Renal Transplant Surgeons Research Articles

Safety, efficacy, and timing of transplantation(s) in propionic and methylmalonic aciduria.

Propionic (PA) and methylmalonic aciduria (MMA) share many clinical similarities, which include the risk of acute metabolic encephalopathies, and some long-term complications, such as optic neuropathy, pancreatic involvement, developmental disability, and similar management approaches, but they also represent distinct clinical and biochemical entities. In the severe forms of PA and MMA, most long-term complications cannot be prevented with conventional clinical management. Organ transplantation represents a form of partial enzyme replacement to improve the long-term outlook for these disorders. There is evidence that early liver transplant in both disorders greatly improves metabolic stability and reduces the risk of long-term complications. For MMA, early liver transplant reduces methylmalonic acid levels which in turns reduces its effects on kidneys, and therefore slows progression of chronic kidney disease. However, established organ damage cannot be reversed. For patients with MMA who present with chronic kidney disease, consideration should be given for combined liver and kidney transplants. Transplantation in PA and MMA carries a high risk of complications and requires highly specialised pre-operative and peri-operative management. Involvement of a multidisciplinary team is essential and should include metabolic team, nephrologist, hepatologist, hepatobiliary and renal transplant surgeons, anaesthesiologists, cardiologists, intensive care team, dieticians and specialist nurses. These patients require life-long multidisciplinary follow-up. There is increasing evidence in the literature on excellent short to medium-term patient and allograft survival following transplantation when patients are managed by a multidisciplinary team in a specialist centre. Improved early diagnosis and reductions in transplant-related mortality and morbidity have allowed early transplantation to be used electively to further improve the outcome.

A survey of Canadian renal transplant surgeons: Use of ureteric stents and technique of the ureteroneocystotomy.

The role of ureteric stenting in renal transplant has been well-demonstrated. The goal of this survey was to determine the utilization of ureteric stents by Canadian transplant surgeons, and how the ureteroneocystotomy and followup is performed. An online survey was sent to the 40 surgeon members of the Canadian Society of Transplantation. The primary outcome was the rate of ureteric stent use at the time of renal transplantation. The secondary outcomes were the ureteric stent dwell time, use and type of prophylactic antibiotics, and the use of routine post-transplant ultrasonography. All respondents (25) used ureteric stent routinely and 92% remove the stent between four and six weeks postoperatively. Prophylactic antibiotics were used 64% of the time for ureteric stent removal. The majority of surgeons do not routinely perform a post-stent removal ultrasound. Fifty-six percent of respondents perform a refluxing anastomosis. Ureteric stents are routinely used in renal transplant in Canada. Areas for improvement and topics of debate identified from this survey are the need for peri-stent removal antibiotics, the role of post-stent removal ultrasound, the duration of stent dwell time, and the need for a non-refluxing ureteroneocystotomy.

The Discussion of Sexual Dysfunction Before and After Kidney Transplantation From the Perspective of the Renal Transplant Surgeon.

Sexual dysfunction (SD) is a common problem in chronic kidney disease (CKD) and endures in 50% of patients after kidney transplantation (KTx), diminishing patients' expectations of life after KTx. Unfortunately, SD is often ignored by renal care providers. Research questions as part of a research project among all renal care providers, transplant surgeons' perspectives were obtained on sexual health care for KTx recipients, including their opinion on who should be accountable for this care. In addition, surgeons' practice and knowledge regarding SD were evaluated. A 39-item questionnaire was sent to all Dutch surgeons and residents specialized in KTx (n = 47). Response was 63.8%. None of the respondents discussed SD with their patients, before or after surgery. Most important barrier was that surgeons do not feel accountable for it (73.9%); 91.7% thought this accountability should lie with the nephrologist. Another barrier was insufficient knowledge (39.1%). In 75% of the respondents, (almost) no knowledge regarding SD was present and 87.5% noticed education on SD was insufficient during residence training. Dutch renal transplant surgeons rarely discuss SD with their patients with CKD, as they do not feel accountable for it; this accountability was appointed to the nephrologist. Knowledge and education regarding SD were found insufficient in enabling surgeons and for some it reflects in barriers toward discussing SD. Results emphasize that accountability for providing sexual health care to patients with CKD should lie elsewhere; however, surgeons could briefly provide information on sexual health after KTx, so unfulfilled expectations may be prevented.

Lithium rechallenge after renal transplant.

Mrs B is a 65-year-old, married, white woman with long-standing history of bipolar disorder type I who achieved mood stability with chronic lithium treatment. She developed end-stage renal disease, which was suspected to be the result of chronic lithium exposure in the context of medical comorbidity, and subsequently required renal transplantation. Following transplantation and discontinuation of lithium, Mrs B was unable to achieve mood stability with multiple medication trials and required more than 40 medical and psychiatric hospitalizations with eventual transition to skilled nursing care. After much discussion among the psychiatric treatment team, the patient, and her husband, primary care provider, nephrologist, and renal transplant surgeon, the decision was made to restart the patient on lithium given her previous treatment success. The purpose of this case report is to discuss the use of lithium following renal transplantation. In this case, a multidisciplinary approach was used to assist the patient in carefully weighing the risks and benefits of her treatment decisions. The consensus of the patient, her husband, and her providers was that the benefit of mood stabilization outweighed the potential risks of renal toxicity. Although treatment with lithium after renal transplant is not a first-line treatment option, this case illustrates that lithium could be considered in certain cases.

Renal Artery Calcification and Stenosis in Potential Live Kidney Donors: Results of a UK-Wide National Survey of Transplant Surgeons.

Renal artery calcification (RAC) is highly associated with calcification in other vascular beds, independent of traditional risk factors. There is no evidence-based consensus on the suitability for live donor nephrectomy (LDN) in donors with non-flow limiting RAC or renal artery stenosis (RAS). This national survey aimed to explore opinions of all renal transplant surgeons in the UK. Methods: An online survey was distributed to 101 renal transplant surgeons from 23 institutions in the UK. Opinions were sought on donor suitability with unilateral or bilateral RAC or RAS, in the context of anti-hypertensive treatment (0, 1, 2 or 3+ agents) and presence or absence of other vascular disease. Results: The response rate was 66.3%.Table: No Caption available.Conclusions: This national survey has demonstrated that there is a tendency for UK transplant surgeons to consider a donor with RAC potentially suitable for LDN, however opinion varies depending on the number of anti-hypertensive agents, comorbidities and whether both renal arteries are affected. Most respondents consider bilateral RAS a contraindication to LDN, irrespective of comorbidities. Further studies are required to investigate.

Safe vaginal delivery in a renal transplant recipient: A case report.

Here, we aimed to present a case of safe vaginal delivery in a renal transplant recipient and to mention the possible additional risks of caesarean section in such cases. A 40 year-old patient (G4P3), who had undergone renal transplantation 5 years ago, was admitted to our clinic at 39(2/7) weeks of pregnancy. The transplanted kidney at right iliac fossa was sonographically normal except for grade 1 hydronephrosis; the proximity of vascular anastomoses between the transplanted kidney and iliac vessels to the lower segment of the uterus was remarkable. There was no contraindication for vaginal delivery and it was believed that there would be a possible risk of injury to the transplanted kidney with caesarean delivery. The patient delivered a healthy baby weighing 3540 grams. There is a risk of injury to the renovascular and ureter anastomoses in renal transplant recipients during caesarean delivery. Normal vaginal delivery without abdominal compression is the safest method of delivery in these patients. If a situation that can necessitate internal iliac artery ligation or caesarean hysterectomy such as placenta accreata is expected, surgery should be performed in a centre where the renal transplant surgeon can oversee the surgery.

Impact of Surgeon Experience on Complication Rates and Functional Outcomes of 484 Deceased Donor Renal Transplants

Introduction: To determine how postoperative and functional outcomes after deceased donor renal transplantation (DDRT) are related to surgeon experience. Methods: Outcomes of 484 adult DDRT performed by 13 urologic surgeons were retrospectively reviewed. After completion of a staged renal transplant training program under supervision of an attending, the 13 surgeons were either assigned to the inexperienced group (n=8) or the experienced group (n=5). Surgeons in the experienced group had performed more than 30 unsupervised DDRT in a standard fashion with routine ureteral stenting. Between 1988 and 2005, inexperienced surgeons performed 152 DDRT, whereas experienced surgeons performed 332 DDRT. Results: Demographic and perioperative data were comparable between the two groups. Two-year patient and graft survival was 98% and 94.7%, respectively. Early graft loss in 5 recipients was not related to surgeon experience. Delayed graft function occurred in 29% of cases and median 1-year serum-creatinine was 1.48 mg/dl, with no difference between surgeon groups. Postoperative bleeding and lymphocele formation were the most frequent surgical complications with equal distribution between groups. Ureter complications had a significantly higher incidence among inexperienced surgeons (6.6% vs. 2.7%, P = 0.04). Conclusion: We conclude that DDRT performed by inexperienced urologic renal transplant surgeons have acceptable short and long term outcomes.

A study of renal and gonadal vein variations

Abstract Background and aims : The development of the renal veins is a complex process with many possible alternative patterns of formation. Variations of renal veins are usually clinically silent until discovered during venography, operation or autopsy. In the era of renal transplantation, a meticulous knowledge of anatomy and variational patterns of renal vein is mandatory. The present study is aimed at finding out the incidence of variations in the drainage pattern of renal vein and gonadal vein and to correlate its clinical and embryological significance. Materials and methods : Twenty cadavers (twelve males and eight females) of adult age procured from Mahatma Gandhi Medical College and Research Institute, Puducherry were included in the study. Renal and gonadal veins on both sides were dissected and the pattern of termination of the renal and gonadal veins were observed and studied on both sides. Results : Out of twenty cadavers, two male cadavers showed the presence of termination of right testicular vein into right renal vein and both right kidneys showed multiple right renal veins. In the remaining 18 cadavers both renal and gonadal veins terminated in normal pattern. Conclusion: In present study 10% incidence of variation of right testicular vein draining into right renal vein was found, with the associated presence of multiple renal veins. The knowledge of these variations would be of definite help to renal transplant surgeons and clinicians.

2136 IS UROLOGIC SURGICAL TRAINING BENFICIAL IN THE POSTOPERATIVE CARE OF THE RENAL TRANSPLANT PATIENT?

You have accessJournal of UrologyTransplantation & Vascular Surgery: Renal Transplantation, Vascular Surgery I1 Apr 20122136 IS UROLOGIC SURGICAL TRAINING BENFICIAL IN THE POSTOPERATIVE CARE OF THE RENAL TRANSPLANT PATIENT? Hannah Kerr, Antonia Harford, and Michael Davis Hannah KerrHannah Kerr Albuquerque, NM More articles by this author , Antonia HarfordAntonia Harford Albuquerque, NM More articles by this author , and Michael DavisMichael Davis Albuquerque, NM More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.2306AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Historically, urologists have had a dominant role in renal transplantation. However, with the advent of other abdominal organ transplants, this procedure has become the purview of general surgeons. At UNM, renal transplantation is performed by the Division of Urology. We analyzed our experience to ascertain whether renal transplant recipients benefited postoperatively from the surgical expertise of a urologic renal transplant surgeon. METHODS We retrospectively reviewed 172 renal transplants from 2006–2010, looking at operative procedures up to 36 months after transplant that related to the transplant outcome. We compared the procedures that required a urologist to the procedures that any trained renal transplant surgeon could perform. RESULTS 132 of 172 patients (77%) required at least 1 subsequent surgical procedure. 178 procedures were performed. Of these, 144 (81%) were urologic procedures, and 34 (19%) were procedures that any trained renal transplant surgeon could perform. See table. Urologic Procedures Number General Transplant Surgery Procedures Number Cystoscopy/stent removal 119 Removal of PD catheter 15 Native nephrectomy 5 Revision of ureteroneocystotomy 2 TURP/TUIP 4 Seroma/lymphocele drainage 5 Radical orchiectomy 1 Removal of JP drain 2 Ileal conduit stoma revision 1 Transplant nephrectomy 5 Bladder biopsy 1 Wound dehiscence closure 1 Retrograde pyelograms 5 Adrenalectomy 1 Re-stenting 5 Open renal biopsy 3 Deflux injection 2 Dorsal slit 1 Total 144(81%) 34(19%) CONCLUSIONS Our data demonstrates that renal transplant patients benefit from the expertise of a urologist. A number of secondary operations/procedures are performed post-transplant which influence graft outcome. The advantage of having a urologist as the renal transplant surgeon is that care does not have to be coordinated with another specialist. The ultimate benefit is long term continuity of surgical care for these complex patients. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e862-e863 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Hannah Kerr Albuquerque, NM More articles by this author Antonia Harford Albuquerque, NM More articles by this author Michael Davis Albuquerque, NM More articles by this author Expand All Advertisement Advertisement PDF DownloadLoading ...

Impact of surgeon experience on complication rates and functional outcomes of 484 deceased donor renal transplants: a single-centre retrospective study

To determine how postoperative and functional outcomes after deceased donor renal transplantation (DDRT) are related to surgeon experience. The outcomes of 484 adult DDRT performed by 13 urological surgeons were retrospectively reviewed. After completion of a staged renal transplant training programme under supervision of an attending urological transplant surgeon, the 13 surgeons were either assigned to the inexperienced group (n = 8) or the experienced group (n = 5). Surgeons in the experienced group had performed more than 30 unsupervised DDRT in a standard fashion with routine ureteric stenting. Between 1988 and 2005, inexperienced surgeons performed 152 DDRT, whereas experienced surgeons performed 332 DDRT. Patient and graft survival at 2 hyears were 98% and 94.7%, respectively. Early graft loss in five recipients was unrelated to surgeon experience. Delayed graft function occurred in 29% of cases and median 1-year serum-creatinine was 1.48 mg/dL, with no difference between surgeon groups. Postoperative bleeding and lymphocele formation were the most frequent surgical complications, with an equal distribution between groups. Ureteric complications had a significantly higher incidence among inexperienced surgeons (6.6% versus 2.7%; P = 0.04). We conclude that DDRT as performed by inexperienced urological renal transplant surgeons has both acceptable short- and long-term outcomes.

A study of renal and gonadal vein variations

Background and aims : The development of the renal veins is a complex process with many possible alternative patterns of formation.Variations of renal veins are usually clinically silent until discovered during venography, operation or autopsy. In the era of renal transplantation , a meticulous knowledge of anatomy and variational patterns of renal vein is mandatory. The present study is aimed at finding out the incidence of variations in the drainage pattern of renal vein and gonadal vein and to correlate its clinical and embryological significance. Materials and methods : Twenty cadavers (twelve males and eight females) of adult age procured from Mahatma Gandhi Medical College and Research Institute, Puducherry were included in the study. Renal and gonadal veins on both sides were dissected and the pattern of termination of the renal and gonadal veins were observed and studied on both sides. Results : Out of twenty cadavers, two male cadavers showed the presence of termination of right testicular vein into right renal vein and both right kidneys showed multiple right renal veins. In the remaining 18 cadavers both renal and gonadal veins terminated in normal pattern. Conclusion: In present study 10% incidence of variation of right testicular vein draining into right renal vein was found, with the associated presence of multiple renal veins. The knowledge of these variations would be of definite help to renal transplant surgeons and clinicians.

Outcome of renal transplantation with and without intra-operative diuretics

Aims This paper presents an e-survey of current clinical practice of use of intra-operative diuretics during renal transplantation in the United Kingdom and a study to compare outcome of renal transplants carried out with or without intra-operative diuretics in our centre. Methods An e-mail questionnaire to renal transplant surgeons exploring their practice of renal transplantation with or without intra-operative diuretics, the type of a diuretic/s if used and the relevant doses. An observational study comparing the outcome of renal transplant recipients, group no-diuretics (GND, n = 80) carried out from 2004 to 2008 versus group diuretics (GD n = 69) renal transplant recipients who received intra-operative diuretics over a one year period is presented. Outcome measures were incidence of delayed graft function and a comparison of graft survival in both groups. Results Forty surgeons answered from 18 transplant centres with a response rate of 67%. 13 surgeons do not use diuretics. Mannitol is used by 10/40, Furosemide 6/40 and 11 surgeons use a combination of both. In comparative study there was no significant overall difference in one year graft survival of GD versus GND ( N = 65/69, 94% and 75/80, 94% respectively, p = 0.08) and the incidence of delayed graft function was also comparable (16/69, 23% and 21/80, 26% respectively, p = 0.07). The donor characteristics in both groups were comparable. Conclusion The study showed variation in clinical practice on the use of intra-operative diuretics in renal transplantation and it did not demonstrate that the use of diuretics can improve renal graft survival.

Antibody-mediated rejection presenting as allograft hydronephrosis

An 18-year-old boy underwent living-donor renal transplantation. His mother was the donor. The patient was started on tacrolimus (0.1 mg/kg/d), prednisolone (20 mg/d) and azathioprine (2 mg/kg/d), after initial 3 days of I.V. methyl prednisolone (15 mg/kg/d), as immunosuppressive regimen. Six months after transplantation, he presented with fever that had occurred for two days. There was no history of dysuria, altered urine colour, pyuria or edema. Serum creatinine increased from 1.0 mg/dl to 1.9?2.8?3.7 mg/dl over the next 3 days. On the day of admission, serum tacrolimus levels, blood and urine cultures, and search for polyoma virus were ordered. A Doppler ultrasound of the renal allograft artery revealed a resistive index of 0.9 and hydronephrosis, which had not been present on any of the previous ultrasound exams. A CT scan of the abdomen, with an empty urinary bladder, confirmed hydronephrosis of the allograft, with possible pelvic ureteric junction obstruction (Fig. 1). Blood clots, a technically poor ureteral implantation and ureteral are common causes of obstruction in the early post operative phase, whereas periureteral fibrosis, lymphocele and calculi are possible causes in the late post-operative phase. On the same day, the renal transplant surgeon reviewed the operation protocol notes and confirmed that an antireflux procedure, the Lich reimplantation, had indeed been performed. The radionuclide micturition cystography did not reveal vesicoureteral reflux. Ureteric stenosis due to polyoma virus–associated nephropathy (PVAN) was provisionally diagnosed. However, it is known that PVAN typically induces stenosis in the distal rather than the proximal part of the ureter [1, 2]. On day two, the polyoma virus DNA was found to be negative in both urine and blood. Blood and urine cultures were also sterile. Serum tacrolimus levels were found to be 1.8 ng/l. Circulating donor-specific antibodies determination was unfortunately not available in our hospital. The allograft biopsy was done, under ultrasound guidance, and it revealed neutrophils in the capillaries and in the interstitium, diffuse acute tubular injury and C4d positivity in peritubular capillaries. PVAN may be differentiated from acute antibody-mediated rejection (AMR), but not from acute cellular rejection, by the presence of mononuclear and plasma cell infiltration. After renal transplantation, the ureter receives its entire blood supply from the ureteral branch of the renal artery [3]. Acute rejection involves both the kidney and the ureter, and the resulting edema and possible secondary ischaemia may also lead to ureteral obstruction [3]. In an animal model, Hricak et al. [4], found significant alterations in the ureteral dynamics during rejection, as shown by the progressive decrease in electrical activity of the ureteral muscle on electromyography and the reduced G. Swarnalatha R. Ram (&) B. H. Santosh Pai V. Ramesh K. V. Dakshinamurty Nizam’s Institute of Medical Sciences, Punjagutta, Hyderabad 082, India e-mail: ram_5_1999@yahoo.com

Laparoscopic live donor nephrectomy: a visit to the Mayo Clinic

Despite being a career renal transplant surgeon, I enjoy laparoscopic surgery and perform laparoscopic cholecystectomy regularly, which has helped preserve the skills necessary to undertake laparoscopic live donor nephrectomy (LLDN). Ratner et al introduced LLDN and demonstrated its advantages over open donor nephrectomy in terms of post-operative pain, hospital stay and time to return to work.

Evaluation of molecular techniques in prediction and diagnosis of cytomegalovirus disease in immunocompromised patients

OBJECTIVES: To evaluate selected molecular tests in diagnosis and screening of cytomegalovirus (CMV) infection in immunosuppressed patients. DESIGN: Clinical and cost-effectiveness were assessed through a prospective two-stage trial of CMV screening regimes in a routine service setting. Different molecular test results were fed back to clinicians in each stage, plus antigenaemia results. The technical performance of the molecular methods was assessed through an independent masked comparison of each molecular test against the established (antigenaemia) test. Scientists performing a particular test were blind to the other test results for that sample. Diagnostic and therapeutic impact were recorded prospectively for all tests, to include any effect on diagnostic certainty, changes to CMV therapy and any other reported impact on patient management. The cost of each test was estimated under different laboratory conditions. Prospective patients undergoing CMV screening were compared with consecutive historical controls in the same unit. Towards the end of the study, a survey of all UK virology laboratories was undertaken to identify current CMV screening practice and test preferences. In addition, all UK renal transplant surgeons and haematology transplant centres were surveyed in order to identify current clinical practice and perceptions of the benefits of CMV screening. SETTING: Study patients were recruited from University Hospital Wales (UHW), Cardiff. Staff in the Cardiff Public Health Laboratory Service virology laboratory performed the tests. PARTICIPANTS: A consecutive series of transplant patients was recruited to the prospective study over a 42-month period, totalling 98 renal and 140 haematology patients. A consecutive series of historical controls was identified, with 199 renal and 136 haematology patients who underwent transplants in the UHW during the 29 months prior to the prospective CMV screening trial.

Early graft loss: the Cinderella of transplantation.

The loss of a graft in the first few days or weeks of transplantation is a devastating event for the patient and his surgeon. Historically, many early losses were related to hyperacute or aggressive acute rejection, but many centres now find that this is a diminishing cause of graft loss. The role of graft thrombosis has now become a leading cause of such early graft loss. Many centres are now reporting 1-year graft survival rates of the order of 90-95%, and under these conditions are finding that most of the 5-10% lost are thrombosed grafts. The keys to prevention are clearly multifactorial and include careful preparation of the donor, adequate hydration of the recipient, meticulous attention to anatomical and surgical details, the reduction of delayed graft function, and the realization that the non-functioning graft has a high likelihood of being the target of insidious acute allograft rejection. In practical terms, we should ensure that all transplant surgery is done by the most technically capable surgeons, and we should strive to reduce the anastamosis time to below or around 30 min [8]. There is often little justification for anastamosis times in excess of 60 min except for surgical inexperience. Further, there are growing data to suggest that we should no longer be complacent about the apparent length of cold ischaemia that we allow. Perhaps the time has come for renal transplant surgeons to get out of their beds and reduce the maximum cold ischaemia to below 24 h--surely not too onerous a task?(ABSTRACT TRUNCATED AT 250 WORDS)

Rapid progress in kidney transplants for children.

Paediatric renal transplantation has progressed rapidly since the first child received a donor kidney in 1968, with more operations, lower rejection rates and shorter waiting times, according to Geoff Koffman, renal transplant surgeon at Guy's Hospital, London.

Renal transplantation – A clinical handbook

Medical Journal of AustraliaVolume 140, Issue 13 p. 793-793 Department Renal transplantation – A clinical handbook D. Urquhart-Hay, D. Urquhart-Hay Renal Transplant Surgeon The Terrace, Wellington, NZSearch for more papers by this author D. Urquhart-Hay, D. Urquhart-Hay Renal Transplant Surgeon The Terrace, Wellington, NZSearch for more papers by this author First published: 01 June 1984 https://doi.org/10.5694/j.1326-5377.1984.tb132611.xAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume140, Issue13June 1984Pages 793-793 RelatedInformation