Pretransplant Bilateral Nephrectomy Research Articles

Beneficial effect of bilateral native nephrectomy as complete denervation on left ventricular mass and function in renal transplant recipients.

Left ventricular hypertrophy (LVH) is a risk factor for cardiovascular morbidity and mortality in renal transplant recipients. The development of LVH is connected with excessive activation of the sympathetic nervous system. A bilateral nephrectomy is an example of complete renal denervation. The aim of this study was to evaluate the effect of pretransplant bilateral native nephrectomy on left ventricular mass and function during a long-term follow-up of patients after kidney transplantation. The study group consisted of 32 renal transplant recipients who had previously undergone pretransplant bilateral native nephrectomy. The control group involved 32 recipients with preserved native kidneys, matched for age, sex, creatinine levels, estimated glomerular filtration rate, immunosuppressive treatment, and the time of renal replacement therapy. All patients were evaluated by echocardiography, and 16 patients--by cardiac magnetic resonance (CMR). In addition, all patients had their arterial blood pressure (BP) and metabolic markers measured. In comparison with controls, the study group had lower systolic BP (P = 0.048) and received a lower number of antihypertensive agents (P = 0.001). Lipid and hemoglobin levels were similar in both groups. The study group had a lower left ventricular mass index (LVMI; P = 0.001) and left atrial volume index (LAVI; P = 0.004). The left ventricular mass evaluated by CMR was also lower in the study group (P <0.001). Mild left ventricular diastolic dysfunction (LVDD) was more frequent in the study group compared with the control group ( P <0.001). In a long-term follow-up of patients after kidney transplantation, the bilateral native nephrectomy before transplantation was associated with a lower LVMI and LAVI as well as a lower grade of LVDD. These patients had lower systolic BP and used fewer antihypertensive drugs.

Dorsal lumbotomy versus laparoscopy for pretransplant bilateral nephrectomy of small kidneys

Dorsal lumbotomy versus laparoscopy for pretransplant bilateral nephrectomy of small kidneys

Pretransplant bilateral nephrectomy for control of malignant hypertension: Is it justified?

Pretransplant bilateral nephrectomy for control of malignant hypertension: Is it justified?

OPTIMAL APPROACH FOR PRETRANSPLANT BILATERAL NEPHRECTOMY FOR SMALL KIDNEYS: DORSAL LUMBOTOMY VERSUS LAPAROSCOPY

You have accessJournal of Urology1 Apr 2008OPTIMAL APPROACH FOR PRETRANSPLANT BILATERAL NEPHRECTOMY FOR SMALL KIDNEYS: DORSAL LUMBOTOMY VERSUS LAPAROSCOPY Aneesh Srivastava, K Murugananadham, Parag Gupta, Anant Kumar, Rakesh Kapoor, and Deepak Dubey Aneesh SrivastavaAneesh Srivastava More articles by this author , K MurugananadhamK Murugananadham More articles by this author , Parag GuptaParag Gupta More articles by this author , Anant KumarAnant Kumar More articles by this author , Rakesh KapoorRakesh Kapoor More articles by this author , and Deepak DubeyDeepak Dubey More articles by this author View All Author Informationhttps://doi.org/10.1016/S0022-5347(08)62027-3AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "OPTIMAL APPROACH FOR PRETRANSPLANT BILATERAL NEPHRECTOMY FOR SMALL KIDNEYS: DORSAL LUMBOTOMY VERSUS LAPAROSCOPY." The Journal of Urology, 179(4S), pp. 694–695 © 2008 by American Urological AssociationFiguresReferencesRelatedDetails Volume 179Issue 4SApril 2008Page: 694-695 Advertisement Copyright & Permissions© 2008 by American Urological AssociationMetricsAuthor Information Aneesh Srivastava More articles by this author K Murugananadham More articles by this author Parag Gupta More articles by this author Anant Kumar More articles by this author Rakesh Kapoor More articles by this author Deepak Dubey More articles by this author Expand All Advertisement PDF downloadLoading ...

BILATERAL NEPHRECTOMY OF HUGE POLYCYSTIC KIDNEYS ASSOCIATED WITH A RECTUS ABDOMINIS DIASTASIS AND UMBILICAL HERNIA

Patients with end-stage renal failure due to huge autosomal dominant polycystic kidney disease usually have an umbilical hernia and rectus abdominis diastasis, which are very troublesome. Pretransplant bilateral nephrectomy techniques does not manage the umbilical hernia and rectus abdominis diastasis. We report our experience in performing bilateral nephrectomy and repairing the rectus abdominis diastasis and umbilical hernia through the one, small incision. Four patients aged 37 to 43 years with huge polycystic kidneys, an umbilical hernia, and a rectus abdominis diastasis underwent bilateral pretransplant nephrectomy through a midline supraumbilical incision including the umbilical hernia defect. The kidneys were removed through this incision. The incision was closed with the transposition of rectus abdominis muscle, pants-over-vest-style, to correct the diastasis and the umbilical hernia. The average operative time was 160 minutes (range, 130-180); the average larger kidney size was 33 cm (range, 32-34 cm); no major complications occurred; one patient who had preoperative low hemoglobin required blood transfusion. Patients were discharged from the hospital on postoperative day 7 with an esthetically pleasing belly, no rectus abdominis diastasis, and no umbilical hernia. One to two months after bilateral nephrectomy, the patients received a live donor kidney with an uneventful outcome. A midline supraumbilical incision is an excellent approach for bilateral nephrectomy of huge polycystic kidneys. In addition, an umbilical hernia and rectus abdominis diastasis may be successfully repaired through same incision with good cosmetic results.

Effect of prior bilateral nephrectomy on haemoglobin and blood pressure outcome after transplantation

Changes in blood pressure and haemoglobin concentration before and after renal transplantation were compared in 15 patients with renal failure due to chronic pyelonephritis who had undergone pretransplant bilateral nephrectomy and 15 control patients whose primary renal disease was chronic pyelonephritis and who were matched for age, sex and graft function but had not undergone nephrectomy. Bilateral nephrectomy resulted in a significant worsening of anaemia prior to transplantation and a decline in blood pressure. However, by 6 and 12 months after renal transplantation both haemoglobin and blood pressure were similar in nephrectomized and non-nephrectomized patients and in the normal range. We conclude that in patients with renal failure due to chronic pyelonephritis, pretransplant nephrectomy has no major impact on long-term blood pressure and haemoglobin levels achieved after successful renal transplantation.

Post-transplant haemoglobin levels and host kidney status.

Erythrocytosis after renal transplantation has been ascribed to inappropriate production of erythropoietin by the recipient's native kidneys. In a retrospective analysis we examined the effect of pre-transplant bilateral nephrectomy on post-transplant haemoglobin level (Hb) and haematocrit (Ht) in 370 renal transplant patients. Hb and Ht were significantly higher in the 341 patients with host kidneys in situ compared with the 29 patients who had undergone bilateral nephrectomy (Hb, 8.5 +/- 1.2 mmol/l vs 7.8 +/- 1.3 mmol/l, P = 0.005; Ht, 41 +/- 6% vs 38 +/- 7%, P = 0.02). Moreover, a very high Hb and/or Ht (defined as a value above the 80th percentile of the whole group) occurred more frequently in patients with host kidneys in situ (20.5% vs 3.5%, P = 0.02). It thus appears that host kidneys significantly contribute to the unexpectedly high haemoglobin levels occurring after renal transplantation.

Post-transplant haemoglobin levels and host kidney status

Erythrocytosis after renal transplantation has been ascribed to inappropriate production of erythropoietin by the recipient's native kidneys. In a retrospective analysis we examined the effect of pre-transplant bilateral nephrectomy on post-transplant haemoglobin level (Hb) and haematocrit (Ht) in 370 renal transplant patients. Hb and Ht were significantly higher in the 341 patients with host kidneys in situ compared with the 29 patients who had undergone bilateral nephrectomy (Hb, 8.5 ± 1.2 mmol/l vs 7.8 ± 1.3 mmol/l, P = 0.005; Ht, 41 ± 6% vs 38 ± 7%, P = 0.02). Moreover, a very high Hb and/or Ht (defined as a value above the 80th percentile of the whole group) occurred more frequently in patients with host kidneys in situ (20.5% vs 3.5%, P = 0.02). It thus appears that host kidneys significantly contribute to the unexpectedly high haemoglobin levels occurring after renal transplantation.

Renal transplantation for end-stage polycystic kidney disease

From 1963 to 1984, 56 renal transplants were performed in 51 patients with end-stage renal failure due to autosomal dominant polycystic kidney disease (ADPKD). There were 49 cadaver and 7 living-related transplants. Overall patient and graft survival was 88 per cent and 66 per cent at one year, 59 per cent and 49 per cent at five years, respectively. There was no significant difference in patient or graft outcome with cadaver versus living-related donor kidneys. One-year graft success with and without pretransplant bilateral nephrectomy (BN) was 78 per cent versus 58 per cent, respectively (n.s.). Patient survival after return to dialysis after graft loss was not compromised by the earlier performance of BN. In patients who did not undergo pretransplant BN, there were no complications from the retained native kidneys after transplantation. In cadaver recipients, the two-year graft success rate with and without preliminary blood transfusions was 54 per cent versus 61 per cent, respectively (n.s.). Cadaver graft survival with and without adjunctive antilymphocyte globulin (ALG), excluding 3 recipients managed with cyclosporine, was 88 per cent versus 50 per cent at one year, and 70 per cent versus 32 per cent at five years, respectively (p < 0.05). This beneficial effect of ALG was still evident when only transfused cadaver recipients were analyzed and was achieved with no resulting compromise in patient survival. Follow-up computerized tomography (CT) scanning of the transplant kidney in 10 recipients with a long-term (1–9 years) functioning allograft showed no evidence of recurrent ADKPKD.

THE BIOLOGIC SIGNIFICANCE OF THE MIXED LYMPHOCYTE KIDNEY CULTURE IN HUMANS

The mixed lymphocyte kidney culture (MLKC) in humans has been studied in normal and abnormal clinical conditions. Human renal cortical cells were extracted by collagenase treatment from the kidneys of "normal" heart-beating cadaver organ donors (n = 13), patients with end-stage renal disease (ESRD) at pretransplant bilateral nephrectomy and splenectomy (n = 13), and from irreversibly rejected renal allografts at the time of graft nephrectomy (n = 5). Proliferation of peripheral blood T lymphocytes of 2-DR-mismatched volunteers occurred in response to kidney cortical cells extracted from each of the 3 donor categories in a reaction termed the allogeneic mixed lymphocyte kidney culture. Additionally, splenic T cells from cadavers and patients with ESRD were seen to react to their autologous kidney cells. The renal cortical cells extracted from ESRD kidneys were more stimulatory in the allogeneic and autologous MLKC responses than those extracted from "normal" cadaver kidneys even when the ESRD kidneys were 99% depleted of passenger T and B lymphocytes by treatment with monoclonal antibodies T11 and B1. In order to help define the antigens operative in the MLKC, we pretreated stimulating lymphocytes and renal cortical cells with anti-class II monoclonal antibodies. The allogeneic mixed lymphocyte reaction and MLKC were inhibited ca. 80% and 30%, respectively. The autologous MLKC was unaffected by this treatment. To further support that tissue-specific immune mechanisms were operative in the reaction, experiments were performed with infiltrating lymphocytes isolated from the ESRD kidneys, which were seen to generate a proliferative response when stimulated with autologous cortical cells. However, the response of these same infiltrating lymphocytes when stimulated with allogeneic lymphocytes (MLR), was markedly weaker than the response of the patients' autologous spleen cells. In addition, two kidneys were obtained at rejection from recipients that had received grafts from HLA-MLR-identical sibling donors. A lymphoproliferative reaction of recipient peripheral blood T lymphocytes occurred in response to (donor) renal cortical cells, but not to donor peripheral blood lymphocytes. In contrast, infiltrating (recipient) kidney lymphocytes responded to the kidney cortical cells and to donor peripheral blood lymphocytes. Moreover, peripheral blood T lymphocytes of the HLA-identical donor responded to his own kidney cortical cells, which were isolated from the rejected recipient kidney, and did not respond to recipient peripheral blood lymphocytes. Finally, a "normal" cadaveric kidney was fortuitously available at the same time that a rejected transplant (cadaver)

The detrimental effects of delayed graft function in cadaver donor renal transplantation.

Data collected prospectively on over 3800 cadaveric renal transplants performed between June 1977 and July 1982 by the 41 member institutions of the South-Eastern Organ Procurement Foundation were analyzed to determine the influence of delayed graft function (DGF) on patient and graft outcome. Approximately 35% of first graft recipients and 47% of regrafted patients were found to have DGF, as determined by the necessity for dialysis at one week posttransplant. First-graft recipients with DGF tended to include more black recipients, patients with higher peak levels of panel reactive antibody (PRA), less use of antilymphocyte serum (ALS) posttransplant, slightly longer organ preservation times and the more frequent use of organs by ice alone. Multivariate (Cox) regression analysis considering DGF simultaneously with ten other potentially confounding variables showed a highly significant association between DGF and overall graft loss from all causes (P less than 10(-5], irreversible graft rejection (P less than 0.001) as well as patient death (P = 0.012). The differences in graft survival between first graft recipients with DGF (n = 961) versus those without DGF (n = 1769) at one and four years posttransplant were 46% +/- 2 vs. 60% +/- 1 and 28% +/- 3 vs. 40% +/- 2, respectively. The detrimental effect of DGF was highly significant irrespective of the source of donor organs or the type of preservation used. For first transplant recipients who recovered good graft function by one month following DGF (n = 564), there was a significant decrease in eventual graft survival, as compared with patients who had graft function at one month but no prior history of DGF (n = 1407; P = 0.008). However, patients with history of DGF who had good graft function at six months (n = 361) showed no significant difference in longer-term graft survival when compared with similar patients with good graft function at six months but no history of DGF (n = 912). Interestingly, first transplant recipients with DGF were found to have significantly better graft survival if they had received bilateral native nephrectomy at least one month prior to transplantation. These results indicate that delayed graft function following cadaver donor renal transplantation provides a significant risk for eventual graft and patients survival that is principally manifested during the first six months posttransplant. In addition, patients who recover graft function following DGF appear to also remain at higher risk for early graft loss, while pretransplant bilateral native nephrectomy may afford some protection against the detrimental effects of DGF.

Splenectomy and Death in Renal Transplant Patients

To the Editor .—Peters et al 1 reported that pretransplant splenectomy is associated with a threefold increase in posttransplant fatal infection. Their report was based on 191 patients having transplants between 1970 and 1981. Of these, 90 (47%) underwent pretransplant splenectomies. Thirty-two of 90 asplenic patients died of sepsis, compared with ten of 101 patients who had not undergone splenectomies. I suggest an alternative interpretation of their findings. The authors report that from 1970 to 1974 only four of 75 patients did not undergo a pretransplant bilateral nephrectomy, splenectomy, and appendectomy. Thus, 71 of their 90 asplenic transplant recipients received their grafts between 1970 and 1974. Ninety-seven of the 101 patients not undergoing a splenectomy had transplants between 1975 and 1981. During the decade between 1970 and 1980, transplant centers across the United States reported significant changes in their immunosuppressive protocols, leading to lowered total immunosuppression, a decreased infection rate,

Why Do Secondary Cadaver Renal Transplants Succeed? Results of the South-eastern Organ Procurement Foundation Prospective Study, 1977-1982

We report the selective and therapeutic factors affecting multiple kidney transplant success from a prospective multicenter study of the South-Eastern Organ Procurement Foundation. From June 1977 to March 1982, 3,215 cadaver kidney transplants were performed at 39 institutions. There were 2,535 first, 564 second, 103 third and 13 fourth grafts. The actuarial graft survival rates at 1 and 2 years were 52 plus or minus 1 and 45 plus or minus 1 per cent, respectively, for first grafts, 44 plus or minus 2 and 40 plus or minus 3 per cent for second grafts, and 42 plus or minus 5 and 31 plus or minus 6 per cent for third grafts. Graft survival rates were significantly lower for second and third than for first transplants (p less than 0.003). There was no difference in patient survival rates. The data were analyzed to determine which selective and therapeutic variables governed success of primary and secondary grafts. Pre-transplant blood transfusions were associated with a significant increase in graft survival rates in primary (p less than 0.00005) and secondary transplants (p less than 0.01), and did not affect patient survival rates. The administration of antilymphocyte serum also improved graft survival rates significantly in primary (p less than 0.00005) and secondary grafts (p less than 0.00002), without alteration of patient survival rates. HLA compatibility improved primary graft survival rates (p less than or equal to 0.022) but this did not reach statistical significance in secondary graft survival rates. Second transplant graft survival rates were best when the primary graft functioned for more than 12 months (Breslow p less than or equal to 0.02) but were not related to the reason for loss of the first graft. Pre-transplant bilateral nephrectomy improved graft survival rates significantly but this phenomenon was linked to other treatment factors. No beneficial effect on graft survival rate could be shown after pre-transplant splenectomy in patients with primary or secondary grafts and this procedure was associated with reduced patient survival rates in both groups.

Pretransplant bilateral nephrectomy and adjuvant operations

Pretransplant bilateral nephrectomy by the posterior approach has been associated with minimal morbidity and mortality. Unfortunately the posterior approach is not applicable to all patients, e.g., patients with polycystic renal disease or patients who need simultaneously another intraperitoneal adjuvant operation such as splenectomy or vagotomy and pyloroplasty. This article presents 34 patients who had a transperitoneal bilateral nephrectomy and 29 other concurrent adjuvant operations. Morbidity and mortality are comparable to that reported for simple bilateral nephrectomy performed posteriorly. The reduction in morbidity and mortality was believed to be due to a careful application of the basic principles of surgical care and an appreciation of the special problems posed by patients on chronic hemodialysis. Perioperative care will be discussed in detail.

Goodpasture's syndrome: A report of seven patients including long-term follow-up of three who received a kidney transplant

Seven patients with Goodpasture's syndrome are presented. Bilateral nephrectomy was performed in five patients, and postnephrectomy pulmonary hemorrhage occurred in three. Three nephrectomized patients underwent a successful renal transplant, renal transplantation being postponed until circulating antiglomerular basement membrane antibody had disappeared. The argument is made that pretransplant bilateral nephrectomy in patients with Goodpasture's syndrome is indicated.

Cost-Benefit Ratio of Pretransplant Bilateral Nephrectomy

The posttransplant courses of 27 chronic dialysis patients with 29 grafts who had undergone pretransplant bilateral nephrectomy were compared to those of 49 patients with 55 transplant who had no pretransplant surgery during the same time period. The latter had better survival and fewer rejection episodes (P less than .05). The six patients who died of bacterial sepsis after transplantation all had pretransplant surgery. The frequency of post transplant hypertension was similar in both groups. Apparently, pretransplant bilateral nephrectomy offers no advantage to the patient awaiting an allograft.

Cost-benefit ratio of pretransplant bilateral nephrectomy

Cost-benefit ratio of pretransplant bilateral nephrectomy