Immediate and early renal function after living donor transplantation.

BACKGROUND: In order to assess the immediate renal function after living donor transplantation, renal function was compared in eight renal allograft recipients and their living related kidney donors during the first 24 h after transplantation. METHODS: Substantial and comparable intraoperative volume loading with Ringer's acetate and mannitol was performed together with the administration of frusemide. Glomerular filtration rate (GFR) and effective renal plasma flow (ERPF) were estimated by the clearances of inulin and p-aminohippurane, respectively. Tubular reabsorptive function and injury were estimated from the clearance of lithium, the fractional excretion of sodium and the urinary excretion of N-acetyl-beta-glucosaminidase. RESULTS: One hour after completion of surgery, GFR (54 +/- 7 ml/min) and ERPF (294 +/- 35 ml/min) were only 30% lower in the grafts than in the remaining donor kidneys, increasing to similar levels within 3 h. Only minor tubular dysfunction and injury were revealed in the grafted kidneys, and these tended to normalize within 24 h. CONCLUSIONS: By the present transplantation procedure comprising short ischaemia time and substantial volume expansion combined with mannitol and frusemide administration, kidneys from living donors regain nearly normal function within a few hours after transplantation.     

Chronic renal outcome after living donor liver transplantation

Chronic kidney disease (CKD) is one of the common complications after deceased donor liver transplantation. Although the worldwide pressing shortage in deceased donors has directed attention to living donor liver transplantation (LDLT), LDLT cohort data focusing on chronic renal dysfunction is limited. A total of 280 adult LDLT recipients (median 49 yr, 156 men) at the University of Tokyo hospital between 1996 and 2006 were reviewed. A total of 224 pre‐transplant liver failure patients (80.0%) showed an estimated glomerular filtration rate (eGFR) of more than 60 mL/min/1.73 m². However, during follow‐up at a mean of 1222 d after transplantation, eGFR declined to 60 mL/min/1.73 m² and 30 mL/min/1.73 m² in 150 (53.2%) and 21 (7.5%), respectively, and four patients (1.4%) required maintenance renal replacement therapy. Multivariate Cox proportional hazard model regression analysis revealed that recipient age (HR, 3.42 per 10‐yr increment; p < 0.001) and pre‐transplant eGFR (HR, 0.85 per 10‐mL/min/1.73 m² increment; p = 0.04) were associated independently with a post‐transplant decrease in eGFR to less than 30 mL/min/1.73 m². We conclude that higher age and lower pre‐transplant eGFR of an LDLT recipient indicate a high likelihood of subsequent development of advanced CKD. Preventive or therapeutic intervention should be optimized for these high‐risk patients.     

手辅助腹腔镜在亲属活体供肾切取中的应用25例报告

目的 探讨手辅助腹腔镜在亲属活体供肾切取中的应用.方法 回顾性分析25名亲属活体供肾者的资料.25名供者中,男性6名,女性19名,年龄(42±17)岁.23例为亲属血缘关系供肾,2例为夫妻间供肾.分析供者选择手辅助腹腔镜下取肾术的原因、供者的手术时间、供肾热缺血时间、术中出血量、肾脏及周围脏器损伤情况、术后恢复情况及移植肾功能恢复情况,评价手辅助腹腔镜下取肾术的临床应用效果.结果 对25名亲属供者应用手辅助腹腔镜下取肾术均获成功,无中转开放手术;24例取左肾,1例取右肾;手术时间(138±42)min,供肾热缺血时间为(145±22)s,术中出血量(53±32)m1;无供肾损伤,无切口相关并发症,仅有1例发生脾包膜撕裂;术后住院时间为(7.2±1.7)d,供者均满意.调查显示,供者选择手辅助腹腔镜下取肾术的主要原因是手术损伤小、切口对外观影响较小、心理负担轻.亲属活体供肾移植后,仅有1例受者发生移植肾功能恢复延迟,其余受者的血肌酐水平均在1周内下降至正常.结论 手辅助腹腔镜下取肾术综合了传统腹腔镜技术和开放性手术取肾的优点,微创,操作方便,供肾损伤机会少,切口对外观影响较小,供者易于接受.     

Gender imbalance in living donor renal transplantation

BACKGROUND: Previous studies have shown more women than men among living donors (LD) and more men among recipients of those kidneys. In this study, we compared the evolving demographics of LD transplants. METHODS: We retrospectively analyzed all LD transplants performed in our center between 1964 and 2000. RESULTS: Among 1182 LD cases, 1035 (88%) were biologically related (LRD) and 147 (12%) were unrelated (LURD). LURD donors and recipients were significantly older than LRD donors and recipients, respectively (P=0.0001). More LURD allograft recipients were male (71%) compared with LRD recipients (57%) (P=0.0013). The proportion of female donors was 55% in both groups. Spousal donations were predominantly wife-to-husband (69%). Compared with the LRD group, there was a greater proportion of female-to-male LURD transplants (46 vs. 30%) and a smaller proportion of female-to-female LURD transplants (10 vs. 25%) (P=0.0001). When spousal pairs were excluded from the analysis, there was a higher proportion of male-to-male (48 vs. 27%) donations and a lower proportion of male-to-female (18 vs. 9%) and female-to-female (25 vs. 17%) transplants in the LURD group (P=0.001). CONCLUSIONS: Gender disparities in LD transplantation are primarily due to a higher proportion of wife-to-husband donations and a lower incidence of male-to-female grafts among nonspousal LURD transplants. Strategies should be devised to ensure access for women to renal transplantation and to encourage and facilitate donation by men.     

Pediatric renal transplantation from related living donor

Living related donor (LRD) provides significant advantages when compared with cadaveric donor (CAD) in term of improved patient and graft survival and shorten waiting time. From 1985, 176 kidney transplants were performed at our Center. Of these, 156 (89%) were from CAD and 20 (11%) were from LRD, first degree. The purpose of this paper is to show our experience at 5 years with use of LRD. All donors underwent standardized metabolic workup, angiography assessed and renal function test. Twelve children received their first transplant and 8 were retransplant (6-second, 1-third and 1-fourth). Immunosuppressive therapy consisted of globulin antithymocyte, azathioprine, cyclosporine and prednisolone, using FK506 and mycophenolate mofetil in some of them. Four kidneys with multiple renal arteries were reconstructed ex vivo with microsurgical technique before transplantation. The most significant morbidity was due to FK506-associated thrombotic microangiopathy (TMA) with graft lost. All patients (donor and recipient) survived. Five years graft survival rate is 95% and mean glomerular filtration rate is 81.33 ml/min/1.73 m2.     

Biliary complications after living donor adult liver transplantation.

The highest rate of complications characterizing the adult living donor liver transplantation (ALDLT) are due to biliary problems with a reported negative incidence of 22-64%. We performed 23 ALDLT grafting segments V-VIII without the middle hepatic vein from March 2001 to September 2005. Biliary anatomy was investigated using intraoperative cholangiography alone in the first five cases and magnetic resonance cholangiography in the remaining 18 cases. In 13 cases we found a single right biliary duct (56.5%) and in 10 we found multiple biliary ducts (43.7%). We performed single biliary anastomosis in 17 cases (73.91%) and double anastomosis in the remaining six (26%) cases. With a mean follow up of 644 days (8-1598 days), patient and graft survivals are 86.95% and 78.26%, respectively. The following biliary complications were observed: biliary leak from the cutting surface: three, anastomotic leak: two, late anastomotic strictures: five, early kinking of the choledochus: one. These 11 biliary complications (47.82%) occurred in eight patients (34.78%). Three of these patients developed two consecutive and different biliary complications. Biliary complications affected our series of ALDLT with a high percentage, but none of the grafts transplanted was lost because of biliary problems. Multiple biliary reconstructions are strongly related with a high risk of complication.     

Pretransplantation soluble adhesion molecule expression predicts outcome after living donor renal transplantation

HYPOTHESIS: Occult pretransplantation systemic inflammation will identify patients at risk for poor outcomes after renal transplantation. DESIGN: Retrospective cohort study. Adhesion molecule levels were measured in pretransplantation serum samples from 86 recipients. Univariate and multivariate analyses were conducted to assess a possible correlation between serum adhesion molecule level and outcome. SETTING: University referral center. MAIN OUTCOME MEASURES: Allograft rejection and survival. RESULTS: Patients with low levels of vascular cell adhesion molecule 1 had less graft rejection (P=.007). Low levels of vascular cell adhesion molecule 1 independently predicted decreased rejection (relative risk, 0.17; P=.01), and high levels of vascular cell adhesion molecule 1 independently predicted graft loss (relative risk, 3.83; P=.02). Similar correlations were observed for intercellular adhesion molecule 1. CONCLUSIONS: Decreased pretransplantation adhesion molecule expression correlates with less rejection, and increased levels correlate with graft loss. Assessment of pretransplantation inflammatory status may be useful in optimizing immunosuppression therapy.     

Exchange donor transplantation: ethical option for living renal transplantation

Purpose

Taking in consideration the opinion of our team, which necessitates obligation of a relative relation between donors and recipients (genetic or matrimonial), we performed donor exchanges as an ethical alternative in living donor transplantations. We reviewed the outcomes of our exchange series.

Methods

Between July 2003 and August 2010 we performed 110 exchange donor transplantations in four hospitals: one four-way, two three-way, and 100 two-way cases. Donors were mostly spouses (n = 71) or mothers (n = 15). The mean age of the donors was 48.8 (range = 23-69) and the recipients 41.4 years (range = 5-66). Two were transplanted preemptively and the others had a mean dialysis duration of 43 months (range = 1-120).

Results

Among 110 patients, three compatible pairs joined the group voluntarily; 71, due to ABO incompatibility and 36, due to crossmatch positivity. Induction therapy was used in 92 patients. HLA mismatches (MM) were: one MM in three; two MM in three; three MM in 18, four MM in 36; five MM in 34; and six MM in 18. Among 90 patients tested for panel-reactive antibodies PRA, five showed class I and 10, class II positivity. In 11 patients, B-cell positivity was detected by flow cytometry. Delayed graft function (n = 2), acute rejection (n = 11), BK virus infection (n = 1), and cytomegalovirus infection (n = 3) were seen postoperatively. Three (2.7%) patients died due to sepsis. Five patients returned to dialysis program due to interstitial fibrosis tubular atrophy (IFTA) (n = 2), renal vein thrombosis (n = 1), de novo glomerulopathy (n = 1), or primary nonfunction (n = 1). The 1- and 5-year patient and graft survival rates were 96% and 96%, 95% and 89%, respectively.

Conclusion

We believe that exchange donor transplantation is as successful as direct transplants; it is a good, ethical alternative to unrelated living transplantations.     

Early bloodstream infection after pediatric living donor living transplantation

To determine the perioperative risk factors for bacterial infections after pediatric living donor liver transplantation (LDLT), we investigated the clinical profiles of 149 children who underwent pediatric LDLT between 1994 and 2008. Bacterial infections were diagnosed based on guidelines proposed by the Centers for Disease Control. We observed 36 bloodstream infections (BSIs) in 32/149 (21.5%) patients (0.24 infections per patient), which, 21 (58.3%) BSIs in 19 patients were due to gram-positive and 15 (41.7%) in 13 patients to gram-negative organisms. The most common pathogens of early BSI were coagulase-negative Staphylococcus; (n = 11; 30.6%) and Klebsiella pneumoniae (n = 8; 22.2%). The most common site of early BSI was catheter-related (n = 14; 38.9%). Multivariate analysis showed that age ≤ 1 year (P < .05; odds ratio [OR] = 3.90; 95% CI, 1.83-15.26) and bile duct complications (P < .05; OR = 6.2, 95% CI = 3.21-35.23) were significant independent risk factors for early BSIs. More cautious management of pediatric LDLTs may be necessary for younger age children particularly with postoperative biliary complications.     

Renal impairment after living donor liver transplantation

BACKGROUND: There are few reports of postoperative renal impairment after living donor liver transplantation (LDLT). METHODS: We reviewed 246 LDLT recipients to examine the effects of postoperative renal impairment on the results of LDLT. RESULTS: The incidence of renal impairment and the requirements for postoperative renal replacement therapy were 29% and 9%, respectively. Intraoperative blood loss (P<.0001) and preoperative serum creatinine (P=.0002) were significant independent risk factors for the development of early renal dysfunction. Patients who required renal replacement therapy had a lower survival rate (P=.01). CONCLUSIONS: We identified the risk factors for postoperative renal impairment, providing useful metrics to establish a treatment strategy for high risk liver transplant patients.     

Workload generated by a living donor programme for renal transplantation.

BACKGROUND: The ethical and medical implications of live kidney donation result in a comprehensive work-up process. The aim of this study was to determine the magnitude of the workload and the yield of renal transplants generated by a live donor programme. METHODS: Referrals to the Leicester live donor programme over the five-year period 1994-1998 were retrospectively assessed. These were initiated by nephrology referral and subsequently investigated in a stepwise manner. Patients were counselled and baseline tests performed prior to consultant surgeon review and assessment of donor renal function/anatomy. RESULTS: One hundred and fifty referrals consisting of 150 recipients with 269 potential donors were originally made. This resulted in 32/120 (27%) related and 3/30 (10%) unrelated recipients (P=0.06) and 32/220 (15%) related and 3/49 (6%) unrelated donors proceeding to live donor transplantation, with a mean work-up time (+/-SD) of 9 (+/-7) months. One hundred and fifteen recipients (77%) and 234 (87%) donors failed to proceed at various stages of assessment, for a variety of immunological, medical and social reasons. A large number of expensive immunological investigations were required for potential donors, the majority of which did not proceed to transplantation. However as a result of performing these in the early stages of assessment the number of more invasive tests is kept to a minimum. CONCLUSIONS: There is a relatively low yield of transplants from live donor referrals, particularly those between unrelated individuals. The vast majority of referrals fail to proceed for legitimate reasons, but as a result, create a significant workload with notable staffing and financial implications.     

The impact of renal replacement therapy before or after living donor liver transplantation

Ikegami T, Shirabe K, Soejima Y, Taketomi A, Yoshizumi T, Uchiyama H, Harada N, Maehara Y. The impact of renal replacement therapy before or after living donor liver transplantation.
Clin Transplant 2012: 26: 143–148.
© 2011 John Wiley & Sons A/S. Abstract: Introduction: The impact of renal replacement therapy (RRT) in living donor liver transplantation (LDLT) has not yet been investigated. Methods: Among 253 LDLT patients, RRT was started before (RRT‐Pre, n = 9), or after (RRT‐Post, n = 27) LDLT. The clinical outcomes were reviewed. Results: The one‐yr graft survival rate was 94.1% without RRT, and 63.9% and in those with RRT (p < 0.0001). Among the RRT patients, the RRT‐Pre patients exhibited acute liver failure, hepatorenal syndrome and high model for end‐stage liver disease score (35 ± 12), whereas the RRT‐Post patients had sepsis as a comorbidity. The one‐yr graft survival rate was 100.0% in the RRT‐Pre patients vs. 51.9% in the RRT‐Post patients (p < 0.01). The duration of RRT was significantly shorter in the RRT‐Pre patients than that in the RRT‐Post patients (5.3 ± 2.1 vs. 17.8 ± 14.1 d, p = 0.02). The mean duration between starting RRT and LDLT was 2.1 ± 0.7 d in the Pre‐RRT patients. Conclusion: The RRT‐Pre patients had excellent outcomes because the severe condition was primarily treated by LDLT after short‐term pre‐transplant RRT. Post‐transplant uncontrollable sepsis was the major cause of graft loss in patients who receive RRT after LDLT.     

Outcome of living donor renal transplantation in obese recipients

The increasing prevalence of obesity among patients with end-stage renal disease accompanies more common renal transplantation from living donors. Since several studies have shown a negative impact of recipient obesity on renal transplantation outcomes, we investigated the influence of recipient-weight and donor-recipient-weight ratio on the outcome of living related renal transplantations. From October 2000 until December 2004, we performed 81 living donor renal transplantation with 30.8% (n = 25) of recipients with a body mass index >25 donor. In this group 6 patients lost their grafts (1-year survival rate, =76%). Among 56 recipients of normal body weight only 3 patients lost their graft (1-year graft survival rate, 94.6%; P < .001). Upon multivariate analysis body mass index was an independent risk factor for graft loss within the first year. When the body weights of the donor and recipient were analyzed in detail the quotient (body weight recipient(2)/ body weight donor) was also an independent risk factor. This study confirmed the results of larger analyses suggesting that body weight matching could significantly improve the outcomes in living donor renal transplantation. As a result of this study, in our institutional policy has changed; recipients of living donor grafts are only accepted when their body mass index is <25.