Preparation For Renal Transplantation Research Articles

A hybrid clampless technique for aortoiliac derivation as a preparation for renal transplantation

A hybrid clampless technique for aortoiliac derivation as a preparation for renal transplantation

#6841 IS NEPHRECTOMY ALWAYS USEFUL IN ADPKD? A CASE REPORT OF HEPATIC FIBROSIS WITH SPLENOMEGALY AND PANCYTOPENIA AS LATE CONSEQUENCE

Abstract Background and Aims Autosomal dominant polycystic kidney disease (ADPKD) is the most common genetic kidney disease. Its main feature is the progressive enlargement of both kidneys with progressive loss of kidney function. ADPKD is the 4th leading cause of dialysis in the world. The disease has systemic involvement. Liver cysts are the most common extrarenal manifestations of ADPKD and are often incidental findings. However the liver can reach considerable size but its function is always preserved. Cysts lead to structural changes of the biliary tree and determine discomfort related to mass effect when significant liver enlargement occurs. Few cases of Budd Chiari syndrome (BCS) or of hepatic fibrosis have been reported in ADPKD patients after nephrectomy. Probably the removal of the kidneys can lead to obstruction of inferior vena cava by liver cysts. Method We report a case of hepatic fibrosis with splenomegaly and severe pancytopenia as a tardive complication after bilateral nephrectomy. Case report A 47 years old man was admitted c/o Division of Nephrology of San Raffaele Hospital in August 2018 because of a high-grade fever, general malaise, nausea and abdominal pain. The patient had a previous diagnosis of ADPKD. Genetic test indicative of PKD1 truncating mutation. He was chronically attended in the outpatient clinic of the same Division. On admission in hospital his renal function was severely impaired (crea 10 mg/dl; urea 213 mg/dl). No abnormalities at the blood count. Reactive C protein was elevated (156 mg/l nv 0-6). Urine culture was found negative. Abdominal NMR showed an important volumetric increase (compared with a NMR performed in 2014) of both kidneys with diameters of about 30 cm, several cysts with hemorrhagic and infective features and numerical and dimensional increase of the hepatic cysts; spleen was reported with normal diameters. Multiple antibiotic treatments were performed unfortunately without benefit. Therefore considering the state of end stage renal disease, the persistent infection and the severe symptoms, in September 2018 the patient underwent bilateral nephrectomy and hemodialysis was started. During the following years imaging studies aimed at the preparation for transplantation were performed. In November 2020 an abdominal NMR showed for the first time splenomegaly with a bipolar diameter of 14 cm. A NMR follow up was started. In January 2021 a further increase was reported as spleen diameter resulted of 14.5 cm and a volumetric increase of hepatic cysts was shown. In September 2022 spleen reached to a diameter of 17 cm. Contextually in November 2020 patient started to present pancytopenia that had progressively been worsening with many concomitant infective and bleeding episodes. All hematologic causes were excluded. Just to explain the genesis of the splenomegaly in September 2022 a fibroscan was performed and a pathological liverstiffness was found. All hepatitis markers were negative and immunologic ones as well. Splenectomy was assumed, but patient clinical conditions so far do not allow it. Transplantation is currently contraindicated Conclusion These evidences underline the necessity of scrupolous evaluation of polycystic kidneys and their anatomic relationship with the liver before nephrectomy. Nephrectomy is frequently considered in the preparation for renal transplantation. In light of these possible complications, maybe removal of kidneys should be considered carefully in ADPKD patients with large involvement of the liver by cysts.

Augmentation Uretero-enterocystoplasty Is an Effective Procedure in Protecting the Upper Urinary Tract Without Accelerating Deterioration of Renal Function

BackgroundAugmentation uretero-enterocystoplasty (AUEC) provides a low-pressure urinary storage capsule that can preserve renal function in patients with lower urinary tract dysfunction for whom conservative treatments have failed. ObjectiveTo summarize the effectiveness and safety of augmentation uretero-enterocystoplasty (AUEC) and evaluate whether it aggravates renal function deterioration in patients with renal insufficiency. Design, setting, and participantsThis was a retrospective cohort study of patients who underwent AUEC from 2006 to 2021. Patients were grouped according to whether they had normal renal function (NRF) or renal dysfunction (serum creatinine >1.5 mg/dl). Outcome measurements and statistical analysisFollow-up of upper and lower urinary tract function was assessed via review of clinical records, urodynamic data, and laboratory results. Results and limitationsWe included 156 patients in the NRF group and 68 in the renal dysfunction group. We confirmed that urodynamic parameters and upper urinary tract dilation were significantly improved for patients after AUEC. Serum creatinine declined during the first 10 mo in both groups and remained stable thereafter. The reduction in serum creatine was significantly greater in the renal dysfunction group than in the NRF group in the first 10 mo (difference in reduction 4.19 units; p < 0.05). A multivariable regression model showed that baseline renal dysfunction was not a significant risk factor for deterioration of renal function in patients who had undergone AUEC (odds ratio 2.15; p = 0.11). The main limitations are selection bias because of the retrospective design, loss to follow-up, and missing data. ConclusionsAUEC is a safe and effective procedure to protect the upper urinary tract and will not hasten deterioration of renal function in patients with lower urinary tract dysfunction. In addition, AUEC improved and stabilized residual renal function in patients with renal insufficiency, which is important in preparation for renal transplantation. Patient summaryBladder dysfunction is usually treated with medication or Botox injections. If these treatments fail, surgery to increase the bladder size using a portion of the patient’s intestine is a possible option. Our study shows that this procedure was safe and feasible and improved bladder function. It did not lead to a further decrease in function in patients who already had impaired kidney function.

Abstract 99: Panniculectomy in Preparation for Renal Transplant Candidates: A 10-Year Experience

PURPOSE: Candidates for renal transplant are frequently denied access to transplant surgery due to obesity and poor functional status. Many patients are required to lose significant weight in order to maintain candidacy. Successful weight loss commonly produces a panniculus encompassing the lower abdominal surgical site used for transplant surgery. These patients are declined for renal transplantation secondary to predictable wound healing complications. To decrease post-transplant wound and graft complications, we implemented a Transplant/Plastic Surgery Program where patients underwent panniculectomy in an effort to regain candidacy on the renal transplant waiting list. We previously published our results of 21 patients in 2015, here we present our updated 10-year experience. METHODS: We performed a retrospective review of all patients deemed high-risk for post-kidney transplant wound complications who underwent panniculectomy in preparation for renal transplantation at our institution from 2008 to 2018. All patients had a minimum of 3 months follow-up. Patient characteristics (age, BMI, medical comorbidities, maximum BMI and weight lost prior to panniculectomy) and surgical outcomes (specimen weight, operation length, time to drain removal, wound complications, time to treat complication) were analyzed after panniculectomy as well as after transplantation. RESULTS: We performed 60 panniculectomies in renal transplant candidates. Wound complications occurred in 29 patients (48%). Minor wound complications (wound separation, cellulitis, skin necrosis) occurred in 21 patients (35%), major wound complications (hematoma, seroma, abscess, unplanned return to the operating room) occurred in 10 patients (17%). 30 patients have since undergone renal transplantation. No patients have had post-transplant wound healing complication. CONCLUSION: Panniculectomy in preparation for renal transplantation can be performed in patients with end-stage renal disease with a high but manageable complication rate, converting previously ineligible patients into eligible candidates for kidney transplantation. These wound complications are more easily managed prior to institution of immunosuppression required for renal transplant. While performing panniculectomies in these high-risk patients clearly shifts the burden of complications from Transplant Surgery to Plastic Surgery, it improves patient access to a life-extending procedure, further supporting Plastic Surgery’s vital role in our comprehensive healthcare system.

Abstract: Panniculectomy Outcomes in Patients with End Stage Renal Disease

INTRODUCTION: Patients with end-stage renal disease (ESRD) may require a panniculectomy in preparation for renal transplantation. ESRD is associated with increased cardiovascular risk factors, electrolyte imbalances, and chronic anemia. These factors may increase the risk of adverse outcomes in patients undergoing panniculectomy. Purpose of this study was to evaluate safety and perioperative complication rates in ESRD patients following panniculectomy. METHODS: Nationwide Inpatient Sample (2006–2011) was employed to identify patients who underwent panniculectomy. Among this cohort, patients with ESRD were identified. Pregnant women, children, emergency admissions, and patients that underwent concurrent nephrectomy or renal transplants were excluded. Demographic factors, comorbidities, and postoperative complications were evaluated. Bivariate and risk-adjusted multivariate logistic regressions were performed to determine if ESRD was associated with increased rates of postoperative complications. RESULTS: A total of 34,779 panniculectomies were performed during the study period. Of these, 613 (1.8%) were performed in patients with ESRD. ESRD cohort was older (mean age 58.9 vs. 49.3, p<0.01) and with a higher proportion of men (29.9% vs 11.1%, p<0.01) than non-ESRD group. As expected, ESRD cohort had higher rates of co-morbidities (p<0.01). Most ESRD patients were treated at urban teaching hospitals (70.0% vs 59.8% for non-ESRD, p<0.01). Post-operatively, patients with ESRD had a higher rate of in-hospital mortality (3.3% vs. 0.2%, p<0.01), wound complications (10.6% vs. 6.2%, p<0.01), venous thromboembolism (4.9% vs. 0.8%, p<0.01), blood transfusions (25.3% vs. 7.0%, p<0.01), non-renal major medical complications (40.0% vs. 8.4%), and longer hospital stay (9.2 vs. 3.8 days, p<0.01). Multivariate logistic regression analysis controlling for age, race, sex, hospital type, insurance status and comorbidities, demonstrated that ESRD was independently associated with increased risk of venous thromboembolism (OR 2.38, 95%-CI 1.48–3.83), non-renal major medical complications (OR 1.51, 95%-CI 1.19–1.91), and in-hospital mortality (OR 6.88, 95%-CI 3.50–13.55). ESRD was not independently associated with increased rate of wound complications or blood transfusions. CONCLUSION: ESRD patients present with significant medical comorbidities and experience higher rates of wound, thromboembolic, and medical complications following panniculectomy. After risk-adjustment for demographic factors and comorbidities, ESRD is independently associated with increased risk of thromboembolic and medical complications, as well as perioperative mortality. Plastic surgeons should carefully discuss risks and benefits of panniculectomy with these patients and work in a multidisciplinary fashion to optimize perioperative management.

The use of laparoscopic nephrectomy in patients with autosomal dominant polycystic kidney disease

The study analyzed the results of treatment of 32 patients with autosomal dominant polycystic kidney disease (PKD). In the period from 2014 to 2016 these patients underwent nephrectomy for clinical indications and in preparation for renal transplantation. The first group (15 patients) performed open surgery using midline laparotomy and lumbotomy (16 operations), of which: bilateral nephrectomy - 11 (68.7%), monolateral nephrectomy - 5 (31.3%). In the second group (17 patients) to perform a monolateral nephrectomy used laparoscopic transabdominal access (24 operations). The average duration of laparoscopic and open surgical interventions were not significantly different and amounted to 146 ± 14 and 134±15 min (p > 0.05). The maximum size of the deleted polycystic-changed kidneys in the first group amounted to 22.5 ± 4.27 cm, in the second of 21.5 ± 3.9 cm (p > 0.05). The frequency of postoperative complications in the first and second groups consisted of 43.75% and 12.5%, respectively. Was observed in 1 (6.25%) case of lethal outcome in the first group. Average postoperative hospital stay in the first group 13-14 (to 13.7 ± 1.3), in the second - 7-8 (7.6 ± 0.4, p < 0.05). Patients after laparoscopic procedures activated in 2-3 days (2.5 ± 0.13) after open procedures on 4-5 (4.13 ± 0.39, p < 0.05). Laparoscopic technology can significantly reduce the frequency of postoperative complications and increase the possibility of the use of nephrectomy in the treatment of patients with PKD. Laparoscopic transabdominal approach is characterized by a more favorable course of the postoperative period after nephrectomy, can reduce the duration of inpatient treatment and to activate patients in the early stages.

Calcified nodules on fingers in primary hyperoxaluria type 2

A 51-year-old man who had been receiving haemodialysis for 15 years was referred to the Toranomon Hospital (Tokyo, Japan) with progressive calcifi ed nodules on his fi ngers. He had been undergoing haemodialysis three times per week, for a total of 12 h per week. The patient had been deemed to have end-stage renal disease of unknown cause. He had undergone a parathyroidectomy 2 years before the referral because he was believed to have progressive extraskeletal calcifi cation caused by hyperparathyroidism with constant hypercalcaemia that was refractory to medical treatment; laboratory fi ndings were compatible with secondary hyperparathyroidism. Since the parathyroidectomy, laboratory fi ndings had returned to normal, but the nodules had progressed and made him unable to grip. A family history could not be obtained because the patient was an orphan, but through a careful interview we identifi ed a past medical history of recurrent urolithiasis, which was judged to be the leading cause of the end-stage renal disease. Physical examination showed clubbed fi ngers with exposed calcifi ed masses (fi gure A). Radiography showed prominent bilateral calcifi ed deposits (fi gure B) and nephrocalcinosis. Gas chromatography– mass spectrometry-based plasma metabolomic assessment showed substantially increased concentrations of oxalate (316 μmol/L) and glycerate (50·2 μmol/L; normal is <10 μmol/L for both), but glycolate concentration was almost normal at 13·3 μmol/L (normal is <12 μmol/L), suggesting the possibility of primary hyperoxaluria type 2. Genetic analysis showed a missense mutation, 181G→A (Asp61Asn), of GRHPR in exon 2. We therefore diagnosed the patient as having primary hyperoxaluria type 2 and started intensive haemodialysis (25 h per week, Monday to Friday, for 2 years so far) in preparation for renal transplantation. The patient is currently on a waiting list for renal transplantation. Primary hyperoxaluria type 2 is a rare autosomal recessive disease caused by mutation of GRHPR, the gene encoding the enzyme glyoxylate reductase/hydroxypyruvate reductase, which results in hyperoxaluria, recurrent urolithiasis, progressive nephrocalcinosis, end-stage renal disease, and, eventually, systemic oxalate deposition. Primary hyperoxaluria type 2, especially when associated with renal failure and caused by plasma oxalate concentrations exceeding the supersaturation index of oxalate in plasma (30 μmol/L), should be identifi ed early because severe manifestations, as seen in our patient, can be prevented with early diagnosis, intensive management of dialysis, and timely transplantation.

PREPARE – étude transversale observationnelle sur la prise en charge de l’insuffisance rénale chronique en néphrologie avant le stade d’épuration extrarénale en France

There are few epidemiologic data on Chronic Kidney Disease management before replacement therapy. The two objectives of the PREPARE study were (1) to describe the characteristics of these patients and accordance to clinical practice guidelines (2) to study nephrologists preference for renal replacement therapy in case of progression to end stage renal disease. PREPARE is a non-interventional cross-sectional study. All the French nephrologists had been solicited to collect information about CKD outpatients not on dialysis, not transplanted, with glomerular filtration rate lower than 60mL/min/1,73m2, followed on any day between 23 and 27 November 2009. Three hundred and eight investigators included 2089 patients, 59% of them were male, they were on average 69 years old, 15, 37 and 48% had respectively a CKD stage V, stage IV and stage III, the nephropathy was the most often (43%) vascular. The most frequently reported cardiovascular risk factors were hypertension (88%), hypercholesterolemia (53%), diabetes (37%). The average time between diagnosis of nephropathy and the first nephrology consultation was too long 1,5 years. The implementation measures of nephroprotection and treatment of complications of CKD were generally satisfactory. However, preparation for replacement therapy was often too late, haemodialysis was more likely scheduled instead of peritoneal dialysis and without preparation for renal transplantation. PREPARE can therefore highlight the qualities of the current management of CKD by nephrologists in France. Nevertheless, PREPARE also shows weaknesses in preparation for replacement therapy. One can suggest that they could be reduced by systematic access of patients with risk of progression to stage V, as soon as the stage IV, to structured multidisciplinary care.

Evaluation of urine biomarkers of kidney injury in polycystic kidney disease

Progressive disruption of renal tubular integrity in the setting of increased cellular proliferation and apoptosis is a feature of ADPKD. Here we evaluated the effect of these processes on the expression of NGAL and IL-18, markers of tubular injury, in rodent models and in the cyst fluid and urine of patients with ADPKD. Two mouse models where Pkd2 was inactivated which resulted in early or adult onset cysts, were used to evaluate NGAL levels. Further, the Han:SPRD rat model of polycystic disease was used to study IL-18 levels. In four annual serial urine samples from 107 patients with ADPKD in the Consortium for Radiologic Imaging for the Study of Polycystic Kidney Disease (CRISP) study, NGAL and IL-18 excretion rates were determined in conjunction with measures of total kidney volume and estimated GFR (eGFR) by the MDRD equation. Kidneys from affected mice and rats showed prominent expression of NGAL and IL-18/IL-18R, respectively, in epithelial cells lining kidney cysts. In human ADPKD cyst fluid, both NGAL and IL-18 were elevated. In CRISP patients, the mean percentage increase in total kidney volume was 5.4 /year and the mean decline in eGFR 2.4 mL/min/year. The trend of increased mean urine NGAL and IL-18 over three years was statistically significant; however, there was no association of tertiles of IL-18 or quartiles of NGAL and the change in total kidney volume or eGFR over this period. Thus, urinary NGAL and IL-18 excretion are mildly and stably elevated in ADPKD, but do not correlate with changes in total kidney volume or kidney function. This may be due, in part, to the lack of communication between individual cysts and the urinary collecting system in this disorder.

Panniculectomy in Preparation for Renal Transplantation

End-stage renal disease patients who have lost a significant amount of weight are increasingly being evaluated for kidney transplantation. An abdominal panniculus, almost uniformly observed, creates an area predisposed to wound complications. Consequently, a panniculus may limit a patient's candidacy for transplantation. The authors describe their preliminary experience utilizing panniculectomy as a prophylactic procedure to reduce wound complications following kidney transplantation in patients whose panniculus would exclude them from renal transplantion. A single-institution chart review was conducted of nine patients with end-stage renal disease who underwent a panniculectomy in preparation for transplantation. Clinical outcomes and complications were reviewed. The nine patients included three men and six women with a mean age of 54.5 years and a mean body mass index of 28.3 kg/m. Four patients had diabetes. All patients underwent an uncomplicated panniculectomy, with a mean resected weight of 3.0 kg, and a mean length of hospital stay of 1.75 days. No one required blood transfusions. All patients were followed postoperatively for 3 months. Complications included an abscess and a skin dehiscence treated with local wound care. After recovery, patients were referred to the transplant center for re-evaluation for kidney transplantation. Thus far, four of these nine patients have undergone transplantation. This case series suggests that panniculectomy can be performed safely in patients with end-stage renal disease. Furthermore, panniculectomy gives these otherwise unsuitable kidney transplant candidates access to a life-saving operation.

Intermediate Volume on Computed Tomography Imaging Defines a Fibrotic Compartment that Predicts Glomerular Filtration Rate Decline in Autosomal Dominant Polycystic Kidney Disease Patients

Total kidney and cyst volumes have been used to quantify disease progression in autosomal dominant polycystic kidney disease (ADPKD), but a causal relationship with progression to renal failure has not been demonstrated. Advanced image processing recently allowed to quantify extracystic tissue, and to identify an additional tissue component named "intermediate," appearing hypoenhanced on contrast-enhanced computed tomography (CT). The aim of this study is to provide a histological characterization of intermediate volume, investigate its relation with renal function, and provide preliminary evidence of its role in long-term prediction of functional loss. Three ADPKD patients underwent contrast-enhanced CT scans before nephrectomy. Histological samples of intermediate volume were drawn from the excised kidneys, and stained with hematoxylin and eosin and with saturated picrosirius solution for histological analysis. Intermediate volume showed major structural changes, characterized by tubular dilation and atrophy, microcysts, inflammatory cell infiltrate, vascular sclerosis, and extended peritubular interstitial fibrosis. A significant correlation (r = -0.69, P < 0.001) between relative intermediate volume and baseline renal function was found in 21 ADPKD patients. Long-term prediction of renal functional loss was investigated in an independent cohort of 13 ADPKD patients, followed for 3 to 8 years. Intermediate volume, but not total kidney or cyst volume, significantly correlated with glomerular filtration rate decline (r = -0.79, P < 0.005). These findings suggest that intermediate volume may represent a suitable surrogate marker of ADPKD progression and a novel therapeutic target.

VIRAL hepatitis in solid organ transplantation other than liver

Transplantation is the best treatment for end-stage organ failure. Hepatitis virus infections, mainly hepatitis B virus (HBV) and hepatitis C virus (HCV) infections still constitute a major problem because they are common in allograft recipients and are a significant cause of morbidity and mortality after transplantation. Recently, hepatitis E virus infection has been added as an emergent cause of chronic hepatitis in organ transplantation. The prevalence of HBV and HCV infections has markedly decreased in patients who are candidates for transplantation since the introduction of screening, hygiene and prevention measures, including systematic screening of blood and organ donations, use of erythropoietin, compliance with universal hygiene rules, segregation of HBV-infected patients from non-infected patients and systematic vaccination against HBV. A liver biopsy is preferable to non-invasive biochemical and/or morphological tests of fibrosis to evaluate liver fibrosis before and even after transplantation. Treatment with entecavir or tenofovir is indicated in HBV-infected dialyzed patients who have moderate or severe disease (≥A2 or F2 on the Metavir scale) in preparation for renal transplantation. Due to the risks of severe reactivation, fibrosing cholestatic hepatitis or histological deterioration after transplantation, systematic use of nucleoside or nucleotide analogues shortly before or at the time of transplantation is recommended (tenofovir or entecavir are preferable to lamivudine) in all patients, whatever the baseline histological evaluation. In HCV-infected dialyzed patients who are not candidates for renal transplantation, the indication for antiviral therapy is limited to significant fibrosis (fibrosis ≥2 on the Metavir scale). Treatment must be proposed to all candidates for renal transplantation, whatever their baseline histopathology, and interferon-α should be used as monotherapy. After transplantation, interferon-α is contraindicated but may be used in patients for whom the benefits of antiviral treatment clearly outweigh the risks, especially that of allograft rejection. All cirrhotic patients, notably after solid organ transplantation, should be screened for hepatocellular carcinoma. Sustained suppression of necro-inflammation may result in regression of cirrhosis, which in turn may lead to decreased disease-related morbidity and improved survival. Finally, due to the high mortality after renal transplantation, active (namely without sustained viral suppression) cirrhosis should be considered a contraindication to kidney transplantation, but an indication to combined liver-kidney transplantation; on the contrary, inactive (namely with sustained viral suppression) compensated cirrhosis may permit renal transplantation alone. Organ transplantations other than kidney (cardiac or pulmonary transplantations) involve the same diagnosis and therapeutic issues.

Long-Term Results of a Staged Approach: Continent Urinary Diversion in Preparation for Renal Transplantation

We provide the long-term results of renal transplantation into continent urinary intestinal reservoirs as a planned 2-stage procedure. Between November 1990 and January 2009, 18 patients underwent cadaveric or living related renal transplantation into continent urinary reservoirs (continent cutaneous diversion 16, orthotopic substitution 2). All patients were prospectively followed. Of these patients 15 are currently free of dialysis. At a mean followup of 89.2 months (range 2 to 188) 13 patients had a serum creatinine ranging from 0.6 to 3.1 mg/dl (mean 1.49) after the first transplantation. Two patients underwent a second transplantation 12 and 122 months after loss of the transplant for renal vein thrombosis and chronic allograft dysfunction, respectively. Two additional patients had to resume hemodialysis 62 and 109 months after renal transplantation. The second transplantation was delayed mainly due to compliance problems. One patient died of fulminant septicemia after laparotomy elsewhere for bowel obstruction with normal renal function before that episode. The continence mechanism needed correction in 3 patients, and 2 further revisions were required for ureteral kinking and lymphocele. The patients with orthotopic substitution (2) voided to completion and showed complete continence. All patients with cutaneous diversion were continent day and night with easy catheterization. This study is among the largest single series to date of renal transplantation into continent urinary diversions. Long-term followup confirms that this approach is a safe and socially well accepted treatment option in carefully selected patients.

Place de la néphrectomie chez les patients atteints de polykystose rénale autosomique dominante de l’adulte en attente de transplantation rénale

To define the indications, results and place of nephrectomy for autosomal dominant polycystic kidney disease (ADPKD) in relation to renal transplantation. Between October 1998 and February 2006, 145 patients with ADPKD were followed in our institution; 38 of them underwent nephrectomy via a subcostal incision, mainly in preparation for renal transplantation. The decision to perform nephrectomy in preparation for renal transplantation was based on clinical examination and CT findings. Indications for nephrectomy were preparation for renal transplantation (n=28, 68%), severe urological complications (n=12) and malignant tumour (n=1). Forty-one nephrectomies were performed, pretransplantation in 36 cases (88%) and five post-transplantation nephrectomies in three patients. The nephrectomy rate was 26%. The median kidney weight was 2800 grams. The mean operating time was 100 minutes and mean blood loss was 76 ml. The overall morbidity was 36.6% with 7.3% of serious complications. The mean hospital stay was 14.5 days. No patient nephrectomized before transplantation (n=13) developed any complications of the contralateral native kidney with a mean follow-up of 33 months. The mean interval between initiation of dialysis and transplantation and between nephrectomy and transplantation was 30 and 16 months, respectively. The optimal timing and incision for nephrectomy for ADPKD are still a subject of debate. In the absence of urological complications, nephrectomy, associated with considerable morbidity, should only be performed when very large kidneys truly interfere with graft implantation. Systematic unilateral or bilateral nephrectomy must therefore no longer be proposed. To avoid the complications of the anephric state, it is preferable to wait, whenever possible, until the patient is placed on dialysis, but the development of pre-emptive transplantation raises the issue of concomitant nephrectomy and transplantation, which may be a feasible option.

Kidney Transplantation in Children With Augmentation Cystoplasty

Treatment of children with end stage renal disease, especially those with significant bladder dysfunction, is difficult. A high pressure and low capacity bladder is a major risk factor for a transplanted kidney. Cystoplasty can protect the kidney allograft by reducing the intravesical pressure and creating an appropriate capacity. The aim of this study was to evaluate the outcome of kidney transplantation in children with and without prior cystoplasty. A total of 43 children with bladder dysfunction in urgent need of cystoplasty were enrolled in the study and were compared to a control group with regard to acute and chronic rejection rates, survival of the transplanted kidney, surgical complications and febrile urinary tract infection. The rates of febrile urinary tract infection and chronic rejection were significantly higher in patients with prior cystoplasty (p<0.001 and p=0.004, respectively). Also, graft loss was much more frequent in these patients (34.9% vs 20.9%), although this difference was not statistically significant. In patients with prior cystoplasty graft survival rates were 92%, 73%, 58% and 45% at postoperative years 1, 3, 5 and 7, respectively. In the control group these rates were 94%, 87%, 81% and 75%, respectively (p=0.007). Based on our findings, the survival rate of the kidney is significantly lower in children with prior cystoplasty, possibly due to the higher prevalence of chronic rejection and febrile urinary tract infection in this group.

Pretransplant native nephrectomy in patients with end-stage renal failure: assessment of the role of laparoscopy

Objectives To evaluate the outcome and morbidity of laparoscopic nephrectomy in patients with end-stage renal disease. Methods Between August 1991 and September 2001, 64 laparoscopic nephrectomies were carried out for the native kidneys of 62 patients with end-stage renal failure. The procedures were performed in preparation for renal transplantation. The indications were vesicoureteral reflux with persistent or recurrent urinary tract infection in 26 renal units, uncontrolled hypertension in 15, chronic pyelonephritis or hydronephrosis with urinary tract infection in 8, renal calculi in 13, heavy proteinuria in 1, and small renal tumor in 1. The left side was removed in 52 procedures and the right side was removed in 12. Forty-eight and 16 renal units were removed through the retroperitoneal and transperitoneal approach, respectively. Results Sixty procedures were successfully performed (94%). Four patients required open exploration (6%). Four major complications were recorded: pneumothorax in 1, large hematoma in 1, colonic injury in 1, and bleeding in 1. No mortality related to the procedures or their complications occurred. The patients received allograft transplantation shortly after the procedure, with a mean of 26 days. Both transperitoneal and retroperitoneal approaches were effectively used with satisfactory outcome. Conclusions Laparoscopy should be considered as the procedure of choice for pretransplant nephrectomy. The high success rate, low morbidity, early recovery, and short duration between nephrectomy and transplantation all are considered as real advantages for this patient population.

Esophagogastroduodenoscopy in chronic hemodialysis patients: 2-year clinical experience in a renal unit.

Upper gastrointestinal (UGI) disorders are frequent in uremic patients and esophagogastroduodenoscopy (OGD) is an important investigation for their management. From January 1, 1997 to December 31, 1998, 57 endoscopies were performed in 96 hemodialysis patients (aged 65+/-12 years, 68 M, 28 F, dialysis duration 51+/-58 months) chronically treated in our unit in that period. The reasons for prescribing OGD were: anemia, after exclusion of poor response to EPO, in 26 patients (mean decrease in hemoglobin (Hb) levels 2.6+/-1.3 g/dl: the reference Hb level was the mean value measured before Hb decrease), dyspepsia in 11 and in preparation for renal transplantation in 20 patients. Twelve patients were diabetics, 24 smokers, 41 alcohol drinkers, 13 had hepatitis B or C, 6 were non-steroidal anti-inflammatory drugs (NSAIDs) abusers for bone pain and 21 were taking H2 receptor antagonists or proton-pump inhibitors chronically. Multiple biopsies of gastric mucosa were performed in 38 patients. Endoscopy revealed normal mucosa in 17.5% of cases, whilst chronic gastritis was diagnosed in 30%. Chronic gastritis was also the commonest microscopic abnormality diagnosed in 71.5% of biopsies. Anemic and non-anemic patients were matched and the 2 groups did not show significant differences in endoscopic findings and histological appearance. Thirteen patients had Helicobacter pylori (HP) infection demonstrated by biopsy specimen examination and were treated by metronidazole, clarithromycin and omeprazole. A logistic regression analysis was carried out in all subjects, considering the decrement in Hb as a dependent variable and demographic and clinical characteristics as independent variables. The analysis demonstrates that age (odds ratio 1.05; p < 0.05), NSAIDs abuse (odds ratio 15.6; p < 0.05) and HP infection (odds ratio 16.7; p < 0.01) were independently related to Hb decrease. In our experience, non-EPO-related anemia and dyspepsia are frequent features in hemodialysis patients. OGD is frequently requested (30% of patients/year) and 83% of patients investigated had abnormal UGI mucosa. Underlying mucosal inflammation might promote UGI bleeding but is not likely to be the cause, making it a necessary superimposed factor such as NSAIDs or HP infection.

ARTHROGRYPOSIS MULTIPLEX CONGENITA: BLOOD VESSEL HYPOPLASIA AND IMPLICATIONS DURING RENAL TRANSPLANTATION

Arthrogryposis multiplex congenita is a crippling congenital abnormality of muscle development characterized by marked muscle contracture and nonprogressive, limb joint deformity. The incidence is 1/3,000 births. The most frequent isolated contractures are clubfoot and congenital hip dislocation. 1 Arthrogryposis is seen in a number of syndromes with or without central nervous system involvement and is associated with multiple developmental defects. However, vascular complications with arthrogryposis multiplex congenita are not well described. 1 We report on a renal transplant recipient with arthrogryposis multiplex congenita. Unexpected severe blood vessel hypoplasia complicated transplant revascularization and led to acute thrombosis of the allograft, necessitating reperfusion and revascularization to the aortic bifurcation and common iliac vein. CASE REPORT A 20-year-old man with arthrogryposis multiplex congenita presented for renal transplantation. He had a small body habitus and classical locomotor findings. At birth he had an imperforate anus for which he underwent perinatal colostomy. The correction was complicated by a vesicorectal fistula necessitating self-catheterization and treatment for recurrent urinary tract infections. Chronic pyelonephritis developed with subsequent renal failure. He underwent a native nephrectomy of a horseshoe kidney for chronic pyelonephritis in preparation for renal transplantation. Cardiac, urological and general assessment for transplantation revealed no contraindications but pelvic angiography was not done. Live related renal transplantation was performed with the biological father of the patient as a kidney donor. Donor nephrectomy was uncomplicated. At the time of the extraperitoneal transplant procedure the iliac vessels of the patient were hypoplastic. The renal artery was anastomosed to the external iliac artery and the renal vein was anastomosed to the external iliac vein. Upon revascularization the graft initially became pink and then gradually turned dusky within a few minutes. The graft was subsequently removed and reperfused with cold Ringer’s lactate, and the external iliac vein was transected and ligated. After reperfusion, the donor kidney was subsequently reanastomosed intraperitoneally to the bifurcation of the aorta and the renal vein was anastomosed end to end to the common iliac vein, followed by reconstruction of the femoral artery. This second anastomosis was successful with fair perfusion of the donor kidney. Upon completion of the procedure, the kidney was perfused in a patchy manner. Postoperatively, the patient required dialysis and intensive care monitoring but recovered and subsequently was discharged home with normal serum creatinine. Coagulation studies performed after transplant were normal. Three months after healthy independent living, he died unexpectedly. Autopsy did not reveal the cause of death.

Bladder Augmentation Can be Problematic With Renal Failure and Transplantation

Ten consecutive patients with failure of urinary bladder augmentation (UBA) performed either prior to or after reaching end-stage renal disease (ESRD) were studied. Seven patients developed increased hydroureteronephrosis, infectious complications, and advanced to ESRD after UBA. The mean time to development of ESRD in patients who had UBA performed with moderate chronic renal failure (CRF) was 1.8 years. The UBAs in all seven patients were taken down prior to transplantation. Subsequently, five of these UBA-takedown patients have received kidney grafts and all have stable, good renal function. Three patients had their UBA performed after they reached ESRD, in preparation for renal transplantation. All three of these patients experienced recurrent urosepsis following transplantation, resulting in death in one patient and loss of graft in another. The third patient will undergo takedown of the UBA. This study suggests that UBA may possibly not be the best option for patients with moderate CRF and those awaiting transplantation.

The Futility of Pretransplant Coronary Bypass Grafting in Asymptomatic Patients on Peritoneal Dialysis

To evaluate the validity of recommending coronary artery bypass grafting (CABG) in preparation for renal transplantation in asymptomatic peritoneal dialysis (PD) patients with evidence of reversible myocardial ischemia. Retrospective review in a single PD unit. Ten asymptomatic PD patients who underwent CABG to be placed on the transplant list comprised the study group. Ten age-, sex-, and disease-matched PD patients who did not receive CABG were used as a comparison group. Clinical outcome from 1990 to the present. Only 1 patient in the study group has received a transplant. Seven patients (70%) have died or have been removed from the list because of comorbid illness. Only 2 patients are still on the waiting list. As a result of the long waiting time for cadaveric renal transplant and the high risk of interim development of comorbid disease, only a minority of patients come to transplantation. The presence of coronary disease is likely a surrogate for more generalized cardiac and vascular disease in this population. In light of these findings, the policy of prophylactic revascularization in asymptomatic dialysis patients in preparation for renal transplantation needs to be reconsidered.