R. J. Millar

Successful ABO-incompatible kidney transplantation with antibody removal and standard immunosuppression.

ABO‐incompatible (ABOi) kidney transplantation is an established therapy, though its implementation to date has been in part limited by the requirement for additional immunosuppression. Here, we describe the outcomes of 37 patients undergoing ABOi kidney transplantation utilizing perioperative antibody depletion and receiving an identical tacrolimus‐based immunosuppressive regimen to contemporaneous ABO‐compatible (ABOc) recipients, with the exception that mycophenolate was commenced earlier (7–14 days pretransplant). Antibody depletion was scheduled according to baseline anti‐ABO antibody titer (tube IAT method: median 1:128, range 1:8 to 1:4096). Patient and graft survival for the 37 ABOi recipients was 100% after a median 26 months (interquartile range [IQR] 18–32). Eight rejection episodes (two antibody‐mediated and six cellular) in ABOi recipients were successfully treated with biopsy‐proven resolution. Latest median eGFR is 50 mL/min × 1.73 m2 (IQR 40–64) for ABOi patients and 54 mL/min × 1.73 m2 (IQR 44–66) in the ABOc patients (p = 0.25). We conclude that ABOi transplantation can be performed successfully with perioperative antibody removal and conventional immunosuppression. This suggests that access to ABOi transplantation can include a broader range of end‐stage kidney disease patients.

ABO‐Incompatible Renal Transplantation Without Antibody Removal Using Conventional Immunosuppression Alone

ABO incompatible living donor renal transplantation (ABOi) can achieve outcomes comparable to ABO compatible transplantation (ABOc). However, with the exception of blood group A2 kidneys transplanted into recipients with low titer anti‐A antibody, regimens generally include antibody removal, intensified immunosuppression and splenectomy or rituximab. We now report a series of 20 successful renal transplants across a range of blood group incompatibilities using conventional immunosuppression alone in recipients with low baseline anti‐blood group antibody (ABGAb) titers. Incompatibilities were A1 to O (3), A1 to B (2), A2 to O (2), AB to A (2), AB to B (1), B to A1 (9), B to O (1); titers 1:1 to 1:16 by Ortho. At 36 months, patient and graft survival are 100%. Antibody‐mediated rejection (AbMR) occurred in one patient with thrombophilia and low level donor‐specific anti‐HLA antibody. Four patients experienced cellular rejection (two subclinical), which responded to oral prednisolone. This series demonstrates that selected patients with low titer ABGAb can undergo ABOi with standard immunosuppression alone, suggesting baseline titer as a reliable predictor of AbMR. This reduces morbidity and cost of ABOi for patients with low titer ABGAb and increases the possibility of ABOi from deceased donors.

Two-stage brachiobasilic arteriovenous fistula for chronic haemodialysis access

Background:  Many haemodialysis patients are unable to have or maintain distal upper limb arteriovenous (AV) fistulas because of inadequate veins or arteries and therefore require more proximal access. We have reviewed our experience with a two‐stage brachiobasilic AV haemodialysis fistula fashioned in the arm.

Pyeloureterostomy in the Management of Renal Allograft Ureteral Complications: An Alternative Technique

Pyeloureterostomy is the standard procedure for reconstructing renal allograft ureteral complications. Most reports describe an end-to-end technique with or without native nephrectomy. An alternative is an end-to-side anastomosis, leaving the native ureter in continuity. We report our experience with the latter method. Since July 1983, 437 renal transplantations have been performed at our institution. End-to-side pyeloureterostomy has been used in 5 cases for urological reconstruction after renal transplantation following ureteral ischemic necrosis or stenosis. In 1 patient the native kidneys had been removed several years previously but in the remaining 4 the native kidneys were left in situ. There have been no significant complications following this procedure. We believe that by not significantly mobilizing, ligating or dividing the native ureter the chance of anastomotic breakdown due to ischemia may be decreased.

Diabetes mellitus as the only manifestation of occult phaeochromocytoma prior to acute haemorrhage in pregnancy

Phaeochromocytoma is a rare tumour arising from adrenal chromaffin cells that causes hypertension in an estimated 0.2% of the general population. It occurs in approximately one in 50 000 pregnancies. If unrecognised, phaeochromocytoma can produce a devastating outcome for both the woman and her fetus. We report a rare case of diabetes mellitus as the only manifestation of an occult phaeochromocytoma, prior to acute haemorrhage in mid-trimester of pregnancy.

SE18 A TALE OF TWO COLLEGES: DO SPECIALIST TRAINEES RECEIVE ADEQUATE HOSPITAL‐BASED TRAINING?

Purpose  Both medical and surgical trainees have a dual reliance on their specialist training college and their respective teaching hospitals to maintain standards in teaching and training. Although guidelines are in place for the administration of this teaching, hospital‐based teaching has been minimally regulated. A review of trainee satisfaction with current levels of hospital‐based training was performed, both to reflect the thoughts of trainees themselves and to highlight specific areas requiring improvement.