Expanded Criteria Donor With Severe Acute Kidney Injury: Worth to Use?

BackgroundExpanded criteria donors (ECDs) may present with acute kidney injury (AKI). Many transplantation centers refuse to use these kidneys because of concerns about poor transplant outcomes, resulting in a high discard rate. However, long-term results of ECDs with AKI (ECDs + AKI) have not been extensively studied.MethodsWe retrospectively compared outcomes of ECDs with ECDs + AKI. Primary outcome was 5-year allograft and patient survival rate. Secondary outcomes were allograft function, rates of delayed graft function, and allograft rejection.ResultsOf 743 deceased donor kidney transplant recipients, 95 ECD cases were included in this study. There were 38 patients (40%) with ECDs and 57 patients (60%) with ECDs + AKI. Mean donor creatinine was progressively higher with severity of AKI. Five-year graft and patient survival were comparable between ECDs and ECDs + AKI (80.6% vs 81.1%, P = .95 and 91.7% vs 88.7%, P = .73). Mean (SD) allograft estimated glomerular filtration rate was 36.7 (14.5) vs 40.6 (22.7) mL/min/1.73 m² with P = .61, respectively. Multivariate analysis showed factors associated graft loss were delayed graft function (P = .01) and donor-recipient age difference ≥10 years (P = .038), not AKI status.ConclusionsKidney transplant from ECDs + AKI has comparable allograft survival with ECDs without AKI. Use of ECDs + AKI is worthwhile and kidneys from ECDs + AKI should not be discarded. Recipient selection and perioperative care are important to optimize the use of scarce resource.     

Retroperitoneal Sarcoma: Is It Time to Change the Surgical Policy?

Background  

Complete tumor resection is the mainstay of treatment for retroperitoneal sarcoma (RPS), but the size and quality of surgical margins for radical resection in RPS are unknown. They are believed to be pushing tumors, but recently, aggressive surgical policies leading to multivisceral resection have seemed to suggest better local control compared with simple tumor resection. We analyzed a single-institution series of RPS to provide information useful to surgical decision-making.     

‘Flexible’ or ‘lifestyle’ dialysis: Is this the way forward?

BACKGROUND: Despite the advent of two new dialysis options, nocturnal home haemodialysis and short daily haemodialysis, many units are yet to build them into the modalities on offer to end-stage renal failure patients. The reasons behind this inertia are complex but primarily include anxieties about workload, budgetary implications and outcome data. METHOD: The Geelong dialysis programme, where both nocturnal home haemodialysis and short daily haemodialysis are offered, is compared with Australian and New Zealand national profiles. RESULTS: Significant profile differences emerge when comparing sessions/week and h/week between the three groups. Most Australian (92.93%) and New Zealand (95.07%) haemodialysis patients dialyse for three sessions/week. This contrasts to Geelong where only 73.6% dialyse for three sessions/week. 18.8% of Geelong haemodialysis patients versus 1.8% (Australia) and 0.9% (New Zealand) dialyse for five or more sessions/week. Australia and New Zealand follow similar h/session patterns although more Australians (44.2%) dialyse for 4 h and fewer (24.2%) for 5 h than their New Zealand counterparts (39.6% and 29.8%, respectively), and few dialyse outside the 3.5-5 h window. In contrast, 6.7% of Geelong patients dialyse for 2-2.5 h/session versus Australia (0.9%) and New Zealand (0.2%). This represents the Geelong short daily dialysis programme. More Geelong patients (>15%) dialyse >/=8 h/week and represent the Geelong nocturnal home haemodialysis programme. CONCLUSION: The flexible Geelong programme has been supported without exceeding the budget applied to a conventional dialysis programme with the same patient numbers.     

Is It Possible to Create a “Mechanical” Arteriovenous Fistula in Hemodialysis Patients?

Manual suturing still remains the best technique for the creation of vascular anastomoses on uremic patients with excellent results, despite being time consuming, difficult to perform with small vessels, and associated with a significant learning curve. We created a full mechanical arteriovenous fistula on a 65‐year‐old uremic patient with a new device already used in cardiac bypass surgery. The fistula was created automatically and rapidly, without the need for temporary occlusion of the artery, reducing the risk of blood clotting. We believe that mechanical devices may be useful to produce precise and fast anastomoses requiring minimal training for the surgeon.     

KDIGO Guidelines and Kidney Transplantation: Is the Cystatin‐C Based Recommendation Relevant?

The KDIGO guidelines propose a new approach to diagnose chronic kidney disease (CKD) based on estimated glomerular filtration rate (GFR). In patients with a GFR value comprised between 45 and 59 mL/min/1.73 m² as estimated by the CKD‐EPI creatinine equation (eGFR_creat), it is suggested to confirm the diagnosis with a second estimation using the CKD‐EPI cystatin C‐based equations (eGFR_cys/eGFR_creat‐cys). We sought to determine whether this new diagnostic strategy might extend to kidney transplant recipients (KTR) and help to identify those with decreased GFR. In 670 KTR for whom a measured GFR was available, we simulated the detection of CKD using the two‐steps approach recommended by the guidelines in comparison to the conventional approach relying on creatinine equation. One hundred forty‐five patients with no albuminuria had eGFR_creat between 45 and 59 mL/min/1.73 m². Among them, 23% had inulin clearance over 60 mL/min/1.73 m² and were thus incorrectly classified as CKD patients. When applying the Kidney Disease: Improving Global Outcomes (KDIGO) strategy, 138 patients were confirmed as having a GFR below 60 mL/min with eGFR_creat‐cys. However, 21% of them were misclassified in reference to measured GFR. Our data do no not support the use of cystatin C as a confirmatory test of stage 3 A CKD in KTR.