Does delayed graft function in the first kidney transplant influence graft outcome in a subsequent transplant?

Background

In kidney transplantation, delayed graft function (DGF) portends adverse graft and patient outcomes. It is unclear whether DGF in the first kidney transplant would adversely impact the outcome of a subsequent transplant.

Methods

Utilizing data from the Organ Procurement and Transplant Network, we identified patients ≥ 18 years of age who underwent at least two deceased donor kidney transplantation (DDKT) between 1987 and 2010. Patients were then divided into two groups based on whether or not they developed DGF in the first transplant (1st TXP DGF group and 1st TXP no-DGF group). Unadjusted and adjusted graft survivals (Cox regression) between the groups were compared.

Results

A total of 10,628 patients were identified who received more than one DDKT (3672 patients in the 1st TXP DGF group and 6956 patients in the 1st TXP no-DGF group). A higher incidence of DGF was observed with the second transplant in patients who had DGF in the first transplant (34% vs 26%, P = .001). Unadjusted graft survival for the second transplant was superior in the 1st TXP no-DGF group (P = .002). After correction for confounding variables, DGF in the first transplant did not have significant adverse impact on the graft survival of the second transplant (hazard ratio 1.2 with 95% confidence interval 0.96–1.09, P = .44).

Conclusions

In patients undergoing more than one DDKT, DGF in the first transplant is associated with higher incidence of DGF in the subsequent transplant but did not have independent adverse influence on the outcome of that graft.     

Technical failure of the pancreas after SPK transplant: are these patients good candidates for later pancreas retransplant?

Abstract:  Technical failure of the pancreas graft after a simultaneous pancreas–kidney (SPK) transplant is not uncommon, affecting roughly 10% of SPK recipients. These patients often recover with good kidney function, but have persistent issues related to their diabetes. The aim of this study was to determine if these patients were good candidates for a later pancreas retransplant. Outcomes were compared between 21 PASPK (pancreas after SPK) recipients and 361 recipients of a primary pancreas after kidney (PAK) transplant. Except for kidney graft source, there was no significant difference in the demographic characteristics between these two groups. In general, early surgical complications were more common in PASPK than PAK recipients (47.6% vs. 35.5%, p = 0.15), although the difference was not statistically significant. The incidence of acute rejection was no different between these two groups (28% vs. 33%, p = NS). At three yr post-transplant, patient and pancreas graft survival rates were also no different between the two groups (p = NS). The most common cause for graft loss in both groups was acute or chronic rejection. In conclusion, pancreas retransplant is a viable option for SPK recipients experiencing early technical failure of the pancreas graft. These recipients are not at higher immunologic risk vs. primary PAK recipients.     

Do inherited hypercoagulable states play a role in thrombotic events affecting kidney/pancreas transplant recipients?

BACKGROUND: Pancreas graft thrombosis remains the leading non-immunologic cause of graft loss after pancreas transplantation. We studied the role of hypercoagulable states (HCS) in pancreas graft thrombosis (pthx). METHODS: Between January 1, 1994, and January 1, 2003, 131 pancreas transplant recipients experienced a pthx (n = 67) or other thrombotic events. Fifty-six recipients consented to have their blood drawn and tested for the HCS. These results were compared with a control group of pancreas transplant recipients who did not experience a thrombotic event. Fisher's exact test was used to compare the groups. RESULTS: We found 18% of the recipients with pancreas thrombosis to have a HCS. Factor V Leiden (FVL) was found in 15% vs. 4% in the control group (p = ns) vs. 3-5% in the general white population. We found 3% of the pancreas thrombosis patients to have a prothrombin gene mutation (PGM) vs. 0% in the control group (p = ns) vs. 1-2% in the general white population. CONCLUSIONS: Of pancreas transplant recipients with thrombosis, 18% had one or more of the most common factors associated with a HCS (FVL or PGM). This can be compared with 4% in a control group and 4-7% in the general white population, respectively. Although the differences are not statistically significant due to small numbers, we feel that the findings may be clinically relevant. While this is only a pilot study, it may be reasonable to screen select pancreas transplant candidates for HCS, especially FVL and PGM, until more data become available.     

Persistent pilonidal disease: What to do when your initial surgery fails?

The crude rate of persistent or recurrent disease following surgical interventions for pilonidal disease correlates with the duration of follow-up. Furthermore, patient and disease related factors, body habitus, and the choice of surgical technique impact both short and long-term outcomes. Despite modern advances in surgical care, persistent and recurrent disease remain a challenge to the surgeon and the patient. Currently there is no standard of care or consensus as to the choice of operation for either primary, persistent, or recurrent disease. The selection of an operation for an individual patient is often determined by the surgeon's training background, personal experience, and own biases. A variety of techniques have been described to treat pilonidal disease ranging from simple minimally invasive procedures to operations entailing wide excision with primary closure, flap reconstruction, or wound management by secondary healing. In this article we share our perspective and approach to patients with persistent disease following failed intervention.     

De novo C1q nephropathy in the renal allograft of a kidney pancreas transplant recipient: BK virus-induced nephropathy?

C1q nephropathy is a distinct entity characterized by extensive and dominant C1q mesangial deposition with associated steroid resistant proteinuria in the absence of systemic lupus erythematosus. Several morphological patterns ranging from very subtle glomerular alterations to focal/segmental glomerulosclerosis and mesangial proliferative changes have been described. Interstitial nephritis secondary to BK polyomavirus is a recently recognized complication in kidney transplant recipients. It may be associated with a tubulitis-like picture, mimicking sometimes acute tubular rejection. We report the case of a kidney pancreas transplant recipient who developed de novo C1q nephropathy, in the setting of BK polyomaviral interstitial nephritis. He presented with renal allograft dysfunction and a kidney biopsy was performed. It was interpreted as acute cellular rejection. C1q deposits were detected by immunofluorescence studies and electron microscopy. The patient did not respond clinically to appropriate anti-rejection treatment and a second renal biopsy was performed. The possibility of an interstitial nephritis secondary to BK polyomavirus mimicking rejection was suggested. Special immunohistochemical and blood/urine PCR studies for BK virus were performed, confirming the diagnosis of BK virus tubulonterstitial nephritis with a persistent, probable BK virus induced C1q nephropathy.     

What happens to the parietal cell following truncal vagotomy?

The mechanism of gastric acid reduction following vagotomy is still unclear: does this reduction result from a decrease in parietal cell mass, or is the reduction just functional? In an attempt to settle the question, we used a litter of puppies, in which rapid multiplication of parietal cells takes place. We performed truncal vagotomy (histologically proven) on 4 puppies, using 3 puppies as a control group. Open gastric biopsies were taken every month from birth uncil 12 months of age. Parietal cells were counted and correlated with age. We found a significant reduction in the parietal cell mass in the vagotomized group during 4 months after delivery. The possible mechanisms explaining this phenomenon, as well as assumed clinical correlation, are discussed.     

What happens to the lost gallstone during laparoscopic cholecystectomy?

Iatrogenic gallbladder perforation with resultant spillage of bile and gallstones is common during laparoscopic cholecystectomy. Although it's assumed to be harmless, several complications may occur as a result of spillage. We present a 57-year-old woman with localized abdominal pain in the upper abdomen, jaundice, and itching because of retained stones in both common bile duct (CBD) and the abdominal cavity, who had undergone laparscopic cholecystectomy three years previously. After reoperation, stones in the CBD were removed after CBD exploration and a T-tube was inserted. A mass (8 x 5 cm) located in the gastrocolic omentum, which was not reported on imaging studies, was found coincidentally and was totally excised. Investigation of the mass resulted in the discovery of eight gallstones located in the abcess-like central cavity, which was surrounded by fibrous tissue. The patient had an uneventful recovery. Despite the unaffected long-term sequelae, any patients with gallbladder perforations and spillage should not be considered for extension of antibiotic prophylaxis to avoid early complications. Whenever gallstones are lost in the abdominal cavity, every effort should be made to find and remove them to prevent late complications.     

Parathyroid resistance to FGF23 in kidney transplant recipients: back to the past or ahead to the future?

Fibroblast growth factor 23 (FGF23) modulates the metabolism of minerals and vitamin D. In chronic kidney disease (CKD), this process is disturbed owing to decreased parathyroid expression of FGF23's receptor complex Klotho-FGF receptor 1. In this issue, Krajisnik and colleagues demonstrate that similar alterations occur in parathyroid glands from kidney transplant recipients in association with a decline in allograft function. Is it possible that these data can be extrapolated to general early-stage CKD patients?     

Does pretransplant obesity affect the outcome in kidney transplant recipients?

The effect of obesity on renal transplant outcome remains unclear due to conflicting published studies. The purpose of this study was to assess whether obesity affects the outcome in renal transplant patients. METHODS: We retrospectively analyzed 33 obese (BMI >30; mean = 34.1 +/- 3.68; group I) and 35 nonobese (BMI < or = 30; mean = 23.6 +/- 3.18; group II) renal transplants performed at our center between March 1999 to December 2002. These two groups were well matched with respect to age, sex, donor source, hypertension, diabetes, ischemic heart disease, hyperlipidemia, native kidney disease (PCKD, 6 vs 4; diabetic, 5 vs 4; glomerulonephritis, 6 vs 7; FSGS, 2 vs 2 and IgA, 2 vs 7), HLA mismatch and immunosuppressants medications (Neoral, 21 vs 25; tacrolimus, 11 vs 10; Cellcept, 28 vs 31; Prednisone, 33 vs 35; ATG, 7 vs 8; Basiliximab, 14 vs 13 and Rapamycin, 5 vs 2, groups I and II, respectively). Follow-up was from 7 months to 4.4 years. RESULTS: Significant differences were noted in operating time, wound infection, perinephric hematoma, lymphocele, and number of hospital days. There were no significant differences between the two groups in the incidence of wound dehiscence, deep vein thrombosis, pulmonary embolism, atelectasis, urine leak, delayed graft function, acute rejection rate, and the following posttransplant variables: diabetes mellitus, myocardial infarction, hyperlipidemia, hypertension, and incisional hernia. We conclude that obesity significantly increases operating time, wound complications, and hospitalizations.     

Cochlear implants in children: What constitutes a complication?

The surgeon must ultimately accept the responsibility for any complications that occur as the result of a cochlear implant. Listening to the cochlear implant team members and responding to their needs may enhance the child’s progress. Surgical complications, (i.e., skinflap problems, infection, and facial paralysis) are indeed infrequent, but nonsurgical problems are not. Surgical and nonsurgical experiences were reviewed in 55 children. Ages ranged from 23 months to 18 years at the time of cochlear implantation, which occurred from 1984 to 1995. There were no surgical complications. However, the most common surgical obstacle was ossification, which was present in 40% and undetected by computed tomographic scanning in 16.3% of children. Ossification occurred at the round window and scala tympani in 32.7% and involved the cochlea more extensively in 7.3% of children. In only one child was the cochlea entirely ossified. There were, however, many nonsurgical problems that were viewed as complications in patient management. The single most important complication was device failure. This occurred in 10.9% (5/46) of children with the Cochlear Corporation multichannel implant. Head banging and other temper tantrums, parental interference with rehabilitation, socioeconomic factors, poor compliance by the family unit, equipment problems, educational deficiencies, and impatience with habilitative training were some of the other problems. (Otolaryngol Head Neck Surg 1997;117:243-7.)     

Why do some diabetic patients on the kidney transplant waiting list not receive a transplant?

The waiting list (WL) history of 405 diabetic patients placed on the kidney transplantation WL for the years 1993–2000 was examined. By 31 December 2000, 295 (73 %) patients had received a transplant. Of the remaining 110 patients 53 (13 %) were still on the WL; 27 of these were temporarily withdrawn, i.e. non-active, 46 others (11 %) had died and 11 (3 %) had been permanently removed. Patient follow-up continued until the end of 2002. Although the mean total time on the WL of the non-transplanted was twice that of the transplanted patients there were no significant differences in the mean active times on the WL. The mean cumulative withdrawal time of the transplanted and those on the active WL was less than 10 % of their total time on the list, but for the patients who had died or were withdrawn on 31 December 2000 it exceeded 50 %, usually because of diabetic complications. The 5-year survival of the transplanted patients was greatly superior to that of the non-transplanted, as expected. However, the better survival of the transplanted patients is not necessarily proof of a better treatment modality but rather a consequence of the exclusion from transplantation of patients suffering from diabetic complications. It is not justified to compare the survival of transplantable and non-transplantable WL patients.     

Transesophageal echocardiography during pectus excavatum correction in children: What happens to the heart?

ObjectivesCardiac compression in pectus excavatum remains difficult to evaluate. We describe the findings with intraoperative transesophageal echocardiography during pectus excavatum correction in pediatric patients.MethodsWe studied right heart changes during surgical correction of pectus excavatum by transesophageal echocardiograph. Four-D echo was associated to assess morphology of the tricuspid annulus.ResultsTwenty patients were included, mean age 13.5 (+/? 2.9). Mean preoperative Haller Index was 6.3 (+/? 2.63) and mean Correction Index 47.63% (+/? 12.4%). Preoperative transthoracic echocardiography at rest showed mild right heart compression in 6. Correction was gained by Nuss technique in 19, and Taulinoplasty in one. Initial transesophageal echocardiography showed compression of the right heart and deformation of the tricuspid annulus in all. During the sternal elevation, diameters of right atrium, ventricle and tricuspid annulus significantly improved: mean augmentation of right ventricle was 5.78 mm (+/? 3.56 p < 0.05), right atrium 6.64 mm (+/? 5.55 p < 0.05) and tricuspid annulus 6.02 mm (+/? 3.29 p < 0.05). The morphology of the tricuspid annulus in 4D normalized.ConclusionsPreoperative transthoracic echocardiography at rest underestimates right chamber compression in pediatric patients with pectus excavatum. Surgical correction improves diameters of the right ventricle, right atrium and tricuspid annulus and normalizes the morphology of the tricuspid annulus (4D).Level of evidenceLevel III.