Steve Mellor

Risk factors for acute rejection in renal transplant recipients experiencing delayed graft function

Abstract:  Acute rejection (AR) superimposed upon delayed graft function (DGF) following renal transplantation worsens graft outcomes. However, risk factors for AR in patients displaying DGF remain unclear. In this study, 71 patients displaying DGF ≥ 5 d were investigated. All received cyclosporine, adjunctive azathioprine or mycophenolate mofetil (MMF), and corticosteroids, with 43 receiving anti‐CD25 monoclonal antibody induction. AR episodes were seen in 20 of 71 (28%) patients. Higher C2 levels at days 3 and 5 and the use of MMF were associated with a reduced incidence of AR, with increased HLA‐DR mismatch associated with an increased risk for AR. C2 levels at days 3 and 5 below 885 and 1096 ng/mL, respectively, showed best discriminatory values for AR. C2 levels showed no correlation with DGF duration. This study suggests that optimizing immunosuppression in patients with DGF (by ensuring adequate calcineurin inhibitor exposure and the use of potent adjunctive immunosuppression) may reduce the incidence of AR without prolonging the duration of dialysis requirement.

The brachiobasilic arteriovenous fistula: effect of patient variables

Purpose The hemodialysis population is constantly expanding as patients on dialysis have increased longevity and the number of kidneys available for transplantation remains static (1). After radiocephalic and brachiocephalic fistulas have been exhausted the use of the autologous brachiobasilic fistula (BBAVF) should be considered prior to use of a synthetic graft. We present our single center experience of 140 brachiobasilic fistulas in a five-year period and examine any factors that influence patency and long-term function. Methods Patients who had undergone formation of a BBAVF between January 2004 and January 2009 were identified; a review of all case notes and databases was undertaken. Details on demographics, cause of renal failure, co-morbidities (including diabetes, cardiac morbidity, hypertension, peripheral vascular disease), dialysis status at the time of fistula creation, hemoglobin, anti-coagulation regimens, and complications from surgery were recorded. Results Patency (defined as use of AVF for dialysis) was 83% at 3 months, 77% at 6 months, and 69% at 12 months. Length of patency ranged from 0 to 1918 days (at study cut-off) with a mean patency of 532 days. Factors found to significantly affect fistula patency included age over 60 (P=<0.001) and presence of peripheral vascular disease (P=0.048). Conclusions Our brachiobasilic fistula patency rates are comparable with published literature and other fistulas. Within our population patient variables including age over 60 and the presence of peripheral vascular disease are associated with worse outcomes as would be expected. In spite of these factors we feel the brachiobasilic fistula is an excellent option for patients with more challenging access and should certainly be undertaken prior to the use of prosthetic grafts.

Anti-tuberculosis prophylaxis following renal transplantation: acceptable variations?

Guidelines suggest tuberculosis (TB) prophylaxis in renal transplant recipients originating in endemic areas or in those at risk from non‐endemic countries. Concern remains that these guidelines may fail to provide adequate prophylaxis for a cohort of patients who remain at potential risk. We aimed to determine variation patterns among different transplant units within the United Kingdom (UK) with regard to TB prophylaxis policy.

Pseudotumoral presentation of fungating mycetoma caused by Phaeoacremonium fuscum in a renal transplant patient

Eumycetoma is an unusual infection in immunocompromised patients outside the tropics, caused by a variety of fungal pathogens. We describe the case of a 51‐year‐old renal transplant recipient who presented with a large pseudotumoral foot lesion necessitating complete surgical excision of the lesion. Cultures and molecular diagnosis confirmed Phaeoacremonium fuscum. This is the first case, to our knowledge, of fungating mycetoma caused by this fungal species in a solid organ transplant recipient.

Calciphylaxis following kidney transplantation: a case report

IntroductionCalciphylaxis occurring after kidney transplantation is rare and rarely reported. It results in chronic non-healing wounds and is associated with a poor prognosis and is often fatal. We present a case of proximal lower limb calciphylaxis that occurred early after kidney transplantation. The patient had no classic associated risk factors. He had previously had a total parathyroidectomy but had normal serum calcium-phosphate product and parathyroid hormone levels. The clinical outcome of this case was favorable and highlights some fundamental issues relating to management.Case presentationA 70-year-old British Caucasian man with end-stage renal failure secondary to IgA nephropathy presented six months post kidney transplantation with cutaneous calciphylaxis lesions involving the medial aspect of the thigh bilaterally.ConclusionTo the best of our knowledge, this is the first reported case of rapid onset cutaneous calciphylaxis occurring soon after kidney transplantation that was associated with a favorable outcome. Cutaneous calciphylaxis lesions should be promptly managed with meticulous wound care, antimicrobial therapy and the correction of calcium-phosphate product where indicated.

The novel use of infrared thermal imaging as an adjunct for the management of haemodialysis access induced distal ischaemia

Introduction Haemodialysis access-induced distal ischaemia (HAIDI) whilst unusual may be a difficult complication to diagnose and manage particularly in patients with small vessel disease. Infrared thermal imaging (IRTI) has been used for several decades to monitor cutaneous temperature distribution and has been used in medical applications. The use of IRTI in HAIDI is attractive as it can be used as a non-invasive measure of tissue perfusion. Method and Results To assess the applicability of IRTI in HAIDI, three cases were assessed and are described. IRTI was well tolerated and provided useful clinical information in all three cases, which was confirmed with further studies. Conclusions This small case series reports on the successful use of infrared thermal imaging in the diagnosis and management of possible HAIDI and may support wider study and use.

Hand-Assisted Laparoscopic Donor Nephrectomy Are Hand Port Devices Really Necessary?

Background. Hand port devices (HPD) are used routinely for hand-assisted laparoscopic surgery including hand-assisted laparoscopic donor nephrectomy (HALDN). However, the cost of such devices may prove prohibitive, particularly in centers with financial constraints. The authors aimed to identify any adverse effects of performing device-free HALDN. Methods. A retrospective analysis was performed of patients undergoing HALDN at the authors’ unit over a 3-year period (2007-2010). Eighty-four patients underwent device-free HALDN, whereas in 80 patients a HPD was used. The primary endpoint was duration of operation, with secondary endpoints including postoperative wound infections and incisional hernias. Results. here was no difference in duration of operation for the device free (98 minutes; range = 43-215 minutes) compared with the HPD group (94 minutes; range = 36-180 minutes; P = .37). A device was required in 3 (3.6%) patients in which a device-free approach was attempted. There was no difference in either group in terms of rates of postoperative wound infections (0% vs 2.5%, respectively; P = .24) or incisional hernia incidence (1.5% vs 1.4%, respectively; P = .50). Conclusion. Device-free HALDN can be performed with no discernable compromise in operating time or patient outcome. This has implications in both cost benefit and translation of this technique to developing units.

Do arteriovenous fistulae cause technical/local complications after renal transplantation?

cations in AV fistulas is reassuringly low. This study excludes the cardiac sequelae of AVFs post transplantation as this has previously been demonstrated whilst surgical and technical complications within this group have not previously been reported. While the debate continues to define the physiologic cardiac sequelae of AVFs in the transplant population, we have demonstrated that the rate of development of technical complications commonly encountered in fistulas over a longitudinal period remains acceptable. Further study will hopefully unequivocally demonstrate whether cardiac effects because of AVFs are sufficient to suggest ligation in all working transplants; the incidence of other complications appears sufficiently low to not routinely mandate this action at present. This is of particular relevance with the increased use of marginal kidneys for transplantation, because of a decreased donor pool, with concomitant limited expectations of long-term graft survival.