Single Allograft Research Articles

Medial Ligament Complex Reconstruction With Allograft Using Less Invasive Onlay Fixation and Suture Tape Augmentation

Injury to the medial complex of the knee may result in persisting valgus and rotatory instability. In combination with concomitant meniscotibial ligament disruption, maldistributed contact forces are placed on the medial compartment, which may result in the progression of osteoarthritis. When facing chronic valgus and/or posteromedial instability, definitive treatment with medial ligament complex reconstruction in combination with additional repair of the meniscotibial ligament when necessary should be done to anatomically restore proper knee biomechanics and kinematics. This technique describes reconstruction of both the superficial medial collateral ligament (sMCL) and posterior oblique ligament with a single allograft, with additional suture tape augmentation used to reinforce the sMCL. Additionally, less invasive onlay fixation is used via a knotless loop mechanism to secure the posterior oblique ligament to its tibial insertion and the sMCL at 2 points along its distal tibial insertion.

Paper 49: Osteochondral Allograft Transplantation for Capitellar Osteochondritis Dissecans: Excellent Patient Reported Outcomes Scores and High Return to Sports

Objectives: Unstable osteochondritis dissecans of the capitellum (OCD-C) is treated surgically, most commonly with loose body removal and marrow stimulation. This treatment has historically been associated with suboptimal return to high-demand upper extremity sports (baseball and gymnastics) and persistent elbow pain. Fresh osteochondral allograft transplantation (OAlloT) is an alternative treatment which restores subchondral bone and articular cartilage without donor site morbidity associated with autograft harvest. The purpose of this study was to evaluate the outcomes of osteochondral allograft transplantation in pediatric patients with unstable OCD-C 10mm or greater in size. Methods: A single-center prospective study was performed of consecutive pediatric patients, less than 19 years of age, with unstable OCD-C 10mm or greater in size treated with primary fresh OCAlloT using pre-cut 10mm, 12mm, or 16mm cores. Imaging, including radiographs and MRI were obtained preoperatively to assess OCD size and characteristics, as well as postoperatively to assess incorporation of the OCA. Patient reported outcome scores (PROs), including sport data, were obtained preoperatively and annually following surgery. Minimum follow-up duration was 2 years. Results: 26 elbows in 24 patients, mean age 13.4 years (11.3 – 17.1 years) met inclusion. The most common primary sport was gymnastics in 11 elbows (42%), baseball/softball in 7 elbows (27%), and cheer in 3 elbow (12%). The majority of patients (88%) played at a competitive level. Median symptom duration prior to presentation was 3 months. The most common presenting symptoms were pain (85%) and mechanical symptoms (81%). Sixteen elbows (62%) presented with a >5° loss of elbow extension compared to the contralateral side. The capitellar physis was open in 23 elbows (88%). OCD location was central in 17 elbows (65%) and far lateral in 9 elbow (35%). Mean MRI size of the OCD was 11 mm in coronal width, 12 mm in sagittal length, and 6 mm in depth. Twelve elbows (48%) had a loose body on MRI. The majority of elbows (22, 85%) were treated with a single allograft plug, while 4 elbows had two allograft plugs transplanted. Median OCA size was 12 mm. There were no infections nor arthrofibrosis. Two elbows (8%) had a secondary surgery, both underwent partial synovectomy and chondroplasty at 14- and 16-months following the primary surgery. Postoperative MRIs were obtained in 15 elbows (58%) and had a mean BOGIE (Boston Osteochondral Graft Incorporation in the Elbow) score of 11, thus documenting a high degree of incorporation. Mean follow-up duration was 40 months (range 25 – 60 months). All patients had preoperative, 1-year, and 2-year PROs (Table 1). 21 elbows (81%) had returned to sports at 1-year postoperatively9, and all but 1 patient had returned to sports by 2 years following surgery. Forty-five percent of gymnasts returned to gymnastics, while the remaining pursued different sports. Five of 6 baseball players (83%) returned to baseball. Conclusions: OCAlloT as a treatment for OCD-C is a procedure associated with low rates of complications, excellent graft incorporation, high elbow function and patient satisfaction, and overall high rates of return to sports at 2-years. Return to sports, particularly among gymnasts was less than 50% in this series, which we attribute to a combination of factors, including loss of training and competition time at a critical time for an elite gymnast as well as physician counseling on alternative sports with less stress on the elbow. Continued patient follow-up is ongoing and will be critical to the assessment of this treatment on the mid- and long-term outcomes in these young athletes. [Figure: see text]

Anterior Cervical Discectomy and Fusion With "Kissing" Allograft Interbodies.

Background: There is recent evidence to suggest that the use of polyetheretherketone (PEEK) interbodies are inherently associated with a higher rate of pseudarthrosis, in particular, at the C5-6 and C6-7 levels. Herein, we describe our technique utilizing two parallel structural allografts or “kissing” allografts, designed to mitigate the risk of pseudarthrosis and subsidence at these levels.Materials and Methods: We retrospectively reviewed all anterior cervical discectomy and fusion (ACDF) procedures with “kissing” for degenerative spine pathology at a single institution between 2018 and 2019 for the C5-6 and C6-7 levels. One-year postoperative flexion/extension cervical X-rays were evaluated for evidence of radiographic pseudarthrosis and subsidence.Results: A total of 28 patients met the study criteria. Solid fusion was achieved in 93%. There were no infections or wound complications. One patient developed postoperative dysphagia that resolved at 3-months post-op. Two patients were found to have clinically asymptomatic radiographic pseudarthrosis that did not warrant intervention. One patient developed a postoperative hematoma that required surgical evacuation.Conclusions: “Kissing” allograft ACDF is a safe and effective method designed to address the intrinsically higher risk of pseudarthrosis at the C5-6 and C6-7 levels. Further prospective studies are warranted to comparatively evaluate this technique against single allograft and PEEK interbodies.

Kidney transplantation with allografts from infant donors-Small organs, big value.

Although infant organ donors remain a rare source of organs for transplantation, technical challenges have resulted in increased rates of complications and inferior graft function. The aim of the present study was to investigate the outcomes of kidneys procured from juvenile and infant donors. We evaluated all kidney transplants from deceased donors<16years of age performed at our center between 01/2008 and 08/2019. We defined three groups based on quartiles of donor body weight: <13kg (infant donors), 13-40kg (juvenile donors), and>40kg (standard criteria donors). Clinical characteristics and outcomes were compared between groups. Ninety-two transplants were included in this study. Out of 92 recipients, there were 32 (34.8%) adult and 60 (65.2%) pediatric patients. All groups demonstrated excellent graft function and survival on both short and long-term follow-up. 1-year, 3-year, and 5-year graft survival rates for the standard criteria donor group were 100%, 95.2%, and 88.4%, respectively, compared with 95.8% for infant and 95% for juvenile donors at all times (P=.79). eGFR at 5years was 98.9±5.5, 74.1±6.2, and 81.6±6.9mL/min/1.73m2 for infant, juvenile, and standard criteria donors, respectively (P<.01). Infant donor allografts can be transplanted with excellent long-term outcomes in both pediatric and adult recipients. Implanting them as single allografts onto pediatric candidates allows for the transplantation of two patients. As such, pediatric recipients should be prioritized for these donor organs.

One-Year MRI Outcomes of Osteochondral Allograft Transplantation of the Knee for Large Chondral Defects: Comparison of Elliptical, Stacked, and Single Allografts

Objectives:Osteochondral allograft transplantation (OCA) is a proven cartilage restoration procedure for patients with large chondral defects. However, elongated condylar lesions pose a challenge for dowel OCA in restoring articular surface congruity. Recently, instrumentation to harvest a single, elliptical allograft has been developed for treating ovoid lesions without requiring an adjacent-plug (stacked or snowman) technique. The purpose of this study was to compare 1-year MRI outcomes of patients treated with elliptical, stacked, or single OCA using the Osteochondral Allograft MRI Scoring System (OCAMRISS) and percent osseous integration.Methods:A retrospective review on patients treated from 2000 to 2018 with OCA for condylar defects of the knee was conducted. Inclusion criteria included those followed prospectively with a MRI at ˜1 year after surgery. OCAMRISS and osseous integration scores (0-25%; 26-50%; 51-75%; 76%-100%) were graded by a musculoskeletal radiologist blinded to the outcomes. Comparisons of demographics and MRI scores were performed with the ANOVA.Results:A total of 57 knees (mean age, 35.8 years; 70% male) met the inclusion criteria and were treated with either elliptical (n=19), stacked (n=19), or single (n=19) OCA. Mean time to post-operative MRI was 10.7, 11.1, and 12.4 months, respectively (p=0.17). There were no significant differences in demographics or number of prior ipsilateral knee surgeries among groups. Defect characteristics were significantly different between groups, where single plugs treated a higher percentage of LFC defects (58%) compared to elliptical and stacked (26%, each) (p=0.02). Total chondral defect area was greatest in the stacked group (5.4 ± 1.3) compared to elliptical (4.6 ± 1.2) and single (4.6 ± 1.4) (p=0.12). Bone, cartilage, ancillary, and total OCAMRISS scores were not significantly different between groups. A trend towards a higher percentage of osseous integration (single>stacked>elliptical) was noted which correlated with less transplanted allograft bone, however, these differences were not significant (p=0.15).Conclusion:One-year OCAMRISS and osseous integration scores did not differ among patients treated with elliptical, stacked, or single OCA. Further investigation is needed to explore potential differences in clinical outcomes and long-term osseous integration between elliptical and stacked OCA for the treatment of elongated condylar defects of the knee.Table 1.Patient Demographics, Intraoperative Data, and OCAMRISS Scores at 1-year Postoperative MRI Elliptical (n = 19) Stacked (n = 19) Single (n = 19) P Value Patient CharacteristicsAge, y37.0 ± 13.937.5 ± 11.133.1 ± 11.80.48Sex (male/female), n14/513/613/60.92Body mass index, kg/m2 25.7 ± 2.826.5 ± 5.025.9 ± 3.20.78No. of prior ipsilateral knee surgeries1.1 ± 1.41.9 ± 2.41.4 ± 0.80.29MRI follow-up, mo10.7 ± 3.911.1 ± 1.912.4 ± 2.20.17Lesion CharacteristicsOCA location, n (%)0.02Medial femoral condyle14 (74)14 (74)8 (42)Lateral femoral condyle5 (26)5 (26)11 (58)Total chondral defect area, cm2 4.6 ± 1.25.4 ± 1.34.6 ± 1.40.12OCAMRISS ScoreCartilage features3.5 ± 1.52.9 ± 1.53.4 ± 2.10.48Bone features3.0 ± 0.72.7 ± 0.72.8 ± 0.60.30Ancillary features3.0 ± 1.12.9 ± 1.02.6 ± 1.10.46Total9.5 ± 2.18.4 ± 2.58.8 ± 3.10.45Osseous Integration Score2.1 ± 1.11.7 ± 0.901.5 ± 0.600.15

Dissemination of a novel organ perfusion technique: ex vivo normothermic perfusion of deceased donor kidneys.

Ex vivo normothermic perfusion (EVNP) technology is a promising means of organ preservation, assessment, and preconditioning prior to kidney transplantation, which has been pioneered by a single group. We describe the challenges of setting up clinical EVNP programs in 2 new centers, as well as early patient outcomes. Governance, training, and logistical pathways are described. In order to demonstrate safety and proficiency in this new technique, early patient outcomes are also described. Patient outcomes included the incidence of primary nonfunction, delayed graft function, graft and patient survival at 1 year. Contralateral kidneys undergoing static cold storage alone were used as a comparator group. Between March 2016 and July 2017, EVNP was performed on 14 kidneys from 12 donors (11 kidneys in center 1, 3 kidneys in center 2). Of the 14 kidneys that underwent EVNP, 12 organs were implanted into 10 recipients. Two pairs of kidneys were implanted as dual grafts and 1 kidney was implanted simultaneously with a pancreas. The remaining 7 kidneys were transplanted as single allografts. Seven pairs of kidneys were available for paired analysis comparing EVNP versus static cold storage. Graft and patient outcomes were comparable between the 2 preservation techniques. The introduction of a clinical EVNP service requires a careful multimodal approach, drawing on the expertise of specialists in transplantation, hematology, and microbiology. Both new clinical EVNP programs demonstrated proficiency and safety when a structured dissemination process was followed.

Do Anatomical Anomalies Affect the Results of Living Donor Kidney Transplantation?

BackgroundMultiple renal artery kidneys still represent a special challenge for surgeons, during both nephrectomy for organ donation and transplantation. Recognition of anatomical conditions with advanced imaging methods is one of the most important elements of the preoperative evaluation process. AimThe purpose of the current study was to assess if anatomical abnormalities affect the outcomes of living kidney donor transplantation procedures. Patients and MethodsA retrospective analysis of 60 living kidney donors and their recipients was performed. Patients were assigned to two groups: pairs with a single allograft vessels (group I) and pairs with any anatomical abnormalities of the transplanted organ (group II). The impact of anatomical abnormalities on initial and long-term outcomes of the transplantation were analyzed. ResultsThe analyzed study group consisted of 60 pairs (35 included in group I and 25 in group II). Immediate graft function was observed in 65.7% vs 64% individuals, recpectively (n.s.). Mean serum creatinine concentration was 1.6, 1.46, and 1.44 mg/mL (group I) vs 1.78, 1.78, and 1.65 mg/mL (group II) at 1, 6, and 12 months posttransplant, respectively (n.s.). Glomerular filtration rate (using the Chronic Kindey Disease Epidemiology Collaboration equation) was estimated at 54.3, 59.9, and 61.0 mL/min/1.73 m2 (group I) vs 59.8, 57.6, and 59.8 mL/min/1.73 m2 (group II) at the same time points, respectively (n.s.). ConclusionsPresence of single renal vessels was not a predictor of immediate graft function in living-donor kidney transplantation. Transplantation outcomes for kidneys with anatomical anomalies did not differ when compared to organs with typical anatomy. Multiple renal arteries did not impact initial graft function if precise surgical technique and proper preoperative diagnostics were provided.

Graft survival of en bloc versus single kidney transplantation from small pediatric donors: a meta-analysis with trial sequential analysis

Background: Although renal transplantation from small pediatric donors can relieve the pressure of the shortage of organs, the graft survival differs among different studies. We conducted this meta-analysis to evaluate the prognosis of patients receiving en bloc versus single allograft from small pediatric donors. Methods: A systematic search in PubMed, Embase, and web of science was performed to identify relevant studies. Individual hazard ratios (HRs) and corresponding 95% confidence intervals (CIs) were combined to calculate the prognostic value. A cumulative meta-analysis based on publication year was also conducted. Trial sequential analysis (TSA) was performed to estimate the quantity of the evidence. Results: Seven studies consisting of 4,284 cases were included, and risk estimates from six of these studies were finally pooled for quantitative analysis. We found that compared with single kidney transplantation from small pediatric donors, en bloc kidney transplant suggested a better graft outcome of recipients (HR=0.57, 95% CI: 0.49–0.67). The findings in the current study were based on sufficient evidence by TSA. Furthermore, no evidence of publication bias in the meta-analysis was noted. Conclusions: En bloc kidney transplantation from small pediatric donors was significantly associated with a superior graft survival when compared with single kidney transplant.

Clinical Outcomes of Patellofemoral Osteochondral Allograft Transplantation: A Prospective Analysis

Objectives:The use of osteochondral allograft transplantation (OAG) for chondral defects of the knee is increasing, particularly for defects involving the femoral condyles. The purpose of this study was to prospectively evaluate the clinical outcomes for patients undergoing patellofemoral OAG for symptomatic chondral lesions.Methods:Consecutive patients undergoing OAG for full-thickness patella and trochlear lesions between 2007 and 2014 by two senior surgeons were analyzed. Pre- and post-operative patient reported outcomes scores were collected, with a minimum 21-month follow-up. Patient demographics, preoperative clinical data including information on prior ipsilateral knee surgeries, and intraoperative details were analyzed for all patients. Complications, reoperations, and conversion to total knee or patellofemoral arthroplasty were recorded. Statistical analysis was conducted with student’s T-tests, with P<0.05 considered significant.Results:A total of 14 patients (10 females, 4 males) with an average age of 32.8±7.5 years (range, 20-48) were identified for inclusion with an average follow-up of 3.6±1.8 years (range, 1.8-7.8) (Table 1). The average body mass index was 27.5±6.9 kg/m2. Patients experienced an average 5.4±4.2 years of symptoms prior to OAG and 100% of patients had undergone previous ipsilateral knee surgery with an average 4.1±3.5 prior procedures before undergoing patellofemoral OAG. The average defect size on the patella was 855mm2 while that on the trochlea was 322mm2. At the time of OAG, 6 (43%) patients received trochlear grafts, 6 (43%) received patellar grafts, and 2 (14%) received bipolar grafts. Nine patients (64%) received a single allograft, 3 (21%) received 2 allografts to 2 separate lesions, and 2 (14%) received grafts to 4 separate lesions. At final follow-up, there were significant improvements in Lysholm, IKDC, KOOS, WOMAC, and SF-12 Physical outcomes scores; no significant improvements were found in the SF-12 Mental subscale (Figure 1). Two patients (both female, ages 27 and 41) were considered failures as they had converted to knee arthroplasty at an average 2.7 years following OAG. Both of these patients had received allografts to the patella with lesion sizes of 506mm2 and 1800mm2, respectively.Conclusion:Osteochondral allograft transplantation of the patellofemoral joint can be considered a viable restoration procedure for patients with symptomatic chondral lesions to the trochlea and patella. At an average follow-up of 3.6 years, the majority of patients will experience significant improvements in nearly all outcomes scores, with an arthroplasty conversion rate of 14%. Additional information on this difficult-to-treat patient population, including a better understanding of risk factors for failure, prognostic factors for success, and long-term outcomes, is needed.Table 1Patient informationCaseBody Mass Index (kg/m2)Symptom Duration(yrs.)History of Failed Prior Articular Cartilage ProcedureType of Previous Cartilage Procedure# OA GraftsLocation of GraftsLesion Area (mm)Failed to TKA/PFATime to Failure (Yrs.)1 (36yo M)33.225NoN/A2Trochlea, MFC400, 225NoN/A2 (27yo M)27.123YesACI1Patella324NoN/A3 (48yo F)23.402No1Trochlea400, 225NoN/A4 (24yo M)27.609No4Trochlea, MFC (x2), LFC625, 324, 225, 625NoN/A5 (34yo M)28.322YesMFX1Trochlea/MFC Junction225NoN/A6 (24yo F)19.583.5Yes1Trochlea225NoN/A7 (30yo F)26.623No2Trochlea, MFC324, 225NoN/A8 (34yo F)33.61YesMFX4patella, trochlea, MFC x21500,254, 254, 201NoN/A9 (41yo F)20.810No1Patella506Yes2.910 (27yo F)42.62.5YesTruFit Plug, DeNovo1Patella1800Yes2.411 (37yo F)35.72YesDeNovo1Patella988NoN/A12 (33yo F)17.311YesOA Graft2Patella, Trochlea375, 300NoN/A13 (20yo F)25.16YesDeNovo, ACI1Patella975NoN/A14 (38yo F)24.415No1Patella375NoN/A

Reconstruction of anterior cruciate ligament of knee joint with single bundle allograft under arthroscopic

Objective To introduce the treatment efficacy of using allograft muscle ligament anatomical to rebuild anterior cruciate ligament(ACL) of knee joint under the arthroscopy. Methods Sixty-two cases patients with ACL rupture in anterior cruciate ligament reconstruction under arthroscopy.Allograft ligaments were used as graft, a bone tunnel was established in the proximal tibia and distal femur, and the graft was fixed by the extrusion screw.After the operation, the knee joint was fixed for 12 weeks, and the subjective evaluation was carried out according to the Lysholm and Larson knee score standards; in order to assess the stability of the ligament and the functional recovery of the knee joint, objective evaluation was carried out according to Lachman test in patients. Results The preoperative average Lysholm scale was (43.1±2.1) points, the final average score of 2 years after the reconstruction of the ligament was (91.0 + 2.3) points, there was significant difference(t=3.460, P=0.001). The preoperative average Larson scale was (41.0±2.9) points, the final average score of 2 years after the reconstruction of the ligament was (90.1±3.5) points, there was significant difference(t=3.232, P=0.001). Lachman test results were negative in 62 patients at the end of the review.No serious postoperative complications occurred, no knee infection, deep vein thrombosis and stiffness.All the patients can be completely straight 1 year after operation, knees up to 120 degrees.All patients were satisfied with the function at the end of the follow-up, no joint instability, no re-rupture occurred during the follow-up period. Conclusion Using the allogeneic single beam anatomy of anterior cruciate ligament reconstruction under arthroscopy can obtain satisfactory clinical efficacy. Key words: Arthroscopy; Anterior cruciate ligament; Allograft; Single beam; The anatomy of the reconstruction

Graft Arterial Stenosis in Kidney En Bloc Grafts From Very Small Pediatric Donors: Incidence, Timing, and Role of Ultrasound in Screening

In previous studies with different donor selection criteria and noncontemporary surgical techniques, graft arterial stenosis (GAS) has been reported to occur more frequently in adult recipients of pediatric en bloc renal allografts (EBKT) as compared to single adult donor allografts. The purpose of our study was to evaluate the incidence of GAS within our EBKT recipient population and to evaluate clinical and imaging features of those cases with GAS. In a retrospective cohort study, we analyzed 182 EBKT performed at a single institution. We identified cases of suspected GAS based on clinical factors, lab results, and noninvasive imaging. Diagnosis of GAS was confirmed by digital subtraction angiography. Two EBKT recipients (1.1% of 182) had angiographically confirmed GAS at 2.5 and 4.5 months after transplant. In both cases, the stenoses were short segment within the proximal (perianastomotic) donor aorta, color Doppler ultrasound demonstrated peak systolic velocities of >400 cm/s, and poststenotic parvus tardus waveforms were present. Both patients underwent angioplasty and demonstrated postintervention improvement in renal function and blood pressure. Restenosis did not occur during follow up. In conclusion, recipients of EBKT have a low incidence of GAS, similar to the lowest reported for adult single allografts.

Single allograft medial collateral ligament and posterior oblique ligament reconstruction: a technique to improve valgus and rotational stability

We present a novel and simple method for single hamstring allograft MCL and PMC reconstruction, which can improve both joint valgus and external rotational stability and maximize utilization of allograft. All patients received arthroscopic evaluation through inferomedial and inferolateral knee incisions to ascertain whether there were intra-articular injuries. An 8-cm-length longitudinal incision was made from 1 cm above adductor tubercle to 5-cm proximal medial tibia joint line. The anterior tibia insertion was defined as 15 mm lateral from the medial tibia edge and 45 mm below the medial tibia joint line. The posterior tibia insertion was defined as 15 mm lateral from the medial tibia edge and 20 mm below the medial tibia joint line. A 5- or 6-mm reamer was used to drill the tibia tunnel along with guide pin, and a 6 or 7 mm drill was used to drill the femur tunnel to a depth of 25 or 30 mm until the proximal adductor tubercle. The allograft was harvested from tibia and placed into the tunnel and fixed with absorbable interference screw. All patients performed active rehabilitation exercises after the operation periodically.

Kidney grafts from donors ≤5 yr of age: Single kidney transplantation for pediatric recipients or en bloc transplantation for adults?

Kidneys from donors ≤5 yr of age represent a controversial issue. The purpose of this study was to compare the transplant outcomes as single and single/en bloc grafts into pediatric and adult KT recipients, respectively. All recipients of kidneys from donors ≤5 yr old transplanted at our institution from 3/2003 to 12/2010 were evaluated, and corresponding data were analyzed. There were 11 pediatric and 14 adult recipients. Median donor age and body weight were 38 months and 14 kg, respectively. PNF, n = 2 and DGF, n = 1 were observed only among adult recipients. Five-yr graft survival was 100% for children and 86% for adults. There were no significant differences in graft and patient survival, PNF, DGF, acute rejection, or postoperative complications among children/single (n = 10), adults/en bloc (n = 10), and adults/single (n = 4) KT. Major complications were documented in six adult recipients and one pediatric recipient after en bloc KT. Pediatric recipients showed significantly higher GFR during the first post-transplant year. Kidneys from donors ≤5 yr of age have at least as good outcomes as when transplanted as single allografts into children. Although the study-volume is small, it seems that children benefit from a pediatric-oriented allocation policy.

Assessment of Epiphyseal Plate Allograft Viability and Function After Ex Vivo Storage in University of Wisconsin Solution

Compromised epiphyseal plate function can result in limb deformities. Microvascular transplantation of an epiphyseal plate allograft is a potentially effective approach to reestablish longitudinal limb growth. For this procedure to become clinically useful, the technique for temporary ex vivo storage of allografts must be reliable. The goal of this study was to determine a time frame for which proximal tibial epiphyseal plate allografts could be stored in University of Wisconsin Preservation Solution (UWPS) and remain functional in vivo after microvascular transplantation. Proximal tibial epiphyseal plate allografts from skeletally immature female New Zealand White rabbits (10 to 12 wk of age) were used. Allografts (isolated on the popliteal arteriovenous pedicle) were stored ex vivo in cold UWPS for periods of up to 21 days. Chondrocyte viability, phenotype, and extracellular matrix composition of growth plate cartilage was assessed. Microvascular transplantations of nonstored or prestored (3 d) allografts were performed and analysis of bromodeoxyuridine and calcein incorporation was done to determine chondrocyte proliferation and new bone growth, respectively. In vitro analysis showed that, compared with control tissue, epiphyseal plate chondrocyte viability (P>0.05), organization, and collagen extracellular matrix was preserved up to 4 days in cold UWPS. Microvascular transplantation of nonstored epiphyseal plate allografts was successful. Despite care being taken to ensure vascular patency during the microvascular procedure, transplantation of prestored allografts failed due to absent flow in the larger vessels and in the allograft based upon the visualization of organized thrombus within the vascular pedicle, and absent flow within the composite graft itself. However, growth plate viability and function was detected in a peripheral region of a single allograft where partial blood flow had been maintained during the transplantation period. Ex vivo storage in cold UWPS for 3 days maintains growth plate chondrocyte viability and function in vivo. However, future studies must be directed toward investigating the direct effect of ex vivo storage on the integrity and function of the vascular pedicles.

Successful outcome of paediatricen blockidney transplantation from the youngest donation-after-cardiac-death donor in the United Kingdom

We wish to highlight the successful outcome of en bloc kidney transplantation from the youngest donation after cardiac death (DCD) donor into a paediatric recipient in the United Kingdom. The donor (Maastricht Category III) was 2 years old and 12 kg male subject who died of drowning. Only kidneys were accepted for transplantation for a single recipient and were retrieved en bloc with aorta and vena cava. The recipient was a 15-year-old female subject weighing 40 kg, with end-stage renal failure secondary to familial nephritis and had a previous failed transplant caused by renal vein thrombosis. The en bloc allograft was implanted extraperitoneally in the left iliac fossa using a modification of the previously described Newcastle technique for graft implantation [1]. In their technique, the infrarenal portions of the aorta and cava are transposed to a ‘suprarenal’ position to facilitate lowering of kidneys in the pelvis and implantation of ureters of shorter length. However, as the liver was not retrieved in this case, and also as sufficient suprarenal aorta and inferior vena cava (IVC) were provided, vascular reconstruction was not required. At the back table, the aorta and IVC below the renal vessels, together with the origins of the coeliac and superior mesenteric arteries were over-sewn using 6.0 Prolene suture (Fig. 1). Graft preparation utilising a modified Newcastle technique [1]. Exclusion of the infra renal portion of the aorta and vena cava (dashed arrow) and origins of coeliac trunk and superior mesenteric artery (arrows). Graft implantation was to the external iliac vein and artery using continuous 6.0 Prolene suture. The ureters were implanted separately onto the bladder using ‘on-lay’ technique over pigtail stent using PDS sutures (Fig. 2). The first warm-, cold- and second ischeamia times were 11 min, 11.5 h and 32 min respectively. Primary function was observed and postoperative recovery was uneventful. Immunosuppression consisted of tacrolimus, azathioprine and prednisolone. The patient remains well to date and 3-month creatinine was 84 μmol/l (0.95 mg/dl). Graft implantation in the left iliac fossa. Arterial and venous anastomosis to external iliac vessels and separate ureteric anastomosis to bladder. The practice of transplanting paediatric en bloc kidneys is not universally accepted. Reports of increased organ discard rates, technical complications, graft thrombosis, rejection, decreased functional nephron reserve, and claims of suboptimal patient and graft survival have all contributed to the reluctance of many centres to transplant kidneys from the very young donors [2-4]. Vascular damage is not uncommon in these small kidneys and a leading cause for discard, particularly within a multi-organ procurement setting [5]. Furthermore, variable periods of first warm ischaemia, higher incidence of delayed graft function and impact on long-term graft survival associated with DCD donors mean that utilization of this source may be questioned. More recently, reports of successful outcomes of paediatric en bloc kidney transplantation into adult recipients has provided evidence of its efficacy [6-8] but its role in paediatric recipients and in the DCD setting remains controversial and little reported. Since 1988, there have been only 39 paediatric heart-beating en bloc donor kidney transplants in the United Kingdom and all into adult recipients. The mean donor- and recipient ages for heart-beating en bloc donors were 3 (range 0–6 years) and 37 (range 15–72 years) years respectively [UK Transplant (September 2008), personal communication]. The decision on transplanting paediatric kidneys either en bloc or as a single allograft at extremes of donor age remains difficult and is at best arbitrary. Borboroglu et al. [9] suggest separation of paediatric kidneys when the kidney is >6 cm in length and the donor weight is > 14 kg. In the United Kingdom, donors of age less than 5 years and/or less than 15 kg are retrieved and offered en bloc for transplantation. Our case is particularly remarkable as it attempts to expand the boundaries of donor and recipient criteria in renal transplantation. Not only is this the first reported case DCD en bloc kidneys into a paediatric recipient, it is also from the youngest DCD donor in the United Kingdom. To our knowledge, only Saito et al. [10] have reported successful outcome in paediatric recipients. We believe paediatric donor- and recipient criteria can be expanded further to increase the number of transplants. Although technically challenging, a careful assessment of the donor and potential recipient and measures to avoid prolonged warm and cold ischeamia can result in successful outcomes from paediatric en bloc DCD donors into paediatric recipients.

Transplantation of adult recipients by single cadaveric kidneys from pediatric donors weighing &lt;=25 kg can be a reliable option

The evidence in favor of transplanting single allografts from cadaveric pediatric donors into adult recipients is equivocal. This study was performed to assess the outcome of transplantation of single kidneys from pediatric donors weighing < 25 kg. Thirty-five adults transplanted by renal allografts from pediatric donors weighing < 25 kg were compared with 30 matched recipients of kidneys from adult donors. Donors in study group were aged 4.2 +/- 2.1 years weighing 16.0 +/- 5.3 kg. In the study group, surgical complications occurred in five of 35 patients, in the control group four of 30. Serum creatinine reached nadir in 47.5 days in study group versus 30 days in controls (P < 0.01). Serum creatinine at 1 and 3 years were comparable in both groups. A 38.9% had proteinuria at 1 year in the study group compared with 22.7% in controls (P = 0.36). One-year graft survival was 91.7% in the study group versus 92.8% for controls. The surgical complications and graft survival in the study group was comparable with that of controls. The incidence of proteinuria may be more frequent, but does not appear to impact graft function. The use of single, as compared with paired, pediatric donor kidneys would allow more patients to be transplanted with equivalent results.

Urgent Contralateral Pneumonectomy After Single Lung Transplantation for Lymphangioleiomyomatosis

Left single lung transplantation in a 33-year-old woman affected by end-stage lymphangioleiomyomatosis was complicated by spontaneous and diffuse bleeding from the right lung at the end of the procedure. The right lung was completely deteriorated and the only option to stop the bleeding was a right pneumonectomy. At 14 months after transplantation, the single allograft showed good lung function with acceptable volumes. Single lung transplant and contralateral pneumonectomy can be considered a safe procedure in case of complications related to native lung either in case of lymphangioleiomyomatosis than for other lung diseases (emphysema, cystic fibrosis).

Synthesis of New and Memory HLA Antibodies From Acute and Chronic Rejections Versus Pregnancies and Blood Transfusions

Background This study compared HLA antibody (abs) production following acute (AR) and chronic (CR) rejection with HLA abs production following blood transfusions (TF) or pregnancies (P) among kidney and kidney pancreas transplant candidates. Methods Serum samples from 145 patients were screened for anti-HLA abs by flow cytometry using beads coated with purified HLA molecules. Among these patients, nine had lost their graft due to AR; 13, CR; six had been immunized by a single P; 20 by no more than two TF; 28 had no documented immunization; and 69 had multiple immunizations. A Fisher exact test was used for the statistical analysis. Results Neither a single P nor a couple of TF by themselves immunized primary transplant recipients ( P = .17, and P = .42, respectively). However, multiple P and TF together provided a potent immunogenic stimulus ( P = .00001). In contrast, a single allograft loss induced a strong anti-HLA response ( P = 1.03 × 10 −8). Following AR, anti-class I and II abs ( P = .001), and following CR, anti-class II abs developed ( P = .03). Waitlisted female candidates had significantly high PRA values than men ( P = .00005), possibly because women had received significantly more immunizations than men ( P = 4.0 × 10 −10). Summary Patients are likely to produce both class I and II HLA abs following AR and only class II abs following CR. A couple of TF or a P may not be immunogenic; however, together they have great potential to sensitize female candidates. Perhaps that is why waitlisted women are far more immunized than waitlisted men.

SYNTHESIS OF NEW AND MEMORY HLA ANTIBODIES FROM ACUTE AND CHRONIC REJECTIONS VERSUS PREGNANCIES AND BLOOD TRANSFUSIONS

Abstract Background This study compared HLA antibody (abs) production following acute (AR) and chronic (CR) rejection with HLA abs production following blood transfusions (TF) or pregnancies (P) among kidney and kidney pancreas transplant candidates. Methods Serum samples from 145 patients were screened for anti-HLA abs by flow cytometry using beads coated with purified HLA molecules. Among these patients, nine had lost their graft due to AR; 13, CR; six had been immunized by a single P; 20 by no more than two TF; 28 had no documented immunization; and 69 had multiple immunizations. A Fisher exact test was used for the statistical analysis. Results Neither a single P nor a couple of TF by themselves immunized primary transplant recipients ( P = .17, and P = .42, respectively). However, multiple P and TF together provided a potent immunogenic stimulus ( P = .00001). In contrast, a single allograft loss induced a strong anti-HLA response ( P = 1.03 × 10 −8 ). Following AR, anti-class I and II abs ( P = .001), and following CR, anti-class II abs developed ( P = .03). Waitlisted female candidates had significantly high PRA values than men ( P = .00005), possibly because women had received significantly more immunizations than men ( P = 4.0 × 10 −10 ). Summary Patients are likely to produce both class I and II HLA abs following AR and only class II abs following CR. A couple of TF or a P may not be immunogenic; however, together they have great potential to sensitize female candidates. Perhaps that is why waitlisted women are far more immunized than waitlisted men.

Dual Transplant of Marginal Kidneys

Double transplantation is one possible answer to the shortage of donor organs. While each donor kidney would be unsuitable when considered as a single allograft, use of both kidneys should provide sufficient nephron mass for effective glomerular filtration. This is the first Swiss report of a dual adult transplant of marginal kidneys in a 46-year-old man, who was transplanted for the fourth time. Follow-up at 6 months is excellent without acute rejection. Recent analysis of dual marginal versus single ideal transplant outcomes, found a comparable 1-yr graft survival in both of the procedures. Long term results are still lacking and guidelines to decide between single, double or no transplantation are emerging.