William P. Shields

Renal artery aneurysm treated with ex vivo repair and autotransplantation

Renal artery aneurysms are being encountered more frequently due to a wider use of angiography. As the risk of rupture is unclear, the indications for surgery remain controversial. Despite advances in treatment, complex aneurysms often require nephrectomy for adequate excision. We report a case of an incidentally diagnosed renal artery aneurysm successfully treated with extracorporeal repair and autotransplantation. Ex vivo repair and renal autotransplantation is a safe and effective treatment for the management of complex renal artery aneurysms

Dual kidney transplantation with organs from extended criteria cadaveric donors.

PURPOSE The critical shortage of kidneys available for transplantation has led to alternate strategies to expand the pool. Transplantation of the 2 kidneys into a single recipient using organs suboptimal for single kidney transplantation was suggested. We assessed results in 24 grafts allocated for dual kidney transplantation vs those in a control group of 44 designated for single kidney transplantation. Each group underwent pretransplant biopsy and recipients were age matched. MATERIALS AND METHODS Dual kidney transplantation was done in 24 of 1,091 transplants (2.1%) from 2001 to 2008. In patients with dual kidney transplant vs single kidney transplant mean recipient age was 60.6 vs 60.8 years, mean HLA-A, B and DR mismatches were 3.3 vs 2.9, and average patient waiting time was 15.6 vs 13.9 months. All grafts were perfused with University of Wisconsin solution with a mean cold ischemia time of 17.9 hours. On donor dual kidney biopsy in the dual kidney transplant vs single kidney transplant group the average fibrosis rate was 30% (range 25% to 45%) vs 25% (range 3% to 40%) and the glomerulosclerosis rate was 17.9% (range 3.2% to 40.7%) vs 7.1% (range 0% to 50%). RESULTS Good postoperative renal function was noted in 14 dual kidney transplantation cases. Acute tubular necrosis requiring dialysis developed in 5 patients as well as acute rejection in 1. Two dual kidney recipients (8%) died in the postoperative period with no single kidney deaths. One patient underwent bilateral transplantectomy. Mean anesthesia time was longer in the dual group (371 vs 212 minutes). Patient and graft survival was equivalent to that in the control group at 36 months. CONCLUSIONS Careful selection of marginal kidneys based on clinical and histological criteria allows the use of organs that would not ordinarily be sufficient for transplantation with acceptable outcomes. This is a valid strategy to address the organ shortage.

Long-term outcome of intensive initial immunosuppression protocol in pediatric deceased donor renal transplantation

Olaitan OK, Zimmermann JA, Shields WP, Rodriguez‐Navas G, Awan A, Mohan P, Little DM, Hickey DP. Long‐term outcome of intensive initial immunosuppression protocol in pediatric deceased donor renal transplantation. 
Pediatr Transplantation 2010: 14: 87–92.

Predictors of 10-year pancreas allograft survival after simultaneous pancreas and kidney transplantation.

Objective This study aimed to identify the preoperative, perioperative, and postoperative factors affecting 10-year pancreas allograft survival after simultaneous pancreas and kidney (SPK) transplantation. Methods Analysis was performed on a prospectively maintained database of 56 SPK transplants consecutively performed between January 1992 and October 2002. The definition cutoff points of specific variables were obtained by the receiver operating characteristic curve and multiple logistic regression analyses that were performed to determine the predictors of pancreas allograft survival after 10 years. Results In total, 44 (79%) patients had an overall survival of more than 10 years, and the overall 10-year pancreas allograft survival rate was 57% (n = 32/56). The significant predictors for pancreas allograft failure in 10 years and above were kidney allograft failure (P = 0.04), serum creatinine 1 year postoperatively (P = 0.002), and serum hemoglobin A1c (HbA1c) level 2 years postoperatively (P = 0.003). A serum creatinine cutoff value of more than 129 &mgr;mol/L at 1 year was 87.5% sensitive and 70% specific for predicting pancreas allograft failure at 10 years. Serum HbA1c of more than 5.6% at 2 years was 85.7% sensitive and 62.5% specific for predicting pancreas allograft failure at 10 years. On multivariate analysis, 129 &mgr;mol/L and above of serum creatinine and more than 5.6% of serum HbA1c were the independent predictors of pancreas allograft failure at 10 years. Conclusions These findings may provide important information for identifying patients at risk for long-term pancreas allograft failure after SPK transplantation.

Mycophenolate mofetil in low-risk renal transplantation in patients receiving no cyclosporine: a single-centre experience

BACKGROUND We assess our long-term experience with regards the safety and efficacy of Mycophenolate Mofetil (MMF) in our low risk renal transplant population and compared it retrospectively to Azathioprine (AZA) immunosuppressive regimen. Patients and methods. Between January 1999 and December 2005, 240 renal transplants received MMF as part of their immunosuppressive protocol (MMF group). AZA group of 135 renal transplants was included for comparative analysis (AZA group). Patients received Cyclosporine was excluded from this study. RESULTS The incidence of biopsy proven 3-month acute rejections was 30 (12.5%) in MMF group and 22 (16%) in AZA group respectively (P = 0.307). Patient survival rates at 1 and 5 years for the MMF group were 97 and 94%, respectively, compared to 100% and 91% at 1 and 5 years respectively for the AZA group (P = 0.61). Graft survival rates at 1 and 5 years for the MMF group were 95 and 83%, respectively, compared to 97 and 84% at 1 and 5 years, respectively for the AZA group (P = 0.62). CONCLUSION There was no difference in acute rejection episodes between MMF and AZA based immunotherapy. Additionally, we observed no significant difference concerning graft survival in the MMF group when compared to AZA group.

Radical Cystectomy in the Octogenarian Population: A Single Centre Experience

Introduction: Radical cystectomy is the treatment of choice for infiltrating non-metastatic bladder cancer. However there is reluctance to perform this surgery in the elderly due to morbidities associated. We sought to examine our institutional experience regarding radical cystectomy in the octogenarians. Patients and Methods: A total of 23 were 80 years or older in age (19 males and 4 females). Overall mortality, early and late morbidity were analyzed. Length of hospital stay, intensive therapy unit admissions, re-hospitalization and overall survival were assessed. Results: Median age at time of cystectomy was 83.5 years (range 80–90 years). Median follow-up time was 7.5 years (range 8–120 months). All patients had standard radical cystectomy. Median operative time was 3 hours (range 3–5 hours). Median number of blood transfusion units was 9 (range 4–14). Median preoperative and postoperative hemoglobin level was 12.5 (range 9.9–14) and 10.8 g/dl (8.7–12.2 g/dl) respectively. Admission to the intensive therapy unit was needed in 3 patients. Median number of hospitalization days following the cystectomy procedure was 23 days (range 5–90 days). Median survival time was 16 months and the actuarial survival at 1, 2 and 3 year was 66.7, 47.6 and 12% respectively. Conclusion: This study highlights the safety and feasibility of radical cystectomy in the treatment of bladder cancer in the octogenarians. It provides palliation of local symptoms and local cancer control. Future research should be directed towards comparing with the non-octogenarian cohorts with particular emphasis on oncological, functional and survival outcomes as end points.