-2 (IL-2)-activated peripheral autologous lymphocytes (LAK) and 250 IU of IL-2. Follow-up included blood biochemistry every 3 months and imaging studies every 6 months. To assess therapy efficacy we considered 12 biochemical parameters, vascular invasion or thrombosis, Child-Pugh scoring system, histological grading, lymphadenopathy, viral state, and alpha-fetoprotein. RESULTS Sixteen patients completed at least 3 cycles, and 10 patients completed more than 6. No clinically significant adverse reactions occurred. Imaging studies showed no significant decrease in tumor mass. However, the survival of patients who completed 12 therapy cycles was significantly higher than survival of patients with fewer than 12 cycles. Both are significantly higher than that of untreated patients. All patients with 12 completed cycles showed an improvement of 9 parameters or more. DISCUSSION Endolymphatic immunotherapy is safe, easily performed, inexpensive, and effective in terms of survival. This study should encourage future large-scale investigations so as to reach a firmer conclusion and define uniform inclusion criteria.

A New Swine Training Model of Hand-Assisted Donor Nephrectomy

INTRODUCTION Despite the described advantages of hand-assisted laparoscopic donor nephrectomy (HALDN), the learning curve risks discourage many transplant centers to switch from the traditional technique to the laparoscopic approach. Considering that the learning curve risk may be softened with practice on a training model the aim of this study was examine a low-cost, high-fidelity model of HALDN in pigs. METHODS Ten female white pigs underwent a left and then a right HALDN in the same session for a total of 20 procedures. For each nephrectomy, we assessed operative times and intraoperative complications. All nephrectomies were performed by a single senior transplantation surgeon. RESULTS All animals that survived bilateral nephrectomy were sacrificed. Two right HALDNs were converted to open procedures due to bleeding. One spleen lesion and one lumbar vein injury were treated laparoscopically. Considering only the 18 HALDN completed, we registered a mean total operative time of 75.4 min (range=52 to 120). DISCUSSION The in vivo training model described herein made it possible to reproduce the positions and operative difficulties similar to those encountered in clinical practice. Moreover, the costs can be considerably reduced by performing two procedures in each animal employing reusable instruments. Our model represented a valid high-fidelity training procedure that was useful and convenient to achieve skills for HALDN that may help transplantation centers adopt this technique to reduce the learning curve risk.

An experimental pilot study on controlled portal vein arterialization with an extracorporeal device in the swine model of partial liver resection and ischemia.

Aim To determine whether the physiologically oxygenated arterial blood reversed in the portal system by means of portal vein arterialization (PVA) through an extracorporeal device which we have called L.E.O2.NARDO (Liver Extracorporeal Oxygen. NARDO) is effective in treating swine with subtotal hepatectomy leading to acute liver failure (ALF). Methods Ten swine with ALF induced by 85–90% liver resection and five minutes of ischemia-reperfusion injury were randomly divided into two groups: five animals received PVA extracoporeal treatment and five swine were not-treated (control group). Blood was withdrawn from the iliac artery and reversed in the portal venous system. An extracorporeal device was interposed between the outflow and the inflow in order to monitoring the hemodynamic parameters. Each treatment lasted 6 hours. Serum and liver samples were collected in both groups. The survival was assessed at 1 week. Results The PVA-extracorporeal treatment yielded beneficial effects for subtotal hepatectomy-induced ALF swine with decreased serum ammonia, transaminases and total bilirubin as compared with the untreated group. INR recovered rapidly in the PVA-extracorporeal group remaining significantly lower than in untreated animals. The 7-day survival of PVA-extracorporeal group swine was significantly higher than that of untreated animals, with a statistically significant difference (p<0.05). Four swine in the PVA-extracorporeal group survived at 1 week while none of the swine in the control group were alive at that time; an average time of 144h±13h and 24.4h±5h was observed in the PVA-extracorporeal and control groups, respectively. Conclusions Arterial blood supply in the portal system through the extracorporeal device is easily applicable, efficacious, safe and may represent a novel approach for ALF swine induced by subtotal liver resection.

Hand-Assisted Laparoscopic Donor Nephrectomy: Analysis of the Learning Curve in a Training Model In Vivo

INTRODUCTION Hand-assisted laparoscopic donor nephrectomy (HALDN) outcomes are impaired mainly by the risks associated with the learning curve. Considering that practice by in vivo training may reduced this risk, we recently assessed a swine model of HALDN. The aim of this study was to analyze the learning curve of HALDN using an in vivo training model. MATERIALS AND METHODS Ten female white pigs underwent a left and then a right HALDN in the same session for a total of 20 procedures by the same first operator. The HALDN were divided into 2 groups: group A, the first 10 nephrectomies and group B, the latter 10. For each group, we assessed operative times, intraoperative complications, estimated blood loss (EBL), warm ischemia time (WIT), and graft quality. RESULTS We observed a significant decrease in operative times among group B. Two right HALDN of group A were converted to open procedures owing to bleeding. The EBL was consequently lower in group B (P < .05); the mean WIT was not significantly different between the 2 study groups. The graft quality was good in 5/8 kidneys evaluated in group A and 9/10 in group B. DISCUSSION Standardization of analyzed parameters after a number of procedures, which were comparable to the clinical settings, confirmed the validity of this in vivo training model and its potential utility to allow many transplantation centers to adopt this technique by reducing the risk of the learning curve.