Mean Cold Ischemia Time Research Articles

Tumor Exposure and Cold Ischemia Using a LapSac® in Partial Nephrectomy by Video-Assisted Minilaparotomy Surgery (VAMS)

Purpose: We report a new method of tumor exposure through a minilaparotomy window and cold ischemia using a LapSacR during partial nephrectomy by video-assisted minilaparotomy surgery (VAMS). Materials and Methods: Partial nephrectomy was performed by VAMS in a total of 31 patients during a period ranging from January 2004 to June 2006, and tumor exposure and cold ischemia were achieved by using a LapSacR. We investigated the tumor size and location, mean operative time, mean estimated blood loss, mean cold ischemic time, and pathologic outcomes retrospectively. We evaluated preoperative and postoperative renal function with the estimated creatinine clearance rate by the MDRD equation. Results: The mean tumor size was 2.59±1.30 cm and mean surgical time was 182.5±44.5 minutes. Mean cold ischemic time was 31.84±8.43 minutes. Mean estimated blood loss was 445.65±202.77 ml (range, 100-800 ml), and 3 patients required transfusion. A histopathologic examination confirmed a diagnosis of renal cell carcinoma in 22 patients (71%). The surgical margin was positive in 1 patient. Twenty-one patients had a mean followup of 53±8.19 months. Nineteen patients survived without any disease recurrence, 1 patient survived with lung metastasis within 5 months, and 1 patient died of unrelated cause. There was no significant difference between the preoperative and postoperative estimated creatinine clearance rate by using the MDRD equation. Conclusions: Tumor exposure and cold ischemia were attempted in a partial resection of the kidney by VAMS with a LapSacR. This technique for partial nephrectomy by VAMS might be an effective, safe modality. (Korean J Urol 2009;50:774-779) 󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏

Living Donor Nephrectomy: Open versus Laparoscopic Technique

Background The living donor nephrectomy has to be safe and effective, allowing a good graft function in the recipient. In the past, donor nephrectomy was performed only by open technique; more recently this nephrectomy has also been performed by laparoscopic technique. The best technique has not been established in literature. The purpose of this study is to report the results of open and laparoscopic nephrectomy in living donors. Materials and Methods From January 1992 to August 2008, 37 living donor nephrectomies were performed. 23 nephrectomies were achieved by laparoscopic procedure (LDN) and 14 by open technique (ODN). The 2 groups were comparable regarding both donor and recipient characteristics. Results All laparoscopic nephrectomies were successfully performed without conversion to open procedure. No donor deaths were reported in either groups. 3 complications (13%) in the LDN group and 1 (7.1%) in the ODN group (p=0.6) were observed. Mean operative time was higher in the LDN group (p<0.036). Mean warm and cold ischemia time, resumption of oral intake and hospital stay were shorter in the LDN group (p<0.04)(p<0.03) (p<0.0001), whereas the return to normal occupational life was similar (p<0.52). We had no significant differences in the surgical complication rates, graft and patient survival. Conclusions Our experience suggests that both procedures can be used safely and efficiently, and assure a good renal function in the recipient. Laparoscopic nephrectomy, although more difficult, provides post-operative advantages. However, laparoscopic procedure must be performed by experienced centres only to prevent serious complications in the donor.

A prospective randomized multicenter trial comparing histidine-tryptophane-ketoglutarate versus University of Wisconsin perfusion solution in clinical pancreas transplantation

We aimed to evaluate early pancreas transplant graft function after histidine-tryptophan-ketoglutarate (HTK) versus University of Wisconsin (UW) perfusion. Prospective randomized multicenter study including 68 pancreas transplantations stratified according to preservation fluid used (27 HTK vs. 41 UW). Primary endpoint was pancreas graft survival at 6 months. Serum alpha-amylase, lipase, C-peptide, HbA1C and exogenous insulin requirement were compared at several time points. Mean pancreas cold ischemia time was 10.8 +/- 3.7 (HTK) vs. 11.8 +/- 3.4 h (UW) (P = 0.247). Simultaneous pancreas-kidney transplantation was performed in 95.6% of the patients, pancreas transplantation alone in 2.9%, and pancreas after kidney transplantation in 1.5%. Six months graft survival was 85.2% (HTK) vs. 90.2% (UW) (P = 0.703). Serum amylase and lipase values did not differ between both the groups during the observation period. C-peptide levels were elevated in both the groups without significant differences at each time point. Higher exogenous insulin requirement early after transplantation in the UW group had resolved at 3 months. Six month patient survival was 96.3% (HTK) vs. 100% (UW) (P = 0.397). With a mean cold ischemia time of 10 h in this study, HTK and UW solutions appear to be equally suitable for perfusion and organ preservation in clinical pancreas transplantation.

Effects of Hypoxia-Inducible Factor-1α Expression and C4d Deposition in Implantation Biopsies on Renal Allograft

Upregulation of hypoxia-inducible factor-1α (HIF-1α) in response to ischemic states has been suggested to have a role in the development of chronic allograft nephropathy. Deposition of C4d in the peritubular capillaries of renal allografts has been reported to be a sensitive marker of acute humoral rejection. The purpose of this study was to determine the effects of HIF-1α expression and C4d deposition in implantation biopsies of renal allografts. Implantation biopsies and 22 rejection proved biopsies were performed in 54 renal transplant recipients between December 1996 and July 1999. The mean follow-up was 82.8 months. Immunohistochemical studies were performed using a mouse monoclonal antibody for HIF-1α expression and a rabbit polyclonal antibody for C4d detection. HIF-1α was demonstrated in 19 of 54 implantation biopsies (35%), and C4d deposition in one (1.9%). The HIF-1α–positive group included a higher percentage of deceased donor organs (66.4% vs 17.1%; P = .002) and longer mean cold ischemia times (261.3 ± 231 vs 103 ± 40 min; P = .008) compared with the HIF-1α–negative group. The relative risks (95% confidence intervals) of expression of HIF-1α for allograft rejection, chronic allograft nephropathy, and graft loss were 1.53 (0.82–2.87), 0.61 (0.06–5.50), and 2.45 (0.62–9.85). The C4d-positive patient developed acute accelerated rejection on postoperative day 4. In the present study, the expression of HIF-1α showed a significant correlation with the use of a deceased donor kidney and with cold ischemia time. However, there were no significant effects on the prognosis for a graft after implantation of a kidney with HIF-1α expression.

Multicenter Study on Double Kidney Transplantation

Background Marginal organs not suitable for single kidney transplantation are considered for double kidney transplantation (DKT). Herein we have reviewed short and long-term outcomes of DKT over a 7-year experience. Patients and Methods Between 2001 and 2007, 80 DKT were performed in the transplant centers of Bologna, Parma, and Modena, Italy. Recipient mean age was 61 ± 5 years. The main indications were glomerular nephropathy (n = 33) and hypertensive nephroangiosclerosis (n = 14). Mean HLA A, B, and DR mismatches were 3.1 ± 1.2. Donor mean age was 69 ± 8 years and mean creatinine clearance was 75 ± 27 mL/min. Almost all kidneys were perfused with Celsior solution. Mean cold ischemia time was 17 ± 4 hours and mean warm ischemia time was 41 ± 17 minutes. Mean biopsy score was 4.4. Immunosuppression was based on tacrolimus (n = 52) or cyclosporine (n = 26). Results Fifty (62.5%) patients displayed good postoperative renal function. Thirty (37.5%) experienced acute tubular necrosis and required postoperative dialysis treatment; 8 acute rejections occurred. Urinary complications were 13.7% with 8/11 requiring surgical revision. There were 6 surgical reexplorations: intestinal perforation (n = 2), bleeding (n = 3), and lymphocele (n = 1). Two patients lost both grafts due to vascular and infectious complications at 7 or 58 days after transplantation. Two patients underwent intraoperative transplantectomy due to massive vascular thrombosis. Four (5%) patients underwent transplantectomy of a single graft due to vascular complications (n = 2), bleeding (n = 1), or infectious complications (n = 1). Graft and patient survivals were 95% and 100% versus 93% and 97% at 3 versus 36 months, respectively. Conclusions DKT is a safe approach for organ shortage. The score used in this study is useful to determine whether a kidney should be refused or accepted.

Reduction in Cold Ischemia Time of Renal Allografts in the United States Over the Last Decade

A reduction in cold ischemia time (CIT) can be associated with better renal allograft outcomes. However, few published surveys of CIT of deceased donor kidneys transplanted in the United States are available. We therefore surveyed the CIT using the United Network for Organ Sharing data of the last decade. A reduction in CIT was observed during the 10-year period with an overall reduction of 4.8 hour ( n = 75,072; mean ± SD, 24.4 ± 10.9 hour in 1990 vs 19.6 ± 8.4 hour in 2000, P < .001) with fewer kidneys being cold-stored over 30 hour in the second half (13% in 1996 to 2000 vs 25% in 1990 to 1995, P < .001). Although the overall rates of delayed graft function were not different between the two periods (24% in 1990 to 1995 vs 25% in 1996 to 2000), possibly due to increased use of kidneys from extended criteria donors and donors after cardiac death and the persistence of CIT over 20 hours in the second half, the 6-month posttransplant graft function (serum creatinine: 1.63 ± 0.01 mg/dL in 1996 to 2000 vs 1.75 ± 0.01 mg/dL in 1990 to 1995; P < .001) and the 3-year graft survival (80% in 1996 to 2000 vs 72% in 1990 to 1995; P < .001) were better. Thus, our analysis demonstrates an overall reduction in mean CIT over the last decade, with fewer kidneys being cold-stored over 30 hours in the latter half. This raises the possibility that besides the influence of improved immunosuppression, reduction in CIT might have also contributed to the recently observed improvements in graft outcomes.

Cadaveric Renal Transplantation: The Chennai Experience

Transplantation of human organs is undoubtedly one of the greatest medical breakthroughs of this century. However, few Indian patients are able to benefit from this medical advance. It is estimated that in India every year over 152,000 people are diagnosed to have end-stage renal failure needing renal transplantation. The Transplantation of Human Organs Act passed by the Indian parliament in 1994 was subsequently ratified by the state legislature of Tamil Nadu in May 1995. It accepted brain death as a form of death and prohibited commerce in organs. The first cadaveric kidney transplant in Sri Ramachandra medical college was performed in 1995 with 68 cadaveric kidney transplants thereafter. The mean age of the donors was 36 ± 12.8 years. The mean cold ischemia time was 5.6 ± 3.2 hours. As many as 14 donors displayed acute renal failure (serum creatinine more than 1.2 mg/dL). Immediate graft function was established in 34 patients (50%). Four had graft rupture, two of which were successfully repaired. Postoperatively 12 patients (17.6%) displayed delayed graft function requiring dialysis. During the first year, 18 patients (26.4%) experienced acute rejection episodes, of which 14 were cellular and four vascular rejection types. As many as eight patients were lost to follow-up within one year; the mean follow-up time was 968 ± 86 days. Patient survival at 1 year was 88.2% and that of the graft 73.5%. The 5-year patient and graft survival rates were 61.7% and 58.8%, respectively. The mean serum creatinine of patients currently followed is 2.2 ± 0.86 mg/dL. The rate of cadaver kidney transplantation in India is low despite initiatives by our university to promote donation. Creating a positive public attitude, early brain death identification, and certification, prompt consent for organ donation, adequate hospital infrastructure, and support logistics are prerequisites for successful organ transplantation.

Organ Preservation With Histidine-Tryptophan Ketogluatarate Solution in Clinical Pancreas Transplantation: An Update of the Indiana University Experience

In May 2003, University of Wisconsin (UW) solution was replaced with Histidine-Tryptophan Ketoglutarate (HTK) solution as the preservation fluid for abdominal organ procurements in our center. Herein we have reported our updated results with HTK in pancreas transplantation. Between May 2003 and October 2006, 152 pancreas transplantations were performed in which 146 used HTK. The procedures were as follows: simultaneous kidney pancreas transplantation (n = 85; 55%), pancreas after kidney transplantation (n = 41; 30%), and solitary pancreas transplantation (n = 20; 15%). Donor and recipient data were collected with primary outcomes as primary nonfunction (PNF), and 30-day and 1-year graft and patient survival. Patient demographics are as follows: age (36 ± 12 years), gender (males, 89: females, 57), race (white, 135; African American, 11). Mean flush volume was 3.8 ± 1 L. The mean cold ischemia time was 8 ± 3 hours. Mean warm ischemia time was 48 ± 23 minutes. There were no cases of PNF in this cohort. Thirty-day and 1-year patient survival rates were 99% and 95%, respectively. The 30-day and 1-year graft survivals rates were 95% and 93%, respectively. There were 10 grafts lost with 7 vascular complications (6 venous and 1 arterial thrombosis). There were 2 cases of chronic rejection and 1 graft lost to noncompliance. These statistics compare favorably with International Pancreas Transplant Registry reported 1-year survival for pancreas allografts. All other patients were insulin independent by discharge. Serum fasting blood glucose and serial amylase remained comparable at all intervals posttransplantation to those of a historical UW cohort. Within this range of cold ischemia times, HTK appears to provide effective pancreas preservation.

Present Status of Pancreas Transplantation in Japan—Donation Predominantly From Marginal Donors and Modified Surgical Technique: Report of Japan Pancreas Transplantation Registry

In Japan, organ donation has been still limited because of the strict donor criteria. The aim of this study was to show the effectiveness of pancreas transplantation (PTx) by analyzing the outcomes even under poor donor conditions. Thirty-six cases of PTx (32 simultaneous pancreas and kidney transplantations [SPK], 4 pancreas after kidney transplantations) performed during the last 8 years were examined especially for donor characteristics. Mean donor age of 41.4 ± 11.9 years was considerably older compared with that in the United States and Europe; donors aged over 40 years comprised 67% of the total. According to the criteria described by Kapur, 29 cases (81%) in our series would be considered marginal. Thus, to increase blood supply into the pancreatic head, the gastroduodenal artery (GDA) was anastomosed using donor artery to common hepatic artery or iliac Y graft. These procedures were performed in 16 of the 24 cases in which there was liver procurement. Eventually, 34 cases (94%) preserved GDA continuity. Mean total cold ischemic time of pancreatic grafts was 12 hours 15 minutes. Of 214 registrants, 17 patients on the waiting list for SPK died of diabetic complications. To date, patient survival remains 100% with a mean follow-up period of 33 months. Pancreas graft survivals at 1, 3, and 5 years posttransplantation were 92%, 80%, and 80%, respectively. In contrast, kidney survivals were 91%, 91%, and 91%, respectively. The integrity of the pancreas head and duodenum by preservation of the GDA continuity might have decreased the risk associated with the marginal donors.

Outcomes of Dual Adult Kidney Transplants in the United States: An Analysis of the OPTN/UNOS Database

The organ shortage has resulted in increased use of kidneys from expanded criteria donors (ECD). For ECD kidneys unsuitable for single use, dual kidney transplants (DKT) may be possible. There are limited data comparing outcomes of DKT to single kidney ECD transplants, making it unclear where DKT fits in the current allocation scheme. Our purpose was to compare outcomes of DKT and ECD transplants in the United States. From 2000 to 2005, a total of 625 DKT, 7686 single kidney ECD, and 6,044 SCD transplants from donors aged>or=50 years were identified from the Organ Procurement and Transplantation Network/United Network for Organ Sharing data. Allograft survival was the primary outcome. DKT comprised 4% of kidney transplants from donors aged>or=50 years. Compared to the ECD donor group, the DKT donor group was older (mean age 64.6+/-7.7 years vs. 59.9+/-6.2 years) and consisted of more African Americans (13.1% vs. 9.9%), and more diabetic donors (16.3% vs. 10.4%; P<0.001). Mean cold ischemic time was longer in DKT (22.2+/-9.7 hr), but rates of delayed graft function were lower (29.3%) compared to ECD transplants (33.6%, P=0.03). Three-year overall graft survival was 79.8% for DKT and 78.3% for ECD transplants. DKT were infrequent and had outcomes comparable to ECD transplants, despite the use of organs from higher risk donors. With a more upfront approach to DKT by offering this option to patients at the time of wait-listing as part of an ECD algorithm, we may be able to further optimize outcomes of DKT and minimize discard of potential organs.

Simultaneous Air Transportation of the Harvested Heart and Visceral Organs for Transplantation

Background The purpose of this study was to evaluate the duration for organ procurement including both heart and visceral organs and outcomes of the simultaneous transportation of the teams back to the recipient hospitals. Patients and Methods Between March 2005 and March 2007, 37/82 organ procurement was performed in the district hospitals and transported to our institution for organ transplantation. Combined heart and visceral organ procurement which was simultaneously transported to the recipient hospitals by one air vehicle was reviewed. After both the thoracic and abdominal cavities were entered, all intra-abdominal organs were mobilized allowing exposure of the inferior mesenteric vein and aorta. The supraceliac abdominal aorta was elevated. The attachments of the liver in the hilar region were incised and both kidneys and pancreas prepared for removal. After the inferior mesenteric vein and aorta were cannulated, simultaneous aortic cross-clamping was performed and cold preservation solution infused. Harvested organs were packed with ice and removed to the back table for initial preparation and packaging for air transport. Results The mean duration of 6 procurement procedures was 63 minutes (range 50–75 minutes) to aortic clamping, and 27.5 minutes (range, 20–40 minutes) between clamping and harvesting. Mean cold ischemia times for 6 hearts, 6 livers, 12 kidneys, 2 pancreas, and 1 small intestine were 2.4 hours (range, 2–3.5 hours), 5 hours (range, 3–8 hours), 10.3 hours (range, 8–15 hours), 6.7 hours, and 9.5 hours, respectively. No graft complication was observed to be associated with the procurement procedure. Conclusion Better collaborations between surgical teams and rapid procurement techniques provide simultaneous air transportation back to the recipient hospital with reduced cold ischemia times of the visceral organs.

Alemtuzumab Pre-Conditioning With Tacrolimus Monotherapy in Pediatric Renal Transplantation

We employed antibody pre-conditioning with alemtuzumab and posttransplant immunosuppression with low-dose tacrolimus monotherapy in 26 consecutive pediatric kidney transplant recipients between January 2004 and December 2005. Mean recipient age was 10.7 +/- 5.8 years, 7.7% were undergoing retransplantation, and 3.8% were sensitized, with a PRA >20%. Mean donor age was 32.8 +/- 9.2 years. Living donors were utilized in 65% of the transplants. Mean cold ischemia time was 27.6 +/- 6.4 h. The mean number of HLA mismatches was 3.3 +/- 1.3. Mean follow-up was 25 +/- 8 months. One and 2 year patient survival was 100% and 96%. One and 2 year graft survival was 96% and 88%. Mean serum creatinine was 1.1 +/- 0.6 mg/dL, and calculated creatinine clearance was 82.3 +/- 29.4 mL/min/1.73 m(2). The incidence of pre-weaning acute rejection was 11.5%; the incidence of delayed graft function was 7.7%. Eighteen (69%) of the children were tapered to spaced tacrolimus monotherapy, 10.5 +/- 2.2 months after transplantation. The incidence of CMV, PTLD and BK virus was 0%; the incidence of posttransplant diabetes was 7.7%. Although more follow-up is clearly needed, antibody pre-conditioning with alemtuzumab and tacrolimus monotherapy may be a safe and effective regimen in pediatric renal transplantation.

Using Verapamil as Protective Factor in Renal Ischemia Reperfusion Injury During Anatrophic Nephrolithotomy

Anatrophic nephrolithotomy (ANL) in the selected cases represents the method of choice in the treatment of staghorn calculi. We evaluated postoperative outcome of patients subjected to standard ANL that received 10 mg of Verapamil immediately before declamping renal artery, due to prevention of reperfusion injury. From 2002 to 2005, 18 nephrolithotomies were performed on 15 patients, in the Urology Clinic, University of Sarajevo Clinics Centre. Preoperative evaluation included intravenous urography and radionuclide renal scans which had been repeated 6 months after the operations. 10 males and 5 females were operated with mean age of 45 years. Urography and renal scans showed severe calyceal distortion and infundibular stenosis in 83% cases, complicated with ureteropelvic junction obstruction in 55% cases. Chronic kidney failure was present in 60% patients. Mean operative time was 150 minutes, with mean cold ischemia time of 61 minutes and mean blood loss of 300ml. There were five minor postoperative complications. Residual small calculi were found in 3 patients. Kidney function was stabilized in the patients suffering from chronic kidney failure, which was proved by radio nuclide imaging. ANL improved by using calcium channel blockers as a protective factor for reperfusion injury proved to be a good treatment choice with a low level of complications and noticeable stabilization and improvement of kidneys function.

Branch renal artery repair with cold perfusion protection

This retrospective review describes the use and clinical outcome of cold perfusion protection during branch renal artery (RA) repair in 77 consecutive patients. From July 1987 through November 2006, 874 patients had open operative RA repair to 1312 kidneys. Seventy-seven patients (62 women, 15 men; mean age, 44 +/- 17 years) had branch RA reconstruction using ex vivo or in situ cold perfusion protection for 78 kidneys. Demographic data and surgical technique were examined. Blood pressure response and renal function were estimated. Patency of repair was determined by angiography and renal duplex ultrasound (RDUS) imaging. Primary RA patency was estimated by life-table methods. Seventy-eight RAs were repaired using ex vivo (49 kidneys) or in situ (29 kidneys) cold perfusion protection. Bilateral RA repair was performed in eight patients, with 13 repairs to solitary kidneys. RA disease included aneurysm (RAA) in 50, fibromuscular dysplasia (FMD) in 37, atherosclerosis in 5, and arteritis in 2; 16 patients had both FMD and RAA. Hypertension was present in 93.5% (mean blood pressure, 184 +/- 35/107 +/- 19 mm Hg; mean of 1.9 +/- 1.1 drugs). RA repair included bypass using saphenous vein in 69, hypogastric artery in 3, polytetrafluoroethylene (PTFE) in 2, composite vein/PTFE in 2, cephalic vein in 1, or aneurysmorrhaphy in 1. The eight bilateral RA repairs were staged. One patient required bilateral cold perfusion protection. One planned nephrectomy was performed at the time of contralateral ex vivo reconstruction. No primary nephrectomies were required for intended reconstruction. Each RA reconstruction required branch dissection and reconstruction (mean of 2.8 +/- 1.6 branches were repaired). Mean cold ischemia time was 125 +/- 40 minutes. Each kidney was reconstructed in an orthotopic fashion. Five early failures of repair required three nephrectomies and one operative revision. Based on postoperative angiography or RDUS, or both, primary patency of RA repair at 12 months was 85% +/- 5%; assisted primary patency was 93% +/- 4%. Among patients with preoperative hypertension, 15% were cured, 65% were improved, and 20% were considered failed. Early renal function was improved in 35%, unchanged in 48%, and worse in 17%. Four patients had perioperative acute tubular necrosis. No patient progressed to dialysis-dependence. Both ex vivo and in situ cold perfusion protection extend the safe renal ischemia time for complex branch RA repair and avoid the need for nephrectomy.

In Situ Intestinal Ischemia‐Reperfusion Injury in the Pig: A Model Using the First Jejunal Artery for Flushing

We describe a new surgical technique of in situ intestinal ischemia-reperfusion injury in the pig, which includes transection of the small bowel, extrinsic autonomic denervation, lymphatic disruption, and finally in-situ cold ischemia of the graft by flushing through the first jejunal artery. Ten female pigs were used for the study. All neural and lymphatic connections to the jejunoileum were transected. The stripped superior mesenteric vessels remained as the only connections. The skeletonized mesenteric vessels were clamped and the superior mesenteric artery was cannulated through the first jejunal artery. The isolated jejunoileum was flushed with cold IGL-1 solution. A small incision on the superior mesenteric vein was made to allow outflow of the effluent. After the flushing process was complete, the small incision in the superior mesenteric vein was closed and the vascular clamps were removed. The proximal 70% of the graft was resected. The mean preoperative weight of the animals was 25.8 +/-7.6 kg. The mean duration of the operation was 242.0 +/- 28.6 min. The mean cold ischemia time was 47.6 +/- 3.9 min. All animals survived the procedure and were sacrificed at day 8. At sacrifice, there were no adhesions. The small bowel appeared normal. On intestinal histology, there were no significant changes between specimens obtained from the animal immediately at the end of cold flushing (T0), 2 h after reperfusion (T1), and at sacrifice (T2). This novel technique for intestinal ischemia-reperfusion injury in the pig provides an extremely useful model for experimental studies of immunological and cold ischemia-reperfusion injury of transplanted small bowels.

Bologna Transplant Center Results in Double Kidney Transplantation: Update

Introduction Double-kidney transplantation is performed using organs from marginal donors with a histological score not suitable for single kidney transplantation. The aim of this study was to verify the results obtained with double-kidney transplantation in terms of graft/patient survivals and complications. Patients and methods Between September 2001 and September 2006. 26 double-kidney transplantations were performed in our center. Indications for surgery were: chronic glomerulonephritis ( n = 17), polycystic disease ( n = 4), reflux nephropathy ( n = 1), hypertensive nephroangiosclerosis ( n = 4). The kidneys were all perfused with Celsior solution and mean cold ischemia time was 16.7 ± 2.5 hours. In all cases, a pretransplant kidney biopsy was performed to evaluate the damage (mean score: 4.3). Immunosuppression was tacrolimus-based for all patients. Results Eighteen patients had good renal postoperative function, while the other eight displayed acute tubular necrosis. Two of the patients who had severe acute tubular necrosis never recovered renal function. There was only one episode of acute rejection, while the incidence of urinary complications was 31%. There were two surgical reoperations for intestinal perforation. Graft and recipient survivals were 82.7% and 100%, and 78.9% and 94% at 3 and 36 months, respectively. Conclusions Double-kidney transplantation is a safe strategy to face the organ shortage. The score used in this study is useful to determine whether a kidney should be refused or suitable for single- or dual-kidney transplantation. The results of our experience are encouraging, but the series is too small to allow a conclusion.

Liver Transplantation Using Non-Heart-Beating Donors: Belgian Experience

Mortality on liver transplantation (OLT) waiting lists has increased dramatically. Until recently, non-heart-beating donors (NHBD) were not considered suitable for OLT, because of a higher risk of primary graft nonfunction (PNF) and biliary strictures. However, recent experimental/clinical evidence has indicated that NHBD-OLT is feasible when the period of warm ischemia is short. Purpose To characterize the results of NHBD-OLT in Belgium, a survey was sent to all Belgian OLT centers. Results Between January 2003 and November 2005, 16 livers originating from NHBD were procured and transplanted. The mean donor age was 48.8 years, including 9 males and 7 females with mean time of stop-therapy to cardiac arrest being 18 minutes and from cardiac arrest to liver cold perfusion, 10.5 minutes. Mean recipient age was 52.2 years including 12 males and 4 females. Mean cold ischemia time was 7 hours 15 minutes. No PNF requiring re-OLT was observed. Mean post-OLT peak transaminase was 2209 IU/L, which was higher among imported versus locally procured grafts. Biliary complications occurred in 6 patients requiring re-OLT (n = 2), endoscopic treatment (n = 2), surgical treatment (n = 1), or left untreated (n = 1). These tended to be more frequent after prolonged warm ischemia. Graft and patient survivals were 62.5% and 81.3%, respectively, with a follow-up of 3 to 36 months. Conclusion This survey showed acceptable graft/patient survivals after NHBD-LT. The NHBD-liver grafts suffered a high rate of ischemic injury and biliary complications and therefore should be used carefully, namely with no additional donor risk factors, lower risk recipients, and short cold/warm ischemia.

Influence of Pulsatile Perfusion Preservation on Outcomes in Kidney Transplantation from Expanded Criteria Donors

Expanded criteria donors (ECDs) increase the donor organ pool, but the value of transplanting these kidneys has been questioned because of concerns about diminished survival, poorer renal function, and higher rates of delayed graft function. Retrospective analysis of intermediate-term outcomes in ECD kidney transplantations according to method of preservation at a single center using a standardized approach. Over a 5-year period, we performed 141 donations-after-brain-death ECD kidney transplantations into adult recipients. A total of 114 kidneys (81%) were managed with combined cold-storage and pulsatile perfusion preservation (PPP), and the remaining 27 (19%) were preserved with cold storage (CS). The PPP group had a higher proportion of kidneys preserved for longer than 30 hours (28% versus 0, p < 0.001) and a longer mean cold ischemia time (24.5 hours PPP versus 19 hours CS, p < 0.01). Other donor and recipient characteristics were similar between groups. Incidence of delayed graft function was 11% in PPP-stored kidneys versus 37% in CS kidneys (p = 0.002). With a mean followup of 27 months, patient (91% PPP versus 96% CS) and kidney graft survival (81% PPP versus 81.5% CS) rates were comparable. Mean 12-month serum creatinine (1.9 mg/dL) and calculated Modification of Diet in Renal Disease glomerular filtration rate (41 mL/min) values were similar between groups. Despite longer cold ischemia times, recipients of ECD kidneys managed with PPP had similar survival and functional outcomes, but experienced a marked reduction in the rate of delayed graft function.

Pancreatobiliary Complications After Composite Visceral Transplantation: Incidence, Diagnosis and Management

Background: Combined liver-intestinal (L/SB) and multivisceral (MV) transplantation has been increasingly utilized with significant improvement in outcome. This is the first report to address the potential risk and management of pancreatobiliary (PB) complications in this unique population. Aim: Assess incidence, clinical features and management outcome of PB complications after the different types of the composite visceral graft. Methods: Between May 1990 and October 2006, a total of 227 consecutive patients received a composite visceral graft. Of these, 115 (51%) were adults and 112 (49%) were children. The composite visceral grafts were L/SB in 130 (57%) and MV in the remaining 97 (43%). The pancreas was included in 61 (53%) of the L/SB and the liver was excluded in 25 (26%) of the MV. Most donors were ABO identical and HLA matching was random with positive cross match in 23%. Immunosuppression was tacrolimus based and induction was used in 150 patients (66%). With a mean cold ischemia time of 9 ± 2 hours, UW solution was used to preserve the allograft in 82% and HTK in 18%. With ERCP being the gold standard for the diagnosis of biliary complications and pancreatic leak, significant injury of the pancreatic gland was diagnosed according to serum tests and operative findings. Results: A total of 28 PB complications were diagnosed in 20 patients with an overall incidence of 9%. Risk was similar among L/SB and MV recipients with a rate of 8% and 10%, respectively. Of the 28 morbid events, 9 were biliary complications alone, 11 were isolated pancreatic injury and 8 were combined pathology. Biliary complications included bile leak (n = 5), bile cast syndrome (n = 4), ampullary dysfunction (n = 3) and recurrent ascending cholangitis (n = 1). Pancreatic injury was necrotizing pancreatitis in 7, distal duct fistulae in 6 and chronic calcific pancreatitis in 2. ERCP was instrumental in diagnosis and treatment of cases with ampullary dysfunction, bile cast syndrome and non-surgical PB leak. However, surgical intervention was performed in patients with significant pancreatic allograft necrosis and anastomotic biliary leak. With no direct complication related mortality, all morbid events were successfully treated with the exception of a case with persistent pancreatico-cutaneous fistula. With no statistically identifiable risk factors, there was a trend toward more pancreatitis events with HTK use. Conclusions: PB complications are not uncommon after composite visceral transplantation. Early diagnosis and prompt intervention with combined surgical and endoscopic approach is essential for proper management and successful outcome.

Cadaveric Renal Transplantation: Our Experience at the Institute of Kidney Diseases & Research Centre, Institute of Transplantation Sciences, Ahmedabad

In a developing country such as India, cadaveric renal transplantation accounts for only less than 1% of total renal transplantations. The reasons for such a low rate of cadaveric transplantation are many, ranging from lack of awareness to socioeconomic reasons. Our institute conducted a statewide public awareness program and initiated an intercity organ harvesting program. This doubled the cadaveric renal transplantations in the last 2 years. We performed 38 cadaveric transplantations among 190 renal transplantations in the last year (August 2005 to July 2006). We retrieved kidneys from 21 donors, of whom 9 were outside our city. From 21 donors we transplanted 38 recipients; out of whom 3 received dual kidneys and one kidney was discarded. The Mean age of the donors was 41.4 ± 18.2 years with a mean cold ischemia time of 6.9 ± 3.8 hours. Sixty-eight percent had delayed graft function. At the last follow-up, which was 190 ± 98 days, patient survival rate was 90%: 4 patients died, including 2 due to bacterial sepsis and 2 due to cytomegalovirus (CMV) disease. The Graft survival rate was 85%, and the death-censored graft survival rate was 90%. Mean serum creatinine value at the last follow-up was 1.2 ± 0.3 mg%. There were 5 episodes of acute rejection in 31 patients during first 3 months (16% acute rejection rate). The increase in cadaveric transplantations was associated with satisfactory patient and graft survival despite the high incidence of delayed graft function.