Cadaveric Heart-beating Donors Research Articles

NK cell compartment in the peripheral blood and spleen in adult patients with primary immune thrombocytopenia

Immune thrombocytopenic purpura (ITP) is a disease characterized by antibody-mediated platelet destruction. The T- and B-cell subsets have been extensively studied in primary ITP, but the NK cell compartment has been less thoroughly explored. We investigated the NK cell receptor repertoire and the functionality of NK cells in the peripheral blood and spleen in patients with primary ITP. An immunophenotypic analysis of peripheral blood lymphocytes from patients revealed that the numbers of CD19+ B lymphocytes, CD4+ and CD8+ T lymphocytes and CD3−CD56+ NK cells were within the normal range. No major alteration to the expression of distinct inhibitory or activating NK cell receptors was observed. The functionality of NK cells, as evaluated by their ability to degranulate in conditions of natural cytotoxicity or antibody-dependent cell cytotoxicity (ADCC), was preserved in these patients. By contrast, these stimuli induced lower levels of IFNγ production by the NK cells of ITP patients than by those of healthy controls. We then compared the splenic NK cell functions of ITP patients with those of cadaveric heart-beating donors (CHBD) as controls. The splenic NK cells of ITP patients tended to be less efficient in natural cytotoxicity conditions and more efficient in ADCC conditions than control splenic NK cells. Finally, we found that infusions of intravenous immunoglobulin led to the inhibition of NK cell activation through the modulation of the interface between target cells and NK cells.

MP-06.13 A Comparison of the Outcomes of Renal Transplantation from Heart-Beating Cadaveric Donors and Non-Heart-Beating Who Present Irreversible Cardiac Arrest Occurring Outside the Hospital

Non-heart-beating donors who present irreversible cardiac arrest occurring outside the hospital are a valuable source of kidneys for renal transplantation and they could help shorten the list of patients who are waiting for a kidney transplant. However, the significant degree of warm ischemic injury suffered by non-heart-beating kidneys leads to a greater incidence of primary non-function and delayed graft function than those from brainstem dead heart-beating donors. Our purpose was to compare the outcomes of kidney transplants from non-heart-beating donors (Maastricht donors type I and II) and heart-beating cadaveric donors.

2065 A COMPARISON OF THE OUTCOMES OF RENAL TRANSPLANTATION FROM HEART-BEATING CADAVERIC DONORS, AND NON-HEART-BEATING WHO PRESENT IRREVERSIBLE CARDIAC ARREST OCCURRING OUTSIDE THE HOSPITAL

You have accessJournal of UrologyTransplantation & Vascular Surgery: Renal Transplantation, Vascular Surgery1 Apr 20112065 A COMPARISON OF THE OUTCOMES OF RENAL TRANSPLANTATION FROM HEART-BEATING CADAVERIC DONORS, AND NON-HEART-BEATING WHO PRESENT IRREVERSIBLE CARDIAC ARREST OCCURRING OUTSIDE THE HOSPITAL Felipe Villacampa, José Medina-Polo, Federico de la Rosa, Manuel Pamplona, Alfredo Rodríguez, Juan Passas, José Manuel Duarte, Eduardo Gutiérrez, Teresa Dipalma, and Rafael Díaz Felipe VillacampaFelipe Villacampa Madrid, Spain More articles by this author , José Medina-PoloJosé Medina-Polo Madrid, Spain More articles by this author , Federico de la RosaFederico de la Rosa Madrid, Spain More articles by this author , Manuel PamplonaManuel Pamplona Madrid, Spain More articles by this author , Alfredo RodríguezAlfredo Rodríguez Madrid, Spain More articles by this author , Juan PassasJuan Passas Madrid, Spain More articles by this author , José Manuel DuarteJosé Manuel Duarte Madrid, Spain More articles by this author , Eduardo GutiérrezEduardo Gutiérrez Madrid, Spain More articles by this author , Teresa DipalmaTeresa Dipalma Madrid, Spain More articles by this author , and Rafael DíazRafael Díaz Madrid, Spain More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.2338AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Non-heart-beating donors who present irreversible cardiac arrest occurring outside the hospital are a valuable source of kidneys for renal transplantation and they could help shorten the list of patients who are waiting for a kidney transplant. However, the significant degree of warm ischemic injury suffered by non-heart-beating kidneys leads to a greater incidence of primary non-function and delayed graft function than those from brainstem dead heart-beating donors. Our purpose was to compare the outcomes of kidney transplants from non-heart-beating donors (Maastricht donors type I and II) and heart-beating cadaveric donors. METHODS We retrospectively compared the results of kidney transplants from non-heart-beating donors performed in our institution from July 2005 to December 2009 with a control group of heart-beating cadaveric donors with similar donor and recipient age. The non-heart-beating donors were mostly of the Maastricht I category. RESULTS Results are shown in the table. Non-heart-beating donors (n = 100) Heart-beating cadaveric donors (n = 100) p value Donors age (years) 38.5±10 39.2±18 ns Recipients age (years) 46±11 45±14 ns Donor serum creatinine (mg/dl) 1.1±0.3 0.9±0.3 ns Delayed onset of Tacrolimus with Timoglobulin induction (%) 85% 8% 0.001 Primary non-function (%) 8% 4% ns Delayed graft function (%) 85% 39% 0.001 Acute rejection incidence (%) 6% 17% 0.01 Graft survival (%) 88% 90% ns Patient survival (%) 98% 98% ns Final serum creatinine (mg/dl) 1.4±0.3 1.4±0.6 ns Follow-up (months) 15±12 15±12 ns Among non-heart-beating donors, the causes of primary non-function were renal venous thrombosis (5), allograft rupture caused by acute rejection (2), and allograft rupture after a graft biopsy (1). Moreover, four more kidneys were lost despite primary graft function, one due to renal artery thrombosis, one due to hydronephrosis, and two patients died during follow-up. CONCLUSIONS Despite being associated with higher rates of primary non-function, and delayed graft function; the intermediate-term graft survival of non-heart-beating donors is very encouraging. It is our conclusion that, with an adequate infrastructure, people who die of cardiac arrest that occurs outside the hospital can be a viable source for kidney transplantation. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e826-e827 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Felipe Villacampa Madrid, Spain More articles by this author José Medina-Polo Madrid, Spain More articles by this author Federico de la Rosa Madrid, Spain More articles by this author Manuel Pamplona Madrid, Spain More articles by this author Alfredo Rodríguez Madrid, Spain More articles by this author Juan Passas Madrid, Spain More articles by this author José Manuel Duarte Madrid, Spain More articles by this author Eduardo Gutiérrez Madrid, Spain More articles by this author Teresa Dipalma Madrid, Spain More articles by this author Rafael Díaz Madrid, Spain More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Organ Donation After Cardiac Death in the Middle East

IntroductionThe shortage of organ donors along with the increased number of waiting recipients have created the need for new strategies to expand the organ pool: living donors, split livers, domino livers, and organs from donations after cardiac death (DCD). The purpose of this article was to focus upon aspects of DCD application in the religious, traditional, ethical, and legal aspects of the Arab world. BackgroundDCD can increase the donor pool by 15%–25%. Several ethical, legal, and social concerns need to be addressed to make DCD more widely accepted by the general population in Western countries as well as in the Middle East. Organs from DCD donors have been transplanted since the 1960s. As soon as brain death criteria were published in 1968, organ retrieval from cadaveric heart-beating donors predominated. Donation after brain death (DBD) almost completely replaced DCD. In the 1990s, the organ shortage led to DCD in many countries, but not in the Arab world. DCD is still not accepted by most in the Arab world due to religious, ethical, social, and legal issues. ConclusionDCD in the Arab world is more complicated than in Western countries. It should be re-evaluated and thoroughly reviewed with the new criteria for DCD and its implementation in our region.

Induction With Basiliximab in Renal Transplantation

Introduction The use of monoclonal antibodies in renal transplantation for induction therapy has been associated with a marked reduction in acute rejection rates with an impact on graft and patient survivals. Objective We sought to evaluate the efficacy of renal transplant induction protocols using Basiliximab based on the rates of acute rejection episodes (ARE) and delayed graft function (DGF) of infectious complications in the first 6 months posttransplant, as well as patient and graft survivals. Methods We retrospectively evaluated all renal transplants performed between 2000 and 2008 that were primary grafts from cadaveric heart-beating donors, into recipients with a panel reactive antibody titer <5% and who were treated with an immunosuppression scheme based on cyclosporine, mycophenolate mofetil/mycophenolic acid plus corticosteroids, with (group 1) or without basiliximab (group 2). Results We enrolled 52 recipients in group 1 (induction with basiliximab) and 189 in group 2 (without basiliximab). The baseline characteristics were similar among the groups, except for time on dialysis which was longer in group 1 and the number of HLA matches, which was lower in group 1. The ARE rate was lower among group 1 (7.8% vs 27.8%; P = .001); rates of DGF and infectious complications were similar. There was no significant difference in graft and patient survivals. Conclusion In this study, induction with basiliximab was associated with a reduced rate rate of ARE, despite a lower number of HLA matches and a longer previous time on dialysis. The use of this induction modality was not associated with a greater rate of infectious complications.

Present Data on Organ Donation and Transplantation in Poland

At present, organ transplantation activity in Poland is located in the middle among European Union countries. There are appropriate law regulations, well-organized legal structures, well-educated transplant teams, good transplantation results, and case registries. There are 24 organ transplant teams in 20 centers, including 46 programs. Since 1966, over 18,000 organs have been transplanted 14,300 kidneys; 1800 livers; 1700 hearts; 250 kidney/pancreases and 30 lungs. Every year almost 1500 organs are procured from about 500 cadaveric heart-beating donors (9–14 per million people [pmp]) with 50 from living donors: 800 to 1000 kidneys (21–28 pmp); over 200 livers (5–6 pmp); and 60 to 100 hearts (1.6–2.7 pmp). National transplant registries are maintained in Poltransplant including a central registry of refusals (the policy of presumed consent with registered objection on donation after death is implemented), waiting lists, a cadaveric and living donor registry, and a transplant registry. There are still some actions that should be undertaken to strengthen the transplantation system in Poland, to increase organ availability, to enhance the efficiency and accessibility of transplantation systems, and to improve quality and safety: namely, increasing deceased donations to their full potential, appointing transplant coordinators in every hospital where there is the potential for organ donation, promoting quality improvement programs, and promoting living donation.

Impact of Donor Age on Renal Allograft Function and Survival

Background The lack of cadaveric donors coupled with a rapidly growing number of potential recipients have stimulated the implementation of several strategies, including the acceptance of older donors, to increase the organ pool and reduce the waiting list for kidney transplantation. However several studies have demonstrated higher incidences of delayed graft function and poor graft outcomes among kidneys harvested from older donors. Objective The objective of this study was to evaluate the influence of donor age on the function and long-term survival of renal allografts. Patients We performed a retrospective review of the clinical data from 441 adult kidney transplantation from cadaveric heart-beating donors performed in our unit from May 1989 to May 2007. Results Recipients of kidney allografts from older donors were significantly older (49.2 vs 43.7 years; P < .0001) and had a higher incidence of delayed graft function (15.1% vs 5.4%; P = .005). Renal function was superior following kidney transplantation using younger donors not only at 3 months ( P < .0001) and 12 months ( P < .0001) posttransplantation, but also upon long-term follow-up at 60 months ( P < .0001) and 96 months ( P = .030). Allograft survival censored for death with a functioning graft and patient survival were not different when comparing older versus younger donors. Multivariate analysis confirmed the lack of correlation between donor age and allograft failure. Conclusion Donor age showed no influence on allograft survival. However, kidney allografts from older donors displayed lower first year and long-term renal function.

Influence of Dialysis Duration and Modality on Kidney Transplant Outcomes

Background The influence of pretransplantation dialysis on kidney transplant outcomes has been the subject of longstanding interest. Although increased time on dialysis prior to kidney transplantation is associated with decreased graft and patient survivals, analyses of the impact of dialysis modality on kidney allograft outcome have produced conflicting results. Objective The objective of this study was to evaluate the influence of dialysis duration and modality on the function and survival of renal allografts. Patients We retrospectively reviewed the clinical data of 421 adults who received first kidney transplantations from cadaveric heart-beating donors performed in our unit from May 1989 to May 2007. Three hundred seventy-four patients (88.8%) were on hemodialysis (HD) prior to kidney transplantation, including 247 patients (58.7%) on treatment for at least 24 months. Results Patients with a dialysis duration ≥24 months were significantly older (45.9 vs 42.8 years; P = .013). Renal function at 3, 12, 60, and 96 months was similar between the 2 groups. Longer duration on dialysis was associated with poorer overall graft and patient survivals. No differences were observed in renal function or graft and patient survivals comparing HD or peritoneal dialysis (PD). Multivariate analysis confirmed the lack of correlation between dialysis duration or modality and allograft failure. Conclusion Longer dialysis duration influenced overall graft and patient survival. However, dialysis modality showed no influence on graft function or survival.

Systematic Microbiological Tests in Kidney Transplantation and Their Value in Predicting Posttransplantation Infection

Background Immunosuppressive therapy has many side effects among which is an increased infectious risk for the recipient. Transmission of pathogens from the graft to the recipient has not been well evaluated; there are no guidelines regarding the need for microbiological tests on the graft prior to transplantation. We routinely performed such tests to evaluate the risk and determine whether a patient should receive preemptive antibiotic therapy after transplantation. We herein have reported our preliminary results. Materials and Methods We reviewed 150 consecutive renal transplantations from cadaveric heart-beating donors. Microbiological tests were systematically performed not only on the preservation solution, but also on graft artery, vein, ureter, and perirenal fat. We reviewed the recipient's medical history for clinically significant infectious episodes in the first month after transplantation. Results Thirty-one percent of all microbiological tests were positive with 23 patients showing multiple positive tests, 74% of which were concordant. We documented 3 cases of direct graft-to-recipient pathogen transmission, all of which presented with 3 positive concordant tests. Graft culture prior to transplantation is often positive, but in more than half of the cases positive tests are either isolated or discordant. We only treated patients with concordant test results; no adverse consequence was observed among the untreated patients. Transmission occurred only in patients with at least 3 concordant tests. Conclusions Multiple microbiological tests on the graft prior to transplantation seemed useful to determine which patients would benefit from preemptive antibiotic therapy. Further studies may help to define which microbiological tests are the most important.

Survey of the Use of Nonheart-Beating Kidneys in Pediatric Practice in the United Kingdom

In the United Kingdom, the introduction of funded programs to recover organs from nonheart-beating donors (NHBDs) has increased the numbers of organs available for transplant into adult recipients. In the latest report from UK Transplant, NHBD organs now account for 12% of adult renal transplants (1). These programs do not appear to have had a significant effect on pediatric practice. Therefore, in June 2006, we distributed an online questionnaire to research leads at all 13 UK pediatric nephrology units in order to assess current practice. Replies were received from 12 units, accounting for a 92% response rate. Ten units were aware of local NHBD programs. Since the establishment of UKT-funded NHBD programs, only one unit had actually transplanted a NHBD organ into a pediatric recipient. Another unit was offering them to pediatric patients and had three children on the waiting list for them. Both of these units had local programs that had been established for 3 years or more and retrieved organs of Maastricht category 3 or 4 (2). None of the units with local programs retrieving Maastricht category 2 organs had plans to transplant them into children, but did not give the category as a reason. The main reasons for not using these organs were lack of outcome data on their use in children (n=6) and lack of outcome data on their use in adults, on which to base decisions about children (n=4) (Table 1).TABLE 1: Reasons given for not using NHB organs in pediatric recipients (more than one reason could be given)There are many published series on the use of NHBD organs in adults from around the world. The most recently published data from UKT show that outcome data is similar between transplants from non-heart beating and heart beating cadaveric donors (1). One-year graft survival for these transplants is 94% and 92%, respectively, with 5-year graft survival being 86% and 84%. A paucity of data exist regarding the use of these organs in children. The largest most recent series has been reported by The United Network for Organ Sharing (3). During a 10-year period, 26 renal transplants were performed with allografts from NHB organs into pediatric recipients. There was no statistical significantly difference in 1- and 5-year graft survival between NHB and heart- beating transplants (1 year: 82.5 and 89.6%, respectively, 5 year: 74.3 and 64.8%, respectively). Although the numbers analyzed are small, this evidence suggests that children should not be denied access to NHB organs in units in which there is a well-established adult NHBD program. We believe that although few data are available regarding the use of organs from NHBD donors in pediatric recipients there is strong evidence that, in adults, organs from NHBDs have equivalent survival to those from heart- beating donors. Therefore, they should be strongly considered as an option for pediatric patients. Anusha G. Edwards Justin D. Morgan Southmead Hospital Westbury on Trym Bristol BS10 5NB Kingdom Carol Inward Bristol Royal Hospital for Children Paul O'Gorman Building Upper Maudlin Street Bristol BS2 8BJ United Kingdom

The Use of Marginal Heart Beating Donor Livers for Transplantation in the United Kingdom

This study investigated the use of deceased heart-beating donor livers offered for transplantation during a 10-year period, during which there has been an increasing disparity between organ supply and demand in the United Kingdom. Summary data from the National Transplant Database were analyzed on all 7107 heart-beating cadaveric donor livers offered for transplantation in the United Kingdom between 1996 and 2006, with particular attention to livers that were not retrieved, not transplanted, or that subsequently failed to function after transplantation. The difference between the number of patients registered for liver transplantation in the United Kingdom and those transplanted increased from 132 in 1996 to 333 in 2006, leading to a 77% increase in the number of waiting list deaths. Mean donor age increased by 6.1 (5.7-6.6) years during the period studied, in part because of a reduction in the proportion of donors arising from road fatalities. Despite this, the rate of primary nonfunction remained low (1.7% during 1996-2006). The absolute risk increase of primary nonfunction arising from receipt of a moderately as opposed to mildly steatotic organ was 2.6%, which translates to a "number needed to harm" of 41 patients. The decline in both the number and the quality of livers offered for transplantation in the United Kingdom during the past 10 years has not been associated with a change in the rate of primary nonfunction. In these times of acute donor shortage, these data may justify a more liberal use of marginal grafts.

The Influence of Pulsatile Preservation in Kidney Transplantation From Non–Heart-Beating Donors

Continuous hypothermic pulsatile perfusion (CHPP) may offer improved early function compared with cold static perfusion (CSP) for heart-beating cadaveric donors. With an expanding pool of donors, ie, non–heart-beating donors (NHBD), we present our preliminary results with the use of CHPP compared with CSP to preserve kidney grafts retrieved from NHBD. Eighteen consecutive locally procured cadaveric kidneys from NHBD were preserved using CHPP using UW machine perfusion solution in the Life Port kidney transporter. Perfusion parameters were measured serially during pulsatile perfusion. This group was compared with 18 NHBD cadaveric kidneys preserved with CSP. No organs were lost due to faulty technique of preparation or preparation of pulsatile perfusion. Immediate renal function was observed in 13 cases (72.2%). In CSP in NHBD, we had 16 cases with delayed graft function (88.8%). These early results show that the use of pulsatile perfusion to preserve kidneys from NHBD may be associated with improved early outcomes. Longer follow-up is required to answer the more important question as to whether it offers long-term improvements that justify the extra cost and complexity.

Outcome of Kidney Transplantation From Nonheart-Beating Versus Heart-Beating Cadaveric Donors

This study aimed to assess outcomes of kidney transplants from nonheart-beating (NHB) compared with heart-beating (HB) cadaveric donors with meta-analytical techniques. A literature search was performed for studies comparing kidney transplants from NHB vs. HB cadaveric donors between 1992 and 2005. The following outcomes were evaluated: warm and cold ischemia times, primary nonfunction, delayed graft function, length of hospital stay, acute graft rejection, patient and graft survival, and post-transplant serum creatinine. Eighteen comparative studies of 114,081 patients matched the selection criteria; 1,858 received kidney from NHB and 112,223 from HB donor. Warm ischemia time was significantly longer for the NHB group by 24 min (P<0.001). Cold ischemia time was similar for the two groups (P=0.97). The incidence of primary nonfunction and delayed graft function was 2.4 times (P<0.001) and 3.6 times (P<0.001) greater, respectively, in the NHB group. Length of hospital stay was longer for the NHB group by 4.6 days (P<0.001). The 6-month, 2-year, and 5-year patient survival were similar between the two groups. The incidence of acute rejection was similar between the two groups whereas the initial graft survival advantage in favor of the HB group diminished gradually over the course of time. There was no statistically significant difference between the two groups for the recipient serum creatinine levels at 3 and 12 months after transplantation. NHB donors carry the potential of expanding the cadaveric kidney pool. Although, transplants from NHB donors are associated with a greater incidence of early adverse events, long-term outcomes appear comparable with those of transplants from HB donors.

Non-Heart-Beating Kidney Transplantation: 6-Year Outcomes

Non-heart-beating donor kidneys (NHBD) are being used to increase the donor pool due to the scarcity of cadaveric heart beating donors (HBD). We evaluated the long-term outcomes of renal transplantation using NHBD kidneys, comparing the first 100 NHBD kidneys transplanted at our facility to the next consecutive cadaveric HBD kidneys for graft survival, recipient survival, and quality of graft function. Recipient survival ( P = .22) and graft survival ( P = .19) at 6 years did not differ between recipients of NHBD (83%, 80%) and HBD (89%, 87%) kidneys. Quality of graft function using the mean glomular filtration rates were significantly lower in the NHBD group up to 3 months following discharge (41 ± 2 vs 47 ± 2, P = .007) but were then comparable up to 6 years following transplantation (43 ± 5 vs 46 ± 4, P = .55).

Follow-up after renal transplantation with organs from donors after cardiac death

Kidneys obtained from donors after cardiac death (DCD) are known to have higher rates of primary nonfunction and delayed graft function (DGF) than heart beating cadaveric donor (CAD) kidneys, but little is known about long-term function of DCD grafts that survive to 1 year. To investigate the outcomes of renal transplant recipients whose DCD graft functioned for at least 1 year, this study analyzed data collected from 326 DCD graft recipients and 340 CAD-matched controls enrolled in a prospective, multinational, observational study--Neoral-MOST (Multinational Observational Study in Transplantation) (Novartis, Basel, Switzerland). No differences were found in the demographics or immunosuppression between the two groups. All patients received a Neoral-based immunosuppressive regimen. Donors after cardiac death graft recipients had a higher incidence of DGF (40% vs. 27% CAD; P < 0.001). One year glomerular filtration rate (GFR) and GFR-decline after 1 year were similar in DCD and CAD recipients (GFR 56 ml/min DCD vs. 59 ml/min CAD; GFR-decline -1.3 ml/min DCD vs. -1.4 ml/min CAD; P = not significant). Multifactorial analyses confirmed that GFR at 1 year was significantly influenced by donor age and gender, DGF, and acute rejection; however, DCD status was not an independent risk factor in cyclosporine-treated patients with grafts that had functioned for at least 1 year.

Split Liver Transplantation

Seventy-five thousand Americans develop organ failure each year. Fifteen percent of those on the list for transplantation die while waiting. Several possible mechanisms to expand the organ pool are being pursued including the use of extended criteria donors, living donation, and split deceased donor transplants. Cadaveric organ splitting results from improved understanding of the surgical anatomy of the liver derived from Couinaud. Early efforts focused on reduced-liver transplantation (RLT) reported by both Bismuth and Broelsch in the mid-1980s. These techniques were soon modified to create both a left lateral segment graft appropriate for a pediatric recipient and a right trisegment for an appropriately sized adult. Techniques of split liver transplantation (SLT) were also modified to create living donor liver transplantation. Pichlmayr and Bismuth reported successful split liver transplantation in 1989 and Emond reported a larger series of nine split procedures in 1990. Broelsch and Busuttil described a technical modification in which the split was performed in situ at the donor institution with surgical division completed in the heart beating cadaveric donor. In situ splitting reduces cold ischemia, simplifies identification of biliary and vascular structures, and reduces reperfusion hemorrhage. However, in situ splits require specialized skills, prolonged operating room time, and increased logistical coordination at the donor institution. At UCLA over 120 in situ splits have been performed and this technique is the default when an optimal donor is available. Split liver transplantation now accounts for 10% of adult transplantations at UCLA and 40% of pediatric transplantations.

Surgical Complications of Simultaneous Pancreas–Kidney Transplantation: A 16-Year-Experience at One Center

Fifty-one simultaneous pancreas–kidney transplants (SPKT) were performed between 1988 and 2004 in patients of mean age 34 years and 23 years duration of diabetes treatment. All kidney and pancreas recipients were on maintenance hemodialysis therapy prior to SPKT. The pancreas with duodenal segment and the kidneys were harvested from cadaveric heart-beating donors. Cold ischemia time in UW solution varied from 4 to 14 hours (mean, 9 hours 35 minutes). Twenty patients had the duodenal segment sutured to the urinary bladder, and the remaining 31 grafts were drained to an isolated ileal loop. Quadruple immunosuppression was administered as well as an anticoagulant and antibiotic prophylaxis. Forty-nine patients (49/51, 96%) regained insulin independence in the immediate postoperative period; 44 (86%) displayed immediate graft function. The remaining patients experienced postoperative ATN, the longest duration was 18 days. Of 51 patients, 38 (14.5%) are alive (follow-up, 6 to 180 months), 26 (68.5%) have good pancreatic function, and 34 (89%), good kidney function. Nineteen (50%) patients regard their quality of life as improved compared to their pretransplant status, which is mainly attributed to being dialysis and insulin free. Of 19 patients, 14 (74%) reported measuring glycemia regularly due to fear of losing the pancreas graft. Of 19 persons, seven (37%) returned to work after transplantation. Four (8.3%) lost their kidney graft secondary to vascular complications ( n = 2) or rejection ( n = 2). Four pancreas grafts with bladder drainage required conversion to enteric drainage owing to persistent urinary infections or urinary fistulae. Fifteen (29%) patients lost their pancreatic grafts within 1 year of transplantation due to the following: vascular complications ( n = 12), septic complications ( n = 1), or rejection ( n = 2). Thirteen patients died within 1 year after transplantation, 5 of septic complications, 5 of neuroinfection, 1 of pulmonary embolism, and 2 of myocardial infarction. In conclusion, SPKT is a successful treatment for diabetic nephropathy, burdened by the possibility of serious complications.

Direct Visualization of Cortical Peritubular Capillary of Transplanted Human Kidney with Reperfusion Injury Using a Magnifying Endoscopy

We developed a direct imaging system of renal microcirculation by a magnifying-endoscopy that enables visualization of the movement of erythrocyte in glomerular and cortical peritubular capillary (CPC). We investigated the microcirculation of CPC in the early phase of both living- and cadaveric-donor transplant kidneys. Erythrocyte velocity in CPC were monitored and measured in 20 renal transplants at 20, 60, 90, and 120 minutes after reperfusion. The kidney grafts came from 11 living donors and 9 non-heart-beating cadaveric donors. In living-donor transplants, erythrocyte velocity in CPC at 20 minutes after revascularization declined to one third of baseline value just before nephrectomy and recovered to the prenephrectomy value 120 minutes after reperfusion. In contrast, it continued to be disturbed for 90 minutes in cadaveric-donor transplants. Erythrocyte velocity in CPC more significantly deteriorated in cadaveric transplants than in those of living transplants at 20 through 60 minutes after the revascularization. In living-donor transplants, erythrocyte velocity did not correlate with donor age, both warm (WIT) and cold ischemic time (CIT), time to the initial urination, and best creatine clearance. In the cadaveric transplants, ischemic time, both WIT and CIT, did not correlate with the erythrocyte velocity. However, donor age, duration of acute tubular necrosis, and best creatine clearance after transplantation significantly correlated with the erythrocyte velocity. The measurement of erythrocyte velocity in CPC is a reliable method for predicting the recovery of renal function and reserved renal function of kidney allografts undergoing prolonged ischemia.

SHORT-TERM TRANSPLANT SURVIVAL OF LIVING DONOR KIDNEY TRANSPLANTS IN THE UK

P350 Aims: The number of kidney transplants from living unrelated donors has been increasing rapidly in the UK in recent years. These transplants are usually less well matched than those from cadaveric heartbeating donors (HBD) or living related donors (LRD). This study investigates the degree of HLA match in transplants from the different donor types, compares short-term transplant survival of HBD and living related and unrelated donor grafts and considers the influence of HLA match and other factors on outcome of all living donor transplants in the UK (1998-2003). Methods: HLA-A, B and DR mismatches of 1624 living related, 402 unrelated kidney donor transplants and 7421 cadaveric HBD transplants were compared. For each group, the transplant survival time (time from transplant to graft failure or patient death) was calculated and analysed. Results: As expected, transplants from living unrelated donors were significantly less well matched. In particular, there were two HLA-DR mismatches in 44% of living unrelated donor transplants but less than 3% in both LRD and cadaveric HBD transplants. There were no significant differences in one-year transplant survival between the two living donor transplant groups (p=0.8). For all living donor transplants one-year transplant survival was 94% (95% confidence interval (CI) 92-95%), while transplant survival of cadaveric HBD grafts (88%, 95% CI 87-89%) was inferior (p<0.0001). There was no difference in one-year transplant survival between the least well matched (2 HLA-DR mismatches) living unrelated donor transplants (90%, 95% CI 85-95%) and 000 HLA-A, B, DR mismatched cadaveric HBD transplants (89%, 95% CI 87-91%). Of the factors analysed, Cox regression modelling showed only older donor age (p<0.01) and recipient gender female (p<0.03) to have a significant adverse effect on one-year transplant survival of living donor transplants. There was evidence of an adverse effect of two HLA-DR mismatches in the living unrelated donor transplants in the early part of the cohort that was not apparent in the later transplants. Conclusions: Living unrelated donor transplants were significantly less well HLA matched than other donor transplants. One-year transplant survival was comparable for LRD and unrelated donor transplants and superior to survival of cadaveric HBD transplants. Multifactorial analysis of one-year outcome of living donor transplants showed significant effects of donor age and recipient gender. An adverse effect of two HLA-DR mismatches in living unrelated donor transplants was apparent only in the earlier years analysed.

Another matter of life and death: what every anesthesiologist should know about the ethical, legal, and policy implications of the non-heart-beating cadaver organ donor.

Summary It remains to be seen whether the use of NHBCDs willsignificantly increase the number of organs available fortransplantation. Organ retrieval from such donors maybe ethical, provided that conflicts of interest amonghealthcare providers are defined and prevented, the ex-ploitation of vulnerable persons is avoided, the with-drawal of care is in accordance with accepted and ap-propriate medical standards, the inadvertent harvestingof vital organs from living patients does not occur, andthe humane treatment of dying patients and their fami-lies is safeguarded. Further, the process must not beimplemented in ways that cause distrust among dyingpatients that their medical and social needs will be putsecondary to those of patients needing transplantableorgans. It is arguable whether any existing protocolcompletely addresses all of these issues.Any anesthesiologist involved with either policies orcare of patients who will become NHBCDs should beeducated about the legal, ethical, and medical issuesinvolved and should not undertake such duties withoutadequate knowledge and training. Even when with-drawal of care is anticipated in an operating room set-ting, only physicians with appropriate knowledge, train-ing, and experience in the withdrawal of life support andcomfort care of the dying patient should be involvedwith the NHBCD. Such specialty expertise is not withinthe customary training and practice of most anesthesiol-ogists. The physician withdrawing life support should besomeone who has been involved with the patient andfamily throughout the decision-making process, so thatdeath does not become, as Renee Fox described it, a“desolate, profanely ‘high-tech’ death that the patientdies, beneath operating room lights, amid masked,gowned, and gloved strangers.”