R. W G Gruessner

Early versus late acute renal allograft rejection : impact on chronic rejection

We studied the effect of acute renal allograft rejection and its timing on the development of chronic rejection and subsequent graft loss. Between January 1, 1987 and April 30, 1991, 424 patients at the University of Minnesota received a primary kidney transplant (minimum follow-up, 1 year). Patients were subdivided by donor source, presence or absence of acute rejection, and the timing of acute rejection onset (early, ≤ 60 days vs. late, > 60 days post-transplant). For living donor (LD) transplant recipients (n=219), the incidence of chronic rejection is 0.8% in those who had no acute rejection (n=130), 20% in those with acute rejection ≤60 days (n=59) (P<0.001 vs. no acute rejection), and 43% in those with acute rejection > 60 days (n=30) (P<0.001 vs. no acute rejection, P=0.04 vs. early acute rejection). For cadaver (CAD) transplant recipients (n=205), the incidence of chronic rejection is 0% in those who had no acute rejection (n=109), 36% in those with acute rejection ≤ 60 days (n=69) (P<0.001 vs. no acute rejection), and 63% in those with acute rejection > 60 days (n=27) (P<0.001 vs. no acute rejection, P=0.03 vs. early acute rejection). For both LD and CAD recipients, no grafts have been lost to chronic rejection among those who did not first have at least 1 acute rejection episode. In contrast, 23 patients with acute rejection have had graft loss to chronic rejection. For both LD and CAD recipients, those with > 1 acute rejection episode had significantly more chronic rejection than those with only 1 rejection (P<0.05). There was no significant difference in the incidence of chronic rejection based on whether the first acute rejection episode was steroid resistant or steroid responsive. We conclude that acute rejection is strongly related to the development of biopsy-proven chronic rejection and subsequent graft loss. Patients undergoing their first acute rejection episode > 60 days (vs. ≤ 60 days) have an increased incidence of chronic rejection.

Short- and long-term outcomes of kidney transplants with multiple renal arteries

ObjectiveThe authors determined whether the use of kidney allografts with multiple renal arteries adversely affects post-transplant graft and patient outcome or increases the incidence of vascular and urologic complications. BackgroundKidney grafts with multiple renal arteries have been associated with an increased incidence of early vascular and urologic complications. Kidney transplants with single versus multiple renal arteries have not been compared in regard to long-term graft and patient outcome or post-transplant incidence of hypertension, acute tubular necrosis, rejection, and late vascular and urologic complications. MethodsWe analyzed 998 adult kidney transplants done from December 1, 1985 through June 30, 1993, in which only the recipients external or internal iliac artery was used for anastomosis. We divided the study population into 3 groups: Group A—1 renal artery, 1 arterial anastomosis (n = 835), Group B—>1 renal artery, 1 arterial anastomosis (n = 112), Group C—>1 renal artery, >1 arterial anastomosis (n = 51). We compared the incidence of post-transplant hypertension, acute tubular necrosis, acute rejection, and vascular and urologic complications; mean creatinine levels at 1, 3, and 5 years post-transplant; and patient and graft survival. Univariate and multivariate analyses were done to identify risk factors for vascular complications. ResultsWe found no significant differences among the three groups for the following variables: post-transplant hypertension, acute tubular necrosis, acute rejection, creatinine levels, early vascular and urologic complications, and graft and patient survival. In kidneys with single arteries, the presence (vs. absence) of an aortic patch and the type of the arterial anastomosis (end-to-end to the hypogastric vs. end-to-side to the external iliac artery) did not have an impact on the incidence of early or late vascular complications. In kidneys with multiple arteries, only the rate of late renal artery stenosis was higher, the rate of early vascular and urologic complications was not different. Our multivariate analysis identified acute tubular necrosis as a risk factor for renal artery and vein thrombosis; graft placement on the left side for arterial thrombosis; and preservation time ≥ 24 hours and multiple renal arteries for renal artery stenosis.

Pancreas transplants from living related donors

Living related donors (LRDs) were first used for kidney transplantation [1]. The consistently high patient and graft survival rates of LRD kidney transplants have led to their increasing popularity in the United States, accounting for up to 50% of all kidney transplants at some centers. The pancreas was the first extrarenal solid organ in which successful LRD transplants were done [2]. Over the last 5 years, the use of LRDs has received increasing attention for liver [3], lung [4], and intestinal [5] transplantation

Living related liver transplantation in infants and children: Report of anesthetic care and early postoperative morbidity and mortality

STUDY OBJECTIVE To determine those infants at high risk for perioperative complications and mortality following living, related liver transplantation. DESIGN Retrospective chart review. SETTING Large metropolitan teaching hospital. MEASUREMENTS AND MAIN RESULTS The charts and anesthetic records of the 12 infants and children who received the left lateral hepatic segment from a living relative the past 2 years at our institution were reviewed. The records were examined to determine the causes of perioperative morbidity and to identify patients at high risk for serious complications and mortality. All infants and children (mean +/- SD age, 29+/-30 months; weight, 13.6 +/-6.8 kg) survived the operation (8.3+/-1.7 hours) without intraoperative complications. The average blood loss, including 500 mL of recipient blood used to flush the liver before reperfusion, was 1483 +/-873 mL (119+/-70 mL/kg). Three infants developed portal vein thrombosis, and one of these infants also had hepatic artery thrombosis. The risk of vessel thrombosis was significantly higher (3/3 vs. 0/9; p<0.0045) in infants less than 9 kg body weight, as was the risk of death (2/3 vs. 0/9; p<0.045). Both children who died had vascular thrombosis. Other serious complications were bleeding, 6; infection, 7; acute rejection, 3; and bile leak, 2. CONCLUSIONS Infants and children can successfully undergo living, related liver transplantation. However, the risks of vascular complications and death are greater in infants less than 9 kg body weight.

Anesthetic complications including two cases of postoperative respiratory depression in living liver donor surgery

Background: Living liver donation is becoming a more common means to treat patients with liver failure because of a shortage of cadaveric organs and tissues. There is a potential for morbidity and mortality, however, in patients who donate a portion of their liver. The purpose of this study is to identify anesthetic complications and morbidity resulting from living liver donor surgery. Patients and Methods: The anesthetic records of all patients who donated a segment of their liver between January 1997 and January 2006 at University of Minnesota Medical Center-Fairview were retrospectively reviewed. The surgical and anesthesia time, blood loss, hospitalization length, complications, morbidity, and mortality were recorded. Data were reported as absolute values, mean ± SD, or percentage. Significance (P < 0.05) was determined using Students paired t tests. Results: Seventy-four patients (34 male, 40 female, mean age = 35.5 ± 9.8 years) donated a portion of their liver and were reviewed in the study. Fifty-seven patients (77%) donated the right hepatic lobe, while 17 (23%) donated a left hepatic segment. The average surgical time for all patients was 7.8 ± 1.5 hours, the anesthesia time was 9.0 ± 1.3 hours, and the blood loss was 423 ± 253 ml. Forty-six patients (62.2%) received autologous blood either from a cell saver or at the end of surgery following acute, normovolemic hemodilution, but none required an allogenic transfusion. Two patients were admitted to the intensive care unit due to respiratory depression. Both patients donated their right hepatic lobe. One required reintubation in the recovery room and remained intubated overnight. The other was extubated but required observation in the intensive care unit for a low respiratory rate. Twelve patients (16.2%) had complaints of nausea, and two reported nausea with vomiting during their hospital stay. There were four patients who developed complications related to positioning during the surgery: Two patients complained of numbness and tingling in the hands which resolved within two days, one patient reported a blister on the hand, and one patient complained of right elbow pain that resolved quickly. Postoperative hospitalization averaged 7.4 ± 1.5 days. There was no patient mortality. Discussion: Living liver donation can be performed with low morbidity. However, postoperative respiratory depression is a concern and is perhaps due to altered metabolism of administered narcotics and anesthetic agents.

IMPROVEMENT OF PATIENT AND GRAFT SURVIVAL IN PANCREAS TRANSPLANTS ALONE (PTA): 2431

Introduction: Whole organ pancreas transplantation in patients with labile insulin-dependant diabetes mellitus achieves excellent metabolic control and avoids or ameliorates secondary diabetic complications. Patients can undergo pancreas transplant alone (PTA), simultaneous pancreas and kidney (SPK) or pancreas after kidney transplant (PAK). Since the time on the wait-list for a SPK is significantly longer than for a PTA and SPK is associated with a significantly higher mortality on the wait-list, a solitary pancreas transplant should theoretically be the preferred procedure. However, there is of reluctance to recommend solitary transplants because of relatively high rejection and graft loss rates in comparison to SPKs. We analyzed the most recent outcomes for PTA vs SPK to identify subgroups with improved outcome. Methods: From January 1, 2005, through December 31, 2009, 5,699 primary deceased donor pancreas transplants were reported to IPTR/UNOS; of those, 4,266 were SPKs, 958 PAKs and 475 PTAs. Univariate and multivariate analyses were done to identify subgroups with improved patient and graft survival. Results: Significant differences of the recipient and donor characteristics were noted between the 2 transplant categories. While significantly more male patients received a SPK, the rate was reversed for PTAs. On average, SPK recipients were older and showed a longer duration of their disease. Enteric drainage was used in 91% of SPKs and in 79% of PTAs. The multivariate analysis identified a large subgroup of PTA recipients with excellent outcome. All patients in this group received anti-T-cell induction therapy in combination with Tacrolimus (TAC) and MMF as maintenance immunosuppression (IS). The type of duct management had no impact on outcome. Table 1 shows patient and graft survival rates during the first year post-transplant. Of note are the low technical failure and the excellent patient survival rates for PTAs. Early PTA graft survival exceeded the one of SPK and showed similar results at one year.

LIVING LIVER DONOR SURGERY: REPORT OF INITIAL ANESTHESIA EXPERIENCE

The charts and anesthetic records of 12 patients who donated the left lateral segment of their liver to a related infant or child to treat liver failure were retrospectively reviewed. Blood loss, need for transfusion, fluids administered, surgical length, and perioperative complications were investigated. The records also were examined to determine the hemodynamic stability of patients undergoing donor hepatectomy to assess their need for invasive monitoring. There were no episodes of hypotension or hemodynamic instability. The average operating time was 9.6 +/- 1.1 hours. The blood loss was 562 +/- 244 mL (range 300 to 1100 mL). Four patients received their own cell saver blood (200 mL, 220 mL, 300 mL, 475 mL), and one patient received 1 U (350 mL) of predonated autologous blood. The average hemoglobin decreased significantly (p = 0.001) from a preoperative value of 14.1 +/- 1.2 to 12.3 +/- 1.8 g/dL in the recovery room. All patients were extubated in the operating room or recovery room. Patients were discharged home in 6.9 +/- 1.3 days (range 5 to 9 days). Living-related liver resection can be performed with noninvasive monitoring and without the need for heterologous blood products.