Double Kidney Transplantation Research Articles

#2323 Sodium-glucose cotransporter 2 inhibitors in kidney transplant recipients—effectiveness and safety

Abstract Background and Aims Given the increasing incidence of posttransplant diabetes and the heightened cardiovascular burden among transplant recipients, the use of SGLT2 inhibitors (SGLT2i) in this population is attractive due to their cardiovascular and renoprotective advantages. However, evidence for diabetic kidney transplant recipients (DKTRs) is limited, primarily due to concerns regarding potential worsening of renal graft dysfunction and adverse effects. Method This retrospective study was conducted to evaluate the effectiveness and safety of SGLT2 inhibitors in kidney transplant recipients (KTRs). Individuals with type 1 diabetes (n = 2) and individuals submitted to a double kidney and pancreas transplant (n = 5) were excluded from the study to avoid diabetes type bias . The primary focus was on assessing SGLT2 inhibitors effect on parameters such as hemoglobin A1c levels, body mass index (BMI), lipid panel, hemoglobin levels, renal allograft function (estimated glomerular filtration rate), and urinary protein-to-creatinine ratio. Demographic, clinical, and laboratory data were collected and subjected to analysis using descriptive statistics with SPSS Statistics software. The data were presented as means ± standard error, and comparisons were conducted using the paired sample t-test. A significance level below 0.05 (P < 0.05) was considered statistically relevant. Results A total of 104 renal transplant patients were included. The study spanned a median observation period of 14 (2.0–71.0) months. Mean HbA1c decreased from 7.3 to 6.9% (P = 0.001). A significant improvement in BMI (27.6 to 27.0 kg/m2; P = 0.008), total and LDL-Cholesterol(P < 0.001 and P = 0.004, respectively) were also observed. Mean haemoglobin rate at baseline was 13.3 g/dL and also improved at end of follow-up to 13.5 g/dL (P = 0.065). Mean estimated glomerular filtration rate at baseline was 60.1 (26–120) mL/min/1.73 m2 and decreased to 54.8 throughout the follow-up (P = 0.007), while mean serum cystatin increased from 1.7 to 2.0 mg/L (P < 0.001). Regarding urinary protein:creatinine ratio, levels slightly but not significantly rose [+0.33 g/g]. Urinary tract infections occurred in 10% of the recipients. No other side effects were observed during the treatment course or neither the patients needed to discontinue the medication. Conclusion This study establishes that the use of SGLT2 inhibitors is both feasible and well-tolerated in kidney transplant recipients (KTRs), with no significant observed side effects. Further studies are required to clarify the impact of SGLT2 inhibitors on long-term patient and allograft survival.

Disposable grasper-integrated flexible cystoscope for ureteral stent removal in transplanted patients; focus on feasibility, safety, and patient experience. Results and micro-cost analysis from a tertiary referral center.

To evaluate ureteral stent removal (SR) using a grasper-integrated disposable flexible cystoscope (giFC-Isiris ®, Coloplast ®) after kidney transplantation (KT), with a focus on feasibility, safety, patient experience, and costs. All consecutive KT undergoing SR through giFC were prospectively enrolled from January 2020 to June 2023. Patient characteristics, KT and SR details, urine culture results, antimicrobial prescriptions, and the incidence of urinary tract infections (UTI) within 1 month were recorded. A micro-cost analysis was conducted, making a comparison with the costs of SR with a reusable FC and grasper. A total of 136 KT patients were enrolled, including both single and double KT, with 148 stents removed in total. The median indwelling time was 34 days [26, 47]. SR was successfully performed in all cases. The median preparation and procedure times were 4 min [3,5]. and 45 s[30, 60], respectively. The median Visual Analog Scale (VAS) score was 3 [1, 5], and 98.2% of patients expressed willingness to undergo the procedure again. Only one episode of UTI involving the graft (0.7%) was recorded. Overall, the estimated cost per SR procedure with Isiris ® and the reusable FC was 289.2€ and 151,4€, respectively. This prospective series evaluated the use of Isiris ® for SR in a cohort of KT patients, demonstrating feasibility and high tolerance. The UTI incidence was0.7% within 1 month. Based on the micro-cost analysis, estimated cost per procedure favored the reusable FC.

Humoral Immunodeficiency in two patients with Alagille Syndrome

IntroductionAlagille syndrome is an autosomal dominant entity caused by mutations that affect the Notch-Jagged1 signaling pathway. It is characterized by cholestasis due to poor bile ducts, congenital heart disease, skeletal abnormalities, ocular abnormalities and characteristic facial phenotype. We present 2 patients diagnosed with Alagille syndrome who presented associated immunodeficiency and required gammaglobulin treatment. Case 117-year-old male patient, who was liver transplanted at 19 months of the age. At 6 years of life, he underwent splenectomy secondary to immune thrombocytopenic purpura. He presented recurrent otitis and severe, large styes on the eyelids. He developed a first episode of pneumonia at 6. He received double kidney transplantation due to end-stage chronic kidney disease at 9. At the age of 10 laboratory results showed: IgG: 374 mg/dl IgM: 43 mg/dl IgE: 3 UI and IgA: 202 mg/dl. Functional responses against protein and polysaccharide antigens were absent. Lymphocytes populations were normal. He started treatment with intravenous gammaglobulin at 10 years of age. Case 27-year-old male patient with liver involvement, portal hypertension and portal vein cavernomas that evolved to hypersplenism with esophageal and gastric varices and gastrointestinal bleeding that required a splenorenal anastomosis and a stent. He presented a ventricular communication with a severe hypoplasia of the left pulmonary branch. He presented multiple infectious events including pneumococcal pneumonia. Laboratory showed pancytopenia secondary to hypersplenism, CD4 T lymphopenia (<250/uL)) with preserved CD4/CD8 ratio with normal lymphocyte proliferations, IgG: 450 mg/dl, IgM: 21 mg/dl, IgA: 136 mg/dl. A humoral response decay against global Pneumococcal capsular polysaccharide was observed. Variable response to protein antigen was present. Daily chemoprophylaxis with trimethoprim sulfamethoxazole was indicated but he repeated infectious episodes, then subcutaneous gammaglobulin was started. ConclusionsWe present2 patients diagnosed with Alagille syndromewith associated immunodeficiency. The NOTCH/Jagged 1 signaling pathway is of profound relevance to the process of somitogenesis and in the development of CD4 and CD8 lymphocytes. The immune compromise of patients with Alagille syndrome should be emphasized and eventually gammaglobulin treatment should be indicated.

Ozone therapy in clinical practice of the diabetic necrotizing foot.

The present paper is the most extensive approach of the effect of ozone therapy on the diabetic foot. Out of all the 45 cases that have been studied in the timeline 2020-2022, some of them who were incredibly severe with little hope for improvement, had a tremendous impact on me and I will try to describe them in a few words and raise your awareness about this not yet explored field that has real potential in aiding those who suffer. A female patient of 49 years old had diabetes mellitus, multiple necrotic lesions, post peritoneal dialysis with skin calcifications of both legs, chronic kidney disease, renal osteodystrophy, calciphylaxis with secondary cutaneous necrosis in remission, renal lithiasis, secondary arterial hypertension, ischemic cardiac disease, paroxistic atrial fibrillation, polycystic kidney disease, hyperuricemia, calcium metabolism alterations, hyperphosphatemia, moderate proteic malnutrition. The first ozone therapy session was done according to ozone therapy protocol for the diabetic foot, after debridement, disinfection of the wounds and disposal of the necrotizing tissue. Drainage from the wound was examined and revealed an E. coli infection. After 30 sessions, the result was spectacular. A 51-year-old patient presented to the clinic with an open wound after amputation of his left leg. A year after, he came back to the clinic with an infected wet gangrene of his right leg, who also caught the first 3 toes. His medical history included type II diabetes mellitus, end stage renal disease with a double kidney transplant until the age of 28. In both cases debridement of the wound was done, exposing healthy tissue, antibiotics were administered according to antibiogram and the entire procedure of ozone therapy was done as follows: washing the wound with oxygenated water, disinfection of the wound, local infiltrations with ozone, major autohemotherapy and ozonized bag. The result: the left leg had a rapid favorable outcome, and after only 20 ozone sessions, the wound closed. The right leg had a total of 45 ozone therapy sessions done, with a 100% improvement. After 5 months, the patient came to the clinic with a postblockage necrotizing fistula on his right second finger, which healed after 6 ozone therapy sessions. Among those 45 patients included in the study, 10 of those who had major amputations presented to the clinic for a primary intervention and only 2 of them for a reintervention. Nevertheless, most of the minor amputations were done as a primary intervention. In many cases though, to obtain the healing of the patients, reinterventions were necessary. Analyzing these data, the necessity of applying a new method of correctly assessing the severity of the lesions to avoid an undervaluation of it, which would unnecessarily prolong the hospitalization and more importantly their suffering. I have encountered 4 cases of extensive wet gangrene associated with severe sepsis. The mortality in this category of patients was 50%. Studies and research in this field have a special and decisive con tribution in treating and recognizing the effects of ozone therapy in curing the diabetic foot. Through their results, studies will allow the free circulation of information in this field, because if we don’t communicate efficiently, we will not be able to present publicly the results we obtained from the studies and research regarding ozone therapy. Free circulation of information, of innovating ideas – can and has to surpass all frontiers, to allow all specialists in this field to contribute in solving the major problem that is the diabetic foot, this ailment of mankind. The most spectacular effects of ozone therapy in the case of diabetics can only be seen in well informed patients, who come to the doctor with impressive ulcerations of the calf. The clinical specter of the diabetic foot is very large, from the simple presence of neuropathy and/or arteriopathy of the legs, without any existing characteristic lesions, to the necessity of an amputation; ozone therapy can cure without an amputation.

Medullary sponge kidney: unusual finding in kidney transplant recipient

BackgroundMedullary sponge kidney is generally considered a benign condition, gold standard for the diagnosis is urography but it has almost been replaced by UroCT that did not present the same sensibility. Although it is really rare, our sonography’s findings were consistent with medullary sponge kidney in the transplanted kidneys.Case presentationA 45-year-old woman with a long history of double-kidney transplantation complained of frequent urinary tract infections, a history of vague loin pain and came to our attention for sonography follow-up. Her kidney function was normal, we did not find signs of infections in the transplanted kidneys and urinary findings were normal. Curiously, the transplanted kidneys came from a newborn and the patient received a double-kidney transplantation in order to guarantee a satisfactory renal function.ConclusionsDespite a long history of kidney transplantation, genetic disease should not be forgotten when symptoms and images recall to specific inherited alterations. Sonography has to be considered in diagnostic path of kidney cystic disease.

Diagnostic Challenges of Binax Urinary EIA for Detection of Legionella pneumophila

A middle-aged African American male with a history of stage 2 chronic kidney disease status post double kidney transplant was admitted after developing symptoms of respiratory infection during the peak of COVID-19. The patient rapidly developed acute hypoxemic respiratory failure. Differentials for the patient included COVID-19, opportunistic infection such as mycoplasma, and legionella. During the admission, the patient had numerous infectious disease screening tests run including a COVID-19 test and Binax urine antigen test for legionella that all came back negative.

MO950SIMULTANEOUS LIVER-KIDNEY TRANSPLANT. SIXTEEN YEARS OF MONOCENTRIC EXPERIENCE

Abstract Background and Aims Combined liver-kidney transplant is the best treatment for patients with hepatic and renal failure, even though some studies reported a poor patient survival. The aim of our study is to summarize the clinical characteristics of subjects who undergo simultaneous combined liver-kidney transplantation (SLKT) for advanced liver and kidney disease. Furthermore, we evaluated patient and kidney survival of SLKT recipients compared to solitary kidney transplant (KT) recipients. Method We performed a retrospective analysis of all SLKT recipients performed in a single transplant Center (University Hospital of Modena, Italy) from 01/01/2004 to 12/31/2016. All patients were aged more than 18 years. Results 34 SLKT were performed over 16 years of transplant activity. Mean age of recipients was 51.3 ±9.1years. Males accounted for 65% of the population. All patients were of Caucasians origin except one of African origin. Mean BMI was 69.5 ± 13.9 Kg. Hepatitis C Virus (HCV)-related cirrhosis was the main cause (38.1%) of hepatic failure. Other causes of hepatic disease were ADPKD (26.5%), hepatitis B Virus (HBV) (11.8%), alcohol (8.8%), combined HCV-HBV infection (5.9%), Von Gierke Disease (2.9%), primary biliary cirrhosis (2.9%), and autoimmune cirrhosis (2.9%). Six patients developed hepatocellular carcinoma before undergoing SLKT. Renal disease was caused by ADPKD (26.5%), diabetic nephropathy (14.7%), glomerulonephrites (29.4%), hepatorenal syndrome (8.8%) and other renal diseases (20.6%). Overall, 14.7% of patients was affected by Human Immunodeficiency Virus (HIV), 50% by hypertension and 41% by diabetes. Mean MELD at transplantation was 42 (39.2-46.5) and mean serum creatinine value in pre-emptive patients was 3.09 ±1.4 mg/dl. Mean of donors was 46.7±15.3 years and main cause of death was cranial trauma (47.1%), followed by cerebral haemorrhage (41.2%). Mean KDPI was 52% (22-63) and KDRI 1 (0.73-1.1). Mean time on waiting list was 2.8±1.2 years and half of patients was on dialysis maintenance before SLKT. Mean ischemia time were 6.5 ±1.3 and 12.3 ±2.1 hours for liver and kidney, respectively. Only one patient (2.9%) received double kidney transplantation. Primary induction agent was anti-IL2 receptor monoclonal antibodies (82.6%), thymoglobulin (13%) and with methylprednisolone (4.1%). Post SLKT, kidney early complication consisted of 3 delayed graft functions and 1 transplanctectomy in the only double kidney transplant recipient. At the end of the follow-up (8±4.1 years), mean creatinine was 1.44 ± 0.5 mg/dl and kidney survival accounted for 87.9%. Cox regression analysis showed recipient’ age as a protective factor (HR, 0.03; CI95%, 0.8-0.9) for kidney rejection and donor age as a risk factor (HR, 1.13,CI95% 1-1.1) for renal graft loss. Patient survival at 10 years was 91.2%. Two deaths were caused by infections (50%) and 2 by digestive haemorrhages (50%). SLKT recipients were confronted with 304 cadaveric donor KT recipients performed in the same transplant Center from 01/01/2006 to 12/31/2016. Statistical analysis showed that SLKT recipients had shorter waiting list, dialysis vintage and ischemia times. SLKT recipients had a major prevalence of diabetes and HCV infection but a lower prevalence of hypertension. DGF were less common in SLKT. Patient and graft survival a 1, 5 and 10 years did not show statistically significant differences between SLKT and KT. Conclusion Our analysis shows excellent kidney and patient survival in SLKT. SLKT and KT recipients had similar 1, 5 and 10-years patient and graft survival.

Effects of Sugammadex Plus Rocuronium vs Neostigmine Plus Cisatracurium During Renal Transplantation on Graft Function: A Retrospective, Case-Control Study

BackgroundRocuronium can be used in patients with severe renal failure (creatinine clearance <30 mL/min), but the duration of muscle relaxation is longer and results in an increased risk of postoperative residual neuromuscular block. Rocuronium can be antagonized by sugammadex, but the elimination of the complex they make (rocuronium-sugammadex complex) varies according to the renal function. Two case reports/series have reported the use of rocuronium-sugammadex complex during renal transplantation. A recently published retrospective study showed no differences in postoperative creatinine levels in patients receiving kidney transplantation. This retrospective case-control study aims to investigate the effects of rocuronium-sugammadex, used during renal transplantation, on transplanted kidney function. MethodsWe analyzed 113 medical records of patients undergoing kidney transplantation from January 2015 to December 2018. Forty-seven medical records were excluded because they did not report the administration of one of the following drugs during the transplantation: rocuronium, sugammadex, cisatracurium, neostigmine. The demographics of patients and donors were collected along with the following data: blood urea and creatinine, serum and urinary electrolytes, and diuresis. Marginal, single, or double kidney transplantations; Karpinski scores; and histologic evaluations of transplanted kidney were collected. ResultsWe included data from 66 medical reports from January 2015 to December 2018. Blood creatinine levels at 6, 12, and 24 hours were significantly lower in the rocuronium + sugammadex group than in the cisatracurium + neostigmine group (creatinine 6 hours P = .05, creatinine 12 hours P = .038, creatinine 24 hours P = .049). Blood urea levels for 24 hours after transplantation were significantly lower in the rocuronium + sugammadex group than in the cisatracurium + neostigmine group (urea 0 hours P = .025, urea 6 hours P = .011, urea 12 hours P = .03, urea 24 hours P = .011). We found no statistically significant differences in blood sodium, blood potassium, blood calcium, diuresis, urinary sodium, or urinary potassium levels before and after transplantation. ConclusionsIn this retrospective case-control study, the use of rocuronium and sugammadex during renal transplant surgery did not affect relevant kidney recovery outcomes in the first week after transplantation.

Double Single-Side Kidney Transplants With Bench Vascular Reconstruction: A Further Challenge Beyond the Marginality Without Future Preclusions

BackgroundDouble kidney transplantation allows the use of marginal kidneys with a significant improvement in the recovery of renal function expected after transplantation, although with a greater anesthesiologic and surgical risk. One-sided positioning, more cautious in the event of functional exhaustion, can be complex due to vascular anomalies. Materials and methodsWe report the case of 2 double unilateral kidney transplants with vascular reconstructions.The first is a double kidney transplant from a 83-year-old donor. Both kidneys (score 5) had 2 arteries and the arterial patch was not usable. A cryopreserved arterial graft was used for the packaging of an arterial axis with which a single T-L anastomosis was performed; the 2 veins were also joined with the packaging of a single anastomosis.The second case is a double kidney transplant from a cadaveric donor performed on a recipient suffering from severe diffuse atheromasia. The right kidney had 2 arteries and the left kidney had 3 arteries (both score 5). The aortic patches and veins of the 2 kidneys were joined together and a single arterial and venous anastomosis was performed. ResultsThe course has been uneventful. In both cases there were no perioperative vascular complications. ConclusionsThe use of marginal organs is an increasingly common reality. Bench vascular reconstructions can further increase donation resources, safely enhancing the transplantation of already marginal organs that would otherwise not be usable and allowing the contralateral vascular axis to be kept intact.

Hypothermic Machine Perfusion as an Alternative to Biopsy Assessment in Transplantation of Kidneys Donated After Cardiocirculatory Death: A Pilot Study

BackgroundTransplantation of kidneys from donation after cardiocirculatory death (DCD) donors is becoming an ever-increasing reality. So far, biopsy histologic assessment is the main parameter for evaluation of graft suitability, but it has several drawbacks and has poor reliability. The aim of this study is to verify if real-time renal resistance (RR) measurement during hypothermic machine perfusion (HMP) can be used as a reliable parameter to evaluate the quality of grafts from DCD and extracorporeal membrane oxygenation (ECMO) donors. MethodsFrom January 2015 to September 2018, HMP has been systematically applied to all organs from DCD and ECMO donors. All grafts underwent preimplantation biopsy histologic assessment with Karpinski’s score. Single kidney transplants (SKTs) or double kidney transplants (DKTs) were performed according to biopsy score results. Kidneys were considered suitable for transplant if RR reached ≤ 1.0 within 3 hours of perfusion. RR trend and postoperative outcome were analyzed considering biopsy score and donor type. ResultsA total of 30 kidneys (15 from DCD and 15 from ECMO donors) were used to perform 26 transplants (22 SKTs and 4 DKTs). Considering RR trend, all grafts were considered suitable for transplant within 1 hour of perfusion. Biopsy confirmed this result in all cases, and median score was 3 (range, 0-7). SKT score kidneys had lower starting RR than DKT ones (1.88 vs 2.88; P = .04) but identical final RR (0.58 vs 0.57; P = .76). DKT recipients had faster postoperative creatinine reduction than SKT recipients but similar postoperative day 30 value (1.42 vs 1.15 mg/dL; P = .20). No differences were found between DCD and ECMO grafts in terms of RR trend and postoperative outcome. ConclusionsHMP can be an alternative to histologic biopsy assessment for evaluation of transplant suitability of DCD and ECMO kidneys. If acceptability threshold is reached, SKT can be performed in all cases. ECMO donors should be considered like DCD donors.

Single Anastomosis of Double Ureter Kidneys – Experience in 12 Kidney Transplant Recipients

Introduction Ureteral duplication is the most common renal abnormality, occurring in approximately 1%. In the transplant setting it is usually an incidental finding. The ureter-bladder anastomosis in that case can be done either separately as two single anastomosis or as one anastomosis after combining the two ureters into one opening. We sought to determine the complication rate and long-term outcome of transplanted kidneys with the single anastomosis technique for double ureter. Patients and Methods We examined the incidence of double ureter kidney transplants using our electronic data-base. A single anastomosis technique was used in all 12 cases. We looked at the complication rate and graft survival and function at follow up. Results The incidence of ureter duplication in our series was 1.04% (12 of 1152 transplants in adult recipients). Eight patients received a deceased donor transplant, among them 3 patients had combined pancreas-kidney transplantation and one double kidney transplantation. Another four patients transplanted with a kidney from a live-donor. The mean patient age was 48.5 years (31-67years). The mean donor age was 38.2 (9-60 years). All patients maintained their graft during the follow up (100% graft survival).There were no ureteral leak or stricture. UTI requiring hospitalization was noted in 4 patients. Conclusions Double ureter kidney transplantation using a single anastomosis technique provides good outcome without additional risk for ureteral complications.

Renal Resistance Trend During Hypothermic Machine Perfusion Is More Predictive of Postoperative Outcome Than Biopsy Score: Preliminary Experience in 35 Consecutive Kidney Transplantations.

Hypothermic machine perfusion (HPM) grants a better postoperative outcome in transplantation of organs procured from extended criteria donors (ECDs) and donors after cardiac death (DCD). So far, the only available parameter for outcome prediction concerning those organs is pretransplant biopsy score. The aim of this study is to evaluate whether renal resistance (RR) trend during HPM may be used as a predictive marker for post-transplantation outcome. From December 2015 to present, HMP has been systematically applied to all organs from ECDs and DCD. All grafts underwent pretransplantation biopsy evaluation using Karpinski's histological score. Only organs that reached RR value ≤1.0 within 3 hours of perfusion were transplanted. Single kidney transplantation (SKT) or double kidney transplantation (DKT) were performed according to biopsy score results. Sixty-five HMPs were performed (58 from ECDs and 7 from DCD/ECMO donors). Fifteen kidneys were insufficiently reconditioned (RR > 1) and were therefore discarded. Forty-nine kidneys were transplanted, divided between 21 SKT and 14 DKT. Overall primary nonfunction (PNF) and delayed graft function (DGF) rate were 2.9 and 17.1%, respectively. DGF were more common in kidneys from DCD (67 vs. 7%; P = 0.004). Biopsy score did not correlate with PNF/DGF rate (P = 0.870) and postoperative creatinine trend (P = 0.796). Recipients of kidneys that reached RR ≤ 1.0 within 1 hour of HMP had a lower PNF/DGF rate (11 vs. 44%; P = 0.033) and faster serum creatinine decrease (POD10 creatinine: 1.79 mg/dL vs. 4.33 mg/dL; P = 0.019). RR trend is more predictive of post-transplantation outcome than biopsy score. Hence, RR trend should be taken into account in the pretransplantation evaluation of the organs.

“Extracorporeal Membrane Oxygenation for Greater Poland” Program: How to Save Lives and Develop Organ Donation?

The “ECMO for Greater Poland” program takes full advantage of the extracorporeal membrane oxygenation (ECMO) perfusion therapy opportunities to promote the health of the 3.5 million inhabitants in the region. The main implementation areas are treatment of patients with hypothermia; severe reversible respiratory failure (RRF); critical states resulting in heart failure, that is, cardiac arrest, cardiogenic shock, or acute intoxication; and promotion of the donor after circulatory death (DCD) strategy in selected organ donor cases, after unsuccessful life-saving treatment, to achieve organ recovery.This organizational model is complex and expensive, so we used advanced high-fidelity medical simulation tests to prepare for real-life experience. Over the course of 4 months we performed scenarios including “ECMO for DCD,” “ECMO for extended cardiopulmonary resuscitation,” “ECMO for RRF,” and “ECMO in hypothermia.”Soon after these simulations, Maastricht category II DCD procedures were performed involving real patients and resulting in 2 successful double kidney transplantations for the first time in Poland. One month later we treated 2 hypothermia patients (7 adult patients with heart failure and 5 patients with reversible respiratory failure) with ECMO for the first time in the region.Fortunately, we have discovered an important new role of medical simulation. It can be used not only for skills testing but also as a tool to create non-existing procedures and unavailable algorithms. The result of these program activities will promote the care and treatment of patients in critical condition with ECMO therapy as well as increase the potential organ pool from DCDs in the Greater Poland region of Poland.

The role of simulation to support donation after circulatory death with extracorporeal membrane oxygenation (DCD-ECMO)

Maintaining the viability of organs from donors after circulatory death (DCD) for transplantation is a complicated procedure, from a time perspective in the absence of appropriate organizational capabilities, that makes such transplantation cases difficult and not yet widespread in Poland. We present the procedural preparation for Poland's first case of organ (kidney) transplantation from a DCD donor in which perfusion was supported by extracorporeal membrane oxygenation (ECMO). Because this organizational model is complex and expensive, we used advanced high-fidelity medical simulation to prepare for the real-life implementation. The real time scenario included all crucial steps: prehospital identification, cardiopulmonary resuscitation (CPR), advanced life support (ALS); perfusion therapy (CPR-ECMO or DCD-ECMO); inclusion and exclusion criteria matching, suitability for automated chest compression; DCD confirmation and donor authorization, ECMO organs recovery; kidney harvesting. The success of our first simulated DCD-ECMO procedure in Poland is reassuring. Soon after this simulation, Maastricht category II DCD procedures were performed, involving real patients and resulting in two successful double kidney transplantations. During debriefing, it was found that the previous simulation-based training provided the experience to build a successful procedural chain, to eliminate errors at the stage of identification, notification, transportation, donor qualifications and ECMO organ perfusion to create DCD-ECMO algorithm architecture.

Liver, Pancreas and Kidney Transplantation for the Treatment of Wolcott–Rallison Syndrome

We present the case of a child who underwent a combined liver, pancreas and double kidney transplant following complications of Wolcott-Rallison syndrome (WRS) a rare genetic disorder that causes infantile insulin-dependent diabetes mellitus (IDDM) and often death in childhood from fulminant liver and concomitant kidney failure. WRS is characterized clinically through infantile IDDM, propensity for liver failure following viral infections, bone dysplasia and growth failure and developmental delay. Fewer than 60 cases with WRS are reported in the literature, mostly from consanguineous parents. Future episodes of liver failure, the main contributor to the increased mortality in WRS, may be prevented through timely liver transplantation. To the best of our knowledge, transplantation has not been utilized to manage complications of WRS prior to this report.

1012 Double kidney transplantation with organs from expanded criteria donors: Review of our series and an update of current indications

1012 Double kidney transplantation with organs from expanded criteria donors: Review of our series and an update of current indications

Assessment of donor biopsies

To provide an up-to-date overview about the assessment of donor biopsies and to discuss the current problems and chances of preimplantation biopsies for transplant allocation with a focus on the technical work up and the histological variables scored. Preimplantation biopsy results are the major reason for discarding procured extended donor criteria kidneys in the USA. There is neither a consensus on the work up, nor the reporting of preimplantation donor biopsies, nor the importance of the biopsy findings in the process of allocation. The best available data have been collected in the context of single vs. double kidney transplantation. A clinical risk factor score may help to define kidneys when a preimplantation biopsy is warranted. Punch biopsies using a skin punch device appear to be a reasonable alternative for surgeons fearing needle biopsies. Donor biopsies are very useful as zero-hour biopsies establishing baseline information for comparison with subsequent transplant biopsies. As none of the histological variables and scores provides perfect prediction, preimplantation biopsy results have to be interpreted in the context of all available donor and recipient information.

Outcomes of Kidney Transplants from Donation after Cardiac Death Donors Aged 70 Years or Older

Introduction: The ongoing expansion of the donation after cardiac death (DCD) donor pool raises questions as to the suitability of using kidneys from very old donors. Double kidney transplantation (DKT) may enable utilisation of a proportion of these kidneys that would otherwise have been discarded. Here we report a single-centre experience of DCD kidney transplants from donors aged 70 years and older, comparing outcomes of single kidney transplants (SKT) and DKT. Methods: Outcomes were assessed for SKT and DKT from DCD donors aged 70 years old between 1 January 2009 and 31 August 2011, with follow-up ceasing on 31 December 2011. The decision to implant a double or single kidney was based on donor and recipient characteristics, macroscopic appearance, and pre-implantation histological score (Remuzzi G et al, NEJM 2006). Estimated GFR (eGFR, mL/min/1.73 m2) was calculated using the 4-variable MDRD equation; delayed graft function (DGF) was defined as the need for dialysis within a week post-transplantation. Continuous variables were described using median (range). Results: Forty-three kidneys were implanted (27 SKT and 8 DKT), with a median follow-up of 13 months. Donor ages were similar in both groups (SKT 73 (70-78) years vs DKT 74.5 (70-79) years; p=0.20). Although median donor terminal creatinine was lower in the SKT group, it did not reach significance (66 (41-88) μmol/L vs 81 (40-235) μmol/L; p=0.07); likewise, there was no difference in donor terminal eGFR (SKT 90 (62-111) mL/min/1.73m2 vs DKT 74 (25-143) mL/min/1.73m2; p=0.25). As expected, kidneys subsequently used as DKT had significantly higher pre-implantation biopsy scores (DKT 5 (3-6) vs SKT 3 (2-6); p< 0.01). Recipients were generally elderly, but median ages were similar between the two groups (SKT 65 (48-75) years vs DKT 64 (57-70) years; p=0.37), as were the cold ischaemic times (SKT 13h18m (9h59m-20h57m) vs DKT 15h40m (11h45m-23h45m); p=0.14). DGF was more frequent in the SKT GROUP, however this did not reach significance (66% (n = 18) for SKT vs 37.5% (n = 3) for DKT, p = 0.15). Graft function (eGFR) was better in recipients of DKT, though this did not reach significance at either one month (SKT 36.7 (19.3-63) mL/min/1.73m2 vs DKT 43.3 (26.5-67.7) mL/min/1.73m2; p=0.46) or 6 months (SKT 34.5 (26.8-58.9) vs DKT 50.8 (28.3-72.7); p=0.26). There were 2 primary non functions and 3 deaths in the SKT group (heart failure, sepsis, invasive aspergillosis), but none of either in the DKT group. Actuarial one-year graft and patient survivals were 92.6% and 88.6% SKT vs 100% and 100% DKT (p=0.44, p=0.37, respectively). Discussion: These early results demonstrate that the DCD donor pool can be expanded through careful selection of donors and recipients. Recipients of DKT from elderly DCD donors had similar outcomes to those receiving SKT, implying that our selection algorithms are adequate. Utilisation of organs from this source is an acceptable strategy to reduce the growing number of older patients waiting for renal transplantation.

Double Kidney Transplantation from EC-DCDs Over 65 a Single Centre Experience

Double Kidney Transplantation from EC-DCDs Over 65 a Single Centre Experience

The Use of Iliac Y-Graft for Arterial Revascularization in Simultaneous Double-Kidney Transplantation

Double-kidney transplantation (DKT) has gained popularity because of results comparable with single-kidney transplantation when applied to marginal old-age donors, aiming at expanding the donor’s pool (1). Initially, the surgical technique of DKT consisted of placing the kidneys by two separate surgical incisions in the right and left iliac groin and performing vascular anastomosis on both the right and left iliac vessels (2, 3). Thereafter, Ekser et al. (4) described the monolateral access, transplanting both kidneys in the right iliac groin with a single surgical incision, and using the right iliac vessels for double venous and arterial anastomoses. The monolateral access has comparable results for graft function, with clear advantages for shorter operative time and leaving the left side untouched for an eventual retransplantation (5). However, this approach always requires two separate arterial anastomoses on the same iliac vessel to provide blood inflow to both grafts. Because well-known patients with chronic kidney disease are affected by severe and diffuse atherosclerotic lesions and many recipients of DKT are older than single-transplant recipients on dialysis for many years before, performing double arterial anastomoses, with two arteriotomies, on the same iliac artery can be risky and challenging because of the high probability of encountering severe atherosclerotic damage (6, 7). To overcome this problem, we developed a new technique of arterial anastomosis adopted from the experience of pancreas transplantation, using a donor’s interposed iliac Y-graft anastomosed during back-table surgery to the renal arteries of both grafts in an end-to-end fashion. This technique allowed performing a single anastomosis on the recipient’s external iliac artery, avoiding additional arterial anastomosis and thereby theoretically reducing the risk of vascular complication on the recipient’s atherosclerotic vessels. Moreover, another advantage of this approach could be the reduction of cold ischemia time of the second kidney and the possibility to revascularized simultaneously both grafts. Finally, also in the presence of more than one renal artery on a separate patch, the additional artery can be anastomosed to the bifurcation of the internal iliac artery of the Y-graft, providing a careful retrieval of the Y-graft including the internal iliac artery. A single venous anastomosis was performed on the external iliac vein of the recipient; in all cases, the left renal vein was reimplanted on the vena cava during bench surgery in the same way as previously described by Nghiem (8). Since now, we applied this approach without encountering any problem or complications related to back-table reconstruction of the renal arteries on the Y-graft (Fig. 1). The only limitation to the widespread use of this technique is the availability of the Y-graft not affected by atherosclerotic lesions, easily and safely usable for back-table reconstruction, which is not always possible in old-age marginal donors.FIGURE 1: Arterial anastomosis using a donor’s iliac y-graft.