Mean Cold Ischemia Time Research Articles

Simultaneous Pancreas-Kidney Transplantation: Initial Results From a Center in Greece

The outcome of simultaneous pancreas-kidney transplantation (SPK) in type 1 diabetes has dramatically improved in recent years. We report the initial results of our SPK program. From 2008 to 2010, we performed and prospectively obtained data on 4 SPKs in 4 type 1 diabetic patients with chronic renal failure. The recipients were 3 men and 1 woman, of overall mean age of 40.75 ± 4.78 years, mean time from diabetes diagnosis of 27 ± 15 years, and time on dialysis of 3.5 ± 0.57 years. All grafts were procured from multiorgan brain-dead donors of mean age 26 ± 8.16 years and mean body weight of 74 ± 4.34 kg. The pancreatic grafts were transplanted first into the right iliac fossa with mean cold ischemia times of 10.62 ± 3.09 hours for the pancreatic and 14.00 ± 2.97 hours for the renal grafts. Pancreas arterial inflow was re-established by an end-to-side anastomosis of an extension Y-graft to the recipient right iliac artery. The portal vein was sutured to the iliac vein directly. The exocrine secretions of the pancreas were managed by duodenojejunostomy extraperitoneally (n = 3) or intraperitoneally (n = 1). The ureteral anastomosis was performed using the Taguchi technique. After SPK, endocrine pancreatic function was immediately restored in all patients. Insulin administration was stopped within the first 24 hours after surgery. Two patients displayed delayed renal graft function necessitating dialysis for 9 and 23 days, respectively. The postoperative course was prolonged with a mean hospital stay of 82 ± 1 day. At a 31.75 ± 9.03 months follow up all patients are alive with functioning grafts. Our experience with SPK, although limited, has shown encouraging results over a short follow-up period.

THE PRELIMINARY STUDY OF EVALUATION OF LEFT VENTRICULAR BULK ROTATION AND UNTWISTING IN HEART TRANSPLANT PATIENTS AT POSTOPERATIVE 3 MONTHS BY TWO-DIMENSIONAL ULTRASOUND SPECKLE TRACKING IMAGING

ObjectivesTo evaluate the change of left ventricular bulk rotation and untwisting in heart transplant patients at postoperative 3 months by two-dimensional ultrasound speckle tracking imaging (STI).MethodsThere were 15 heart transplant...

Pairs of Kidneys Transplanted From the Same Donor: Is There Any Difference?

ObjectivesThe aim of this study was to compare the evolution of the first kidney in relation to the second kidney transplanted from the same donor, focusing on the impact that a longer cold ischemia time may have as an independent variable. Material and MethodsThe study included 44 pairs of kidneys transplanted from the same donor between February 2008 and October 2010, divided into Groups 1 and 2 according to the graft placement order. The variables analyzed were age, sex, comorbidities, number of transfusions, length of hospital stay, maximum peak PRA, immunologic incompatibility, ischemia time, delayed graft function (DGF), presence of rejection, creatinine clearance at first week, at 3 months and at 1 year, and vascular and tract complications in each group. ResultsThe mean cold ischemia time was 15.6 hours in Group 1 and 20.1 hours in Group 2 (P < .001). The average recipient age was 52.79 years in Group 1 and 54.52 years in Group 2, with an equal sex ratio in the two groups; an average of 2.06 PRC were transfused prior to transplantation in Group 1 and 0.93 PRC in Group 2; the average length of stay was similar in the two groups. Major DR incompatibility was only found in Group 2 (P < .03). Creatinine clearance at first week, DGF and acute rejection showed worse results in Group 2, but these differences were not significant. Vascular complications were present in 4.5% and 2.3% of Groups 1 and 2, respectively, and tract complications were 6.8% and 11.4%. ConclusionsA greater tendency to DGF, early rejection and tract complications were found in the group with longer ischemia time, although the difference was not statistically significant. Larger series will be necessary to confirm our results.

V1724 LAPAROSCOPIC LIVE RELATED RENAL TRANSPLANTATION- A FEASIBLE OPTION?

You have accessJournal of UrologyTransplantation, Urolithiasis & Hydronephrosis1 Apr 2012V1724 LAPAROSCOPIC LIVE RELATED RENAL TRANSPLANTATION- A FEASIBLE OPTION? George Abraham, Krishanu Das, Krishnamohan Ramaswami, Datson George, Jisha Abraham, and Oppukeril Thampan George AbrahamGeorge Abraham Kochi, India More articles by this author , Krishanu DasKrishanu Das Kochi, India More articles by this author , Krishnamohan RamaswamiKrishnamohan Ramaswami Kochi, India More articles by this author , Datson GeorgeDatson George Kochi, India More articles by this author , Jisha AbrahamJisha Abraham Kochi, India More articles by this author , and Oppukeril ThampanOppukeril Thampan Kochi, India More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.1683AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Laparoscopic donor nephrectomy is a standard of care approach for renal harvest for transplantation purposes. Contrastingly engraftment has been traditionally achieved through incisional approach. Thereby the allograft recipient is subjected to access related morbidity in addition to procedural morbidity. We evaluate the feasibility of renal transplantation through laparoscopic approach. METHODS Live related subjects planned for left donor nephrectomy with favorable vascular anatomy (single renal artery and vein) was selected. Organ harvest was performed through laparoscopic approach. During bench preparation three orientation stitches were made at apex of renal artery, vein and upper pole of graft to maintain the orientation during laparoscopic engraftment. A peritoneal flap was raised in the graft recipient to place the graft in extraperitoneal location. The graft was inserted through a Pfannenstiel incision. Vascular anastomosis was carried out followed by nonrefluxing ureteroneocystostomy. The peritoneal flap was reattached. Operative and postoperative parameters were recorded. RESULTS 3 patients underwent laparoscopic renal transplantation. Mean age was 32.33 years, mean BMI 22.07 kg/m2. Mean cold ischemia time was 55.33 minutes, mean blood loss was 150 milliliters and mean operation duration was 210 minutes. All patients demonstrated satisfactory graft function immediately. All patients exhibited early oral intake and diminished pain perception. Mean time to creatinine normalization was 5.33 days. Mean duration of hospital stay was 7.33 days. All patients revealed satisfactory vascular flow pattern in postoperative Doppler. No major operative or postoperative events were recorded. Mean creatinine of recipient 3 months post transplant was 1.2 milligrams/deciliter. CONCLUSIONS Although technically demanding, the preliminary results of laparoscopic renal transplantation are encouraging. The procedure offers a superior morbidity profile. The graft function is acceptable. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e694-e695 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information George Abraham Kochi, India More articles by this author Krishanu Das Kochi, India More articles by this author Krishnamohan Ramaswami Kochi, India More articles by this author Datson George Kochi, India More articles by this author Jisha Abraham Kochi, India More articles by this author Oppukeril Thampan Kochi, India More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

2127 COMBINING KIDNEY PAIRED DONATION, DESENSITIZATION, AND LONG-DISTANCE SHIPPING OF LIVE DONOR ORGANS IN IMMUNOLOGICALLY CHALLENGING PATIENTS

You have accessJournal of UrologyTransplantation & Vascular Surgery: Renal Transplantation, Vascular Surgery I1 Apr 20122127 COMBINING KIDNEY PAIRED DONATION, DESENSITIZATION, AND LONG-DISTANCE SHIPPING OF LIVE DONOR ORGANS IN IMMUNOLOGICALLY CHALLENGING PATIENTS Jeremy Blumberg, Albin Gritsch, and Jeffrey Veale Jeremy BlumbergJeremy Blumberg Los Angeles, CA More articles by this author , Albin GritschAlbin Gritsch Los Angeles, CA More articles by this author , and Jeffrey VealeJeffrey Veale Los Angeles, CA More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.2297AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Kidney paired donation (KPD) has become a powerful method for facilitating living-donor transplantation when a donor/recipient pair is incompatible. Incompatible pairs, in essence, are swapped away from each other to a compatible donor and recipient. Yet, there are many highly-sensitized patients that remain difficult to match. These patients can be transplanted by utilizing exchanges to avoid their strong antibodies and suppressing their remaining weak antibodies with IVIG. In this study, we present the outcomes of our single-center experience in which we performed living-donor kidney transplantation through KPD in combination with desensitization in patients with donor-specific antibodies to their matched donor. Additionally, 9 of 12 (75%) laparoscopic donor nephrectomies were performed at partnering transplant centers requiring long-distance shipping of live-donor organs with significant cold-ischemia time (CIT). METHODS We identified 12 highly-sensitized recipients of a living-donor kidney transplant through our KPD program with known DSA to their matched donor. This group of patients underwent desensitization with single high-dose intravenous immunoglobulin (IVIG) prior to transplantation. Nine KPD-matched donors were located at outside transplant centers. Laparoscopic donor nephrectomies were performed at the donor's local center and the organs were shipped by commercial airline. Outcome measures included patient and graft survival, delayed graft function (DGF), and rejection episodes. RESULTS Median follow-up was 19 months (range 7-29). We achieved 100% patient and graft survival at 3,6,12,18 and 24 months. No patients have returned to dialysis. Three patients experienced antibody-mediated rejection, and all rejection episodes were successfully treated with satisfactory return of renal function. Mean CIT for the shipped organs was 12 hours (range 8.7-14.5). There were no episodes of DGF. There were no donor-related complications. CONCLUSIONS KPD is a powerful tool for facilitating kidney transplantation when a patient has a willing, but incompatible living-donor. Highly-sensitized patients can be difficult to match through KPD, and difficult to desensitize. By combining KPD with desensitization patients can be successfully transplanted. Long-distance shipping, with significant CIT can also be tolerated with excellent transplant outcomes. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e859 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jeremy Blumberg Los Angeles, CA More articles by this author Albin Gritsch Los Angeles, CA More articles by this author Jeffrey Veale Los Angeles, CA More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Near Infrared Fluorescence Imaging After Intravenous Indocyanine Green: Initial Clinical Experience With Open Partial Nephrectomy for Renal Cortical Tumors

To evaluate the safety of near infrared fluorescence (NIRF) of intravenously injected indocyanine green (ICG) during open partial nephrectomy, and to demonstrate the feasibility of this technology to identify the renal vasculature and distinguish renal cortical tumors from normal parenchyma. Patients undergoing open partial nephrectomy provided written informed consent for inclusion in this institutional review board-approved study. Perirenal fat was removed to allow visualization of the renal parenchyma and lesions to be excised. The patients received intravenous injections of ICG, and NIRF imaging was performed using the SPY system. Intraoperative NIRF video images were evaluated for differentiation of tumor from normal parenchyma and for renal vasculature identification. A total of 15 patients underwent 16 open partial nephrectomies. The mean cold ischemia time was 26.6 minutes (range 20-33). All 14 malignant lesions were afluorescent or hypofluorescent compared with the surrounding normal renal parenchyma. NIRF imaging of intravenously injected ICG clearly identified the renal hilar vessels and guided selective arterial clamping in 3 patients. No adverse reactions to ICG were noted, and all surgical margins were negative on final pathologic examination. The intravenous use of ICG combined with NIRF is safe during open renal surgery. This technology allows the surgeon to distinguish renal cortical tumors from normal tissue and highlights the renal vasculature, with the potential to maximize oncologic control and nephron sparing during open partial nephrectomy. Additional study is needed to determine whether this imaging technique will help improve the outcomes during open partial nephrectomy.

Laparoscopic Live Related Renal Transplantation: Preliminary Experience

Introduction: Laparoscopic donor nephrectomy has gained popularity because of its excellent morbidity profile and appreciable outcome. However, laparoscopic approach for renal transplantation has been scarcely practiced till date.1,2 We present a video demonstration of laparoscopic renal transplantation and discuss the merits and demerits of this procedure. Methods: Patients were selected after detailed evaluation as per standard criteria for renal transplantation. Related donors with single renal artery and single renal vein were selected. The left side was selected for renal harvest. Renal recipients underwent ultrasonography and voiding cystourethrogram. Renal allograft was harvested through laparoscopic approach, and graft was prepared in bench and perfused with cold perfusant. Orientation stitches were made on the apex of the allograft artery, allograft vein, ureter, and upper pole of the graft. Recipients were placed in supine position with 20° right up tilt. Five ports were utilized. Peritoneal flap was created for placement of allograft. Allograft was inserted through a 5-cm Pfannenstiel incision. Allograft vein was anastomosed to recipient external iliac vein using 5-0 polypropelene suture in a continuous fashion and allograft artery was anastomosed to recipient renal artery using 5-0 polypropelene suture in a continuous fashion. A 11-centimeter-long suture was selected for arterial and venous anastomosis. Ureteroneocystostomy was created obeying Lich Gregoir principle, and a 4F ureteral stent was inserted retrograde across the ureterovesical anastomosis. Cold ischemia time, operative time, operative and postoperative events, and time to normalization of creatinine were noted. Ultrasound-doppler evaluation of the graft was performed at 5 days postprocedure. Results and Discussion: Three cases of laparoscopic live related renal transplantation were performed. Mean age of the donors was 39.67 years and mean age of the recipients was 33.3 years. Two recipients were female and one was male. Mean body mass index was 21.2 kg/m2. All procedures were completed via laparoscopic approach. Mean cold ischemia time was 61 minutes. Mean operation duration was 158.33 minutes and mean blood loss was 79.16 mL. Mean time to oral tolerance was 21.3 hours. Mean urine output on the first day was 9333.33 mL. Mean time to creatinine normalization was 5.33 days. Mean time to drain removal was 6.33 days and mean duration of hospital stay was 7.67 days. No significant intraoperative or postoperative happenings were recorded. On postoperative Doppler satisfactory vascular flow to the kidney was observed. The peak systolic velocity and RI values were within normal range. Laparoscopic renal transplantation ranks among the most advanced laparoscopic exercises practiced till date. The operator needs to be proficient in laparoscopic exercises. Satisfactory vascular reconstruction without undue delay and ureteric reimplantation remain the major challenges with this technique. Despite a longer cold ischemia sustained by the graft in comparison to incisional approach, no delay was experienced in graft function. The morbidity profile is excellent and the graft outcome is comparable to that achieved by conventional incisional approach. No competing financial interests exist. Runtime of video: 5 mins 46 secs

Preliminary results of transplantation with kidneys donated after cardiocirculatory determination of death: a French single-centre experience

Donation after circulatory determination of death (DCDD), formerly non-heart-beating donation and donation after cardiac death, has been re-introduced into clinical practice in France since June 2006 as a potential solution to organ shortage, but this kidney transplantation programme is not popular yet, mainly because of logistical concerns and uncertainty about the long-term warm ischaemia impact on transplanted kidneys. Our institution started the DCDD programme in January 2007, following the national 'BioMedicine Agency' protocol. We only considered uncontrolled donors with an initial no-flow period (i.e. delay between collapse and external cardiac massage start) <30 min. A 5-min stand-off period was observed before declaring the death and performing in situ cold perfusion, and since January 2010, normothermic subdiaphragmatic extracorporeal membrane oxygenation. All kidneys were machine-perfused using the hypothermic pulsatile preservation system before transplantation. Morphologic assessment and perfusion indexes were used to assess the suitability for transplantation. From January 2007 to December 2010, our team performed 58 kidney transplantations from uncontrolled Maastricht Category I and II donors. Mean recipient age was 47 ± 9 years. Male/female ratio was 45/13. Mean waiting time on transplantation registry was 30 months (4-180). Mean cold ischaemia time was 13 h 40 min (7-18) and pulsatile perfusion time 8 h (1-16). We had three cases (5%) of primary non-function (PNF) and 95% of delayed graft function. There was no increase in biopsy-proven acute rejection incidence (12.7%). Patient and graft survivals were 98 and 91.4%, respectively, at 1 year and 98 and 88%, respectively, at last follow-up. Estimated glomerular filtration rate ( Modification of Diet in Renal Disease formula) was 48 ± 16 mL/min/1.73 m(2) at 1 year and 48 ± 15 mL/min/1.73 m(2) at the last follow-up. DCDD kidneys are a valuable additional source of organs for transplantation. Our results show encouraging outcomes, which give rise to further interest in this donor pool. Respecting the national protocol is crucial to prevent PNF and deleterious warm ischaemia effect on transplanted kidney.

Is there a safe cold ischemia time interval for the renal graft?

ObjectiveIt is aimed to characterize the true relationship of the cold ischemia time (CIT) with graft survival and with the principal post-transplantation events. Material and methodsWe analyzed 378 kidney transplants, studying the relationship of the CIT with graft survival using a univariate analysis according to the COX model and seeking the optimum cutoff according to the Kaplan–Meier method and log-rank test. The relationship between CIT and the principal events of the post-transplant was studied using the binary logistic regression. ResultsThe mean follow-up of all the group was 77.8 months (±51 SD) and the mean CIT was 14.8h (±5.1 SD). The univariate analysis revealed that the CIT was not related with the graft survival as a continuous variable (OR=1.04; 95% CI: 0.9–1.08; p>0.05). On establishing the cutoff at 18h, we found differences in the actuarial survival. Survival at 5 years was 91% with CIT <18h versus 84% with CIT >18h. Each hour of cold ischemia increased risk of delay in the graft function by 10% (OR=1.1; 95% CI: 1.05–1.15; p<0.001) and also conditioned a greater incidence of acute rejection (41.5% vs. 55.3%; p=0.02) and less time to the first rejection episode (72.6 days±137 vs. 272.2 days±614.8; p=0.023) after 18h. The CIT did not seem to be related (p<0.05) with the rest of the post-transplantation events, such as surgical complications or hospital admissions. ConclusionsIn our experience, cold ischemia under 18h does not seem to negatively affect graft survival.

A Meta-Analysis for Comparison of the Two-Layer and University of Wisconsin Pancreas Preservation Methods in Islet Transplantation

Conflicting results have been reported on the effectiveness of the two-layer method (TLM) compared with the University of Wisconsin (UW) method for preserving pancreata. The objective of this study was to compile the evidence for or against any difference in human islet yield and viability between these two. PubMed (January 2000 to May 2008) and Cochran Library searches were performed and 17 studies were included for the meta-analysis. Data on donor characteristics, preservation time, and outcomes were abstracted. Studies were subgrouped based on how TLM was used (UW + TLM or TLM alone), on mean cold ischemic time (CIT) (>20 h or <20 h), and on whether special chemical was used (yes or no). Meta-analysis of all studies and subgroups was performed and the pooled standardized mean differences (SMD) with 95% confidence intervals (CI) were reported. Overall, the use of TLM significantly increased islet yield [SMD, 0.74 (0.44-1.04)] and viability [SMD, 0.63 (0.14-1.12)]. The beneficial effects of TLM on islet yield were more evident when TLM was used following UW storage or when prolonged CIT was used. TLM used alone, shorter CIT, and no chemical use all resulted in similar islet viability between TLM and UW groups. Beneficial effects of TLM on islet viability were demonstrated only when TLM was used following UW storage, or with prolonged CIT, or with chemical use. In conclusion, the TLM was beneficial for prolonged pancreas preservation before human islet isolation; however, benefit of the TLM for short-term preservation was not clear.

Liver Transplantation for the Treatment of Liver Metastases From Neuroendocrine Tumors

To determine outcomes in patients undergoing liver transplantation (LT) for metastatic neuroendocrine tumors (NETs). Retrospective analysis. University of Kentucky Medical Center. Patients undergoing LT performed for NET metastases from October 1, 1988, through January 31, 2008, were analyzed using the United Network for Organ Sharing database. Main Outcome Measure Patient survival. During the study period, 87280 LTs were performed. One hundred fifty LTs were performed for metastatic NETs. Among those 150 patients undergoing LT, 51 patients (34.0%) had carcinoid, 6 had insulinoma (4.0%), 3 had glucagonoma (2.0%), 11 had gastrinoma (7.3%), and 9 had vasoactive intestinal peptide-secreting tumors (6.0%); an additional 70 (46.7%) had an unspecified NET. The mean (SE) age of the patients was 45.1 (12.5) years. The mean (SE) cold ischemic time was 8.9 (4.1) hours. One hundred forty-four patients were adults and 6 were children. Thirteen patients received another organ at the time of LT. During the same period, 4693 patients underwent transplantation for hepatocellular carcinoma. Overall, 1-, 3-, and 5-year survival rates for patients with NETs undergoing isolated LT were 81%, 65%, and 49%, respectively. No difference in survival was observed in patients with carcinoid vs noncarcinoid tumors (P=.84). No significant difference was observed in patient survival between those with metastatic NETs and those with hepatocellular carcinoma. Patients waiting for LT longer than 2 months had improved survival (P=.005). Patients with liver metastases from NETs who were undergoing LT had long-term survival similar to that of patients with hepatocellular carcinoma. Longer wait times were associated with better outcomes in our series. Waiting for disease to stabilize before considering patients with liver metastases from NETs for transplantation may be appropriate. Excellent results can be obtained in highly selected patients.

Results of Liver Transplantation With Donors Older Than 70 Years: A Case-Control Study

Older donors are a growing part of the total pool but no definite consensus exists on the age limit for their acceptance. This retrospective case-control unicenter study compared the outcomes of 72 orthotopic liver transplantations (OLTs) from April 1990 to April 2010 using donors older than 70 years versus 738 chronologically correlated OLTs performed with donors younger than 60 years. The percentage of refusal was greater among older than younger donors (48.2 vs 14.3%; P < .001). No difference was observed in mean cold ischemia times between older (370.5 minutes) versus younger groups (389.2 minutes). or in postoperative complications of rejection or renal insufficiency except for sepsis and mortality. Long-term survival was lower among transplant recipients from donors older than 70 years (P = .001) and these cases showed more blood requirements associated with prolonged cold ischemia (P = .02). Multivariate analysis revealed graft dysfunction, mortality, and reduced survival to be associated with donor weight and recipient MELD (Model for End-stage Liver Disease) (P < .05). Interestingly, the mortality related to hepatitis C virus recurrence was not greater among patients whose donors were older than 70. Septuagenarians' livers can be used safely, but careful donor and recipient evaluation are required to avoid additional risk factors.

Impact of Cold Ischemia Time on Initial Graft Function and Survival Rates in Renal Transplants From Deceased Donors Performed in Andalusia

IntroductionProlonged cold ischemic time (CIT) in cadaveric renal transplants has been associated with a high rate of delayed graft function, acute rejection, and even reduced graft survival. We analyzed the influence of CIT on both initial graft function (IGF) and survival rate. MethodsWe studied 2525 noncombined cadaveric cases in recipients over 17 years of age between 2000 and 2008, using data from the renal transplant records of Andalusia. We defined IGF as the need to resume dialysis within the first week or a nonfunctional kidney. The multivariate analyses were corrected by center and year of transplantation. ResultsThe mean and median cold ischemic time was 17 hours. The duration of CIT was significantly associated (P < .001) with older donor and recipient age. The frequency of IGF increased progressively with longer CIT and older donors. However, the influence of CIT persisted among all donor age strata. Logistic regression analysis using both donor and recipient age as covariables showed a relative risk per hour of 1.05 (95% confidence interval = 1.04–1.07; P < .0001). In a univariable study, longer CIT led to a significant reduction in both recipient and graft survival rates. The multivariate study (Cox) using preprocedure covariables, showed CIT to produce significantly worse survival rates for both recipients (relative risk: 1.03, 1.005–1.05, P = .02) and for grafts (relative risk: 1.03, 1.01–1.04, P = .002). However, the survival rates showed no clear progression in terms of CIT within each individual donor age stratum. ConclusionsA longer CIT was associated with an increase in IGF independent of the age of both the donor and the recipient. Our data also suggested that CIT influenced patient and graft survival rates.

¿Existe un intervalo de tiempo de isquemia fría seguro para el injerto renal?

Objective It is aimed to characterize the true relationship of the cold ischemia time (CIT) with graft survival and with the principal post-transplantation events. Material and methods We analyzed 378 kidney transplants, studying the relationship of the CIT with graft survival using a univariate analysis according to the COX model and seeking the optimum cutoff according to the Kaplan-Meier method and log-rank test. The relationship between CIT and the principal events of the post-transplant was studied using the binary logistic regression. Results The mean follow-up of all the group was 77.8 months (± 51 SD) and the mean CIT was 14.8 hours (± 5.1 SD). The univariate analysis revealed that the CIT was not related with the graft survival as a continuous variable (OR = 1.04; 95% CI: 0.9-1.08; p > 0.05). On establishing the cutoff at 18 hours, we found differences in the actuarial survival. Survival at 5 years was 91% with CIT < 18 h versus 84% with CIT >18 h. Each hour of cold ischemia increased risk of delay in the graft function by 10% (OR = 1.1; 95% CI: 1.05-1.15; p < 0.001) and also conditioned a greater incidence of acute rejection (41.5% vs. 55.3%; p = 0.02) and less time to the first rejection episode (72.6 days ± 137 vs. 272.2 days ± 614.8; p = 0.023) after 18 hours. The CIT did not seem to be related (p < 0.05) with the rest of the post-transplantation events, such as surgical complications or hospital admissions. Conclusions In our experience, cold ischemia under 18 hours does not seem to negatively affect graft survival.

The Effect of Gained Experience on Postoperative Complications and Mortality in Cadaveric Liver Transplantation: A Single-Center Experience

Aim Liver transplantation (OLT) has become the treatment of choice for end-stage liver failure, as well as for selected cases of malignancies and metabolic disorders. Decreased postoperative complications and mortality rates are expected to correlate with improvements in the interdisciplinary team approach, the perioperative anesthesiologic and intensive care management, and careful follow-up after transplantation. In this study, we have evaluated the effect of gained experience on postoperative complications and mortality in cadaveric OLT performed in our institution. Materials and Methods Data from cadaveric OLT patients ( n = 34) since 2003 were retrospectively evaluated. Patients were divided into 2 groups: Early (2003–2006; n = 15) and late (2007–2010; n = 19). Age, gender, cold and warm ischemia times, intraoperative transfusion rates, infectious complications, biliary and vascular complication rates, and early and late postoperative mortality rates were compared in the 2 groups. Results The age and gender distribution was similar among both groups. Mean cold and warm ischemia times, intraoperative transfusion rates, and operative times were significantly lower in the late period group ( P = .004, .012, and 0.008, respectively; CI=%95). T-tube usage was also significantly lower in the late period group ( P < .001). There was no significant change for postoperative intensive care period ( P = .404), but the overall length of stay in hospital was shorter for the patients in the late period group ( P = .019). The nonsurgical early postoperative complication rate was lower ( P = .001) and early postoperative mortality was nearly significant ( P = .06) in patients who comprised the late period group. There was no difference in terms of biliary and vascular complication rates and overall survival rates between patients in the early and late groups ( P = .664, .264, and .107, respectively). Conclusion Our results indicate that the institutional improvements toward an interdisciplinary team approach in cadaveric OLT correlate with better results in ischemia and operative times and lower intraoperative transfusion rates and hospital stays. Early postoperative complication and mortality rates were found to decline in parallel to the team experience.

Perioperative management of combined heart-liver transplantation in patients with cirrhosis, renal insufficiency, or pulmonary hypertension

STATING THE MAIN PROBLEM: Only few reports have detailed perioperative management and outcome of combined heart and liver transplantation (CHLT), and none describe the long-term renal function. Three patients presented clinical signs of cardiomyopathy with reduced ejection fraction and proven cirrhosis with evidence of portal hypertension. Two of them presented renal failure, and the other pulmonary hypertension. After cardiac transplantation and closure of the sternum, liver transplantation was performed using systematically venovenous double-limb (portal and caval) bypass. Mean cold ischemic time for heart and liver was 2 h 46 min and 12 h 47 min, respectively. Intraoperative hemodynamics remained grossly stable during surgery. Mean transfusions were 12 red blood cell packs. All three patients received anti-R-Il2 antibodies at post-operative day 1 and 4. Mean plasma creatinine concentration was 90 ± 8 μmol/L one yr post-CHLT, vs 160 ± 62 μmol/L pre-CHLT. All three patients are alive with functional grafts after a mean follow-up of 26 months (12-38). CHLT could be performed safely through two consecutive and independent usual procedures. Perioperative hemodynamic stability, minimal blood loss, and routine splanchnic decompression are probably major determinants of a favorable outcome and good long-term renal function.

To Perfuse or Not to Perfuse Kidneys Donated after Cardiac Death

To Perfuse or Not to Perfuse Kidneys Donated after Cardiac Death

Deceased donor organ transplantation: A single center experience

Renal transplantation (RTx) is the best therapeutic modality for patient suffering from end-stage renal disease (ESRD). Deceased donor organ transplantation (DDOT) accounts for <4% of RTx in India. We report 4 years single centre experience on DDOT vis-à-vis patient/graft survival, graft function in terms of serum creatinine (SCr), rejection episodes, and delayed graft function in 160 DDOT. Between January 2006 to December 2009, 160 RTx from 89 donors were performed, of which 25.2% were expanded criteria donors. Majority of the donors were brain dead due to road traffic/cerebrovascular accidents. The commonest recipient diseases leading to ESRD were chronic glomerulonephritis (49%), diabetes mellitus (10%), and benign nephrosclerosis (10%). Mean recipient/donor age was 35.6±14.68 and 44.03±18.19 years. Mean dialysis duration pretransplantation was 15.37±2.82 months. Mean cold ischemia time was 5.56±2.04 hours. All recipients received single dose rabbit-anti-thymocyte globulin induction and steroids, mycophenolate mofetil/calcinueurin inhibitor for maintenance of immunosuppression. Delayed graft function was observed in 30.6% patients and 14% had biopsy proven acute rejection. Over mean follow-up of 2.35±1.24 years, patient and graft survival rates were 77.5% and 89.3% with mean SCr of 1.40±0.36 mg/dl. DDOT has acceptable graft/patient survival over 4 years follow-up and should be encouraged in view of organ shortage.

Import Kidney Transplants from Nonmandatory Share Deceased Donors: Characteristics, Distribution and Outcomes

Outcomes of locally rejected kidneys transplanted at other centers (import KTX) are unknown. SRTR data from 2000 to 2009 of deceased-donor KTXs excluding 0-mismatch, paybacks, and other mandatory shares were compared by location of KTX at local (n = 48,165), regional (n = 4428) or national (n = 4104) centers using multivariable regression models. Compared to nonmandatory share local transplants, import KTX were associated with significantly higher overall risks of patient death (regional aHR 1.15, p < 0.01; national aHR 1.14, p < 0.01), and graft failure (regional aHR 1.17, p < 0.01; national aHR1.21, p < 0.01). In paired analysis, the risk of delayed graft function (DGF) for import KTX was higher compared to locally transplanted mates (regional aOR 1.53, p < 0.01, national aOR 2.14, p < 0.01); however, despite longer ischemia times, overall graft survival was similar. Mean cold ischemia times (CIT) pre- and post-DonorNet were similar for local and regional transplants, but significantly higher for national transplants (28.9 ± 9.9 vs. 29.9 ± 9.7 h, respectively, p = 0.01). Import KTX is associated with increased risks of graft failure, patient death and DGF. In the era of DonorNet cold ischemia times of kidneys imported to regional centers are not improved compared to pre-DonorNet; and, those of national centers are significantly prolonged.

Simultaneous kidney and pancreas transplantation (SKPT) in patients with type 1 diabetes and chronic renal failure: experience in 12 patients in Chile

Simultaneous kidney and pancreas transplantation (SKPT) is the best alternative for end stage renal disease among patients with insulin dependent diabetes mellitus. To report our experience with SKPT. Retrospective analysis of 12 recipients of SKPT transplanted in one center starting in 1994, with a mean follow-up period of 6.8 years (2-15). Eleven of 12 recipients were in chronic hemodialysis before SKPT. Mean A, B, DR and HLA mismatch was 4.3. Mean preformed anti HLA antibodies was 3.3 %. Mean cold ischemia times for pancreas and kidney were 6 and 10 hours, respectively. In the first eight cases, the pancreas was drained to the bladder, and in the last four, an enteric drainage was performed. Eleven recipients were induced with antibodies, and maintenance immunosuppression consisted of cyclosporin or tacrolimus plus an antiproliferative agent. Ten year patient survival was 70%. Pancreas and kidney survival, defined by insulin and dialysis independence, were 72 and 73% respectively. Fifty percent of recipients experienced acute graft rejection (cellular or humoral), with good response to treatment except in one case. This experience shows that SKPT is associated with an excellent patient survival associated to insulin and dialysis independence in 70% of patients at 10 years.