Renal retransplantation after kidney and pancreas transplantation using the renal vessels of the failed allograft: pitfalls and pearls

Renal retransplantation after a failed prior kidney and pancreas transplant is being increasingly performed. In these complex cases, both iliac fossae have been used for prior transplants, and the placement of the new allograft can be problematic. We describe our experience with an alternative technique for renal retransplantation (RRTx) in the setting of severe bilateral aortoiliac atherosclerosis or scarring and fibrosis on the iliac vessels. Nephrectomy of the failed allograft is performed, and the renal vessels of the failed allograft (RVFA) are preserved. The new kidney is implanted on RVFA at the same operative time. This technique was attempted and successfully accomplished in a total of six patients (mean operative time = 240 ± 63 min). One postoperative complication occurred: poor arterial inflow to the allograft, being corrected reoperatively. Hospitalizations ranged from five to eight d. Five of the six patients were alive with a functioning allograft at last follow‐up (a single graft failure occurred 21 months postoperatively in the setting of post‐transplant lymphoproliferative disease that also led to patient death). Renal vessels of the failed allograft seem to be suitable alternative vascular conduits for renal retransplantation after prior kidney and pancreas transplants.     

Comparison of outcomes of peritoneal dialysis between patients after failed kidney transplant and transplant-naïve patients: a meta-analysis of observational studies

PurposeThe influence of prior failed kidney transplants on outcomes of peritoneal dialysis (PD) is unclear. Thus, we conducted a systematic review and meta-analysis to compare the outcomes of patients initiating PD after a failed kidney transplant with those initiating PD without a prior history of kidney transplantation.MethodsWe searched PubMed, Embase, CENTRAL, and Google Scholar databases from inception until 25 November 2020. Our meta-analysis considered the absolute number of events of mortality, technical failures, and patients with peritonitis, and we also pooled multi-variable adjusted hazard ratios (HR).ResultsWe included 12 retrospective studies. For absolute number of events, our analysis indicated no statistically significant difference in technique failure [RR, 1.14; 95% CI, 0.80–1.61; I²=52%; p = 0.48], number of patients with peritonitis [RR, 1.13; 95% CI, 0.97–1.32; I²=5%; p = 0.11] and mortality [RR, 1.00; 95% CI, 0.67–1.50; I²=63%; p = 0.99] between the study groups. The pooled analysis of adjusted HRs indicated no statistically significant difference in the risk of technique failure [HR, 1.25; 95% CI, 0.88–1.78; I²=79%; p = 0.22], peritonitis [HR, 1.04; 95% CI, 0.72–1.50; I²=76%; p = 0.85] and mortality [HR, 1.24; 95% CI, 0.77–2.00; I²=66%; p = 0.38] between the study groups.ConclusionPatients with kidney transplant failure initiating PD do not have an increased risk of mortality, technique failure, or peritonitis as compared to transplant-naïve patients initiating PD. Further studies are needed to evaluate the impact of prior and ongoing immunosuppression on PD outcomes.     

Constipation and clinical outcomes in peritoneal dialysis: Results from Thailand PDOPPS

Background

Patient-reported outcome measures (PROMs) are widely recognized as valuable predictors of clinical outcomes in peritoneal dialysis (PD). Our study aimed to explore the connections between patient-reported constipation and clinical outcomes.

Methods

We assessed constipation in patients across 22 facilities participating in the Thailand Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS) from 2014 to 2017. Constipation diagnosis utilized objective assessment tools such as the Bristol stool form scale (BSFS) and a self-reported questionnaire known as the constipation severity score (CSS). The BSFS is a 7-level scale that visually inspects feces based on texture and morphology, while the CSS measures constipation duration and severity using a 5-point Likert scale for various factors. We employed Cox proportional hazards model regression to determine the associations between constipation and clinical outcomes, including mortality, hemodialysis (HD) transfer and peritonitis.

Results

Among 975 randomly selected PD patients from 22 facilities, 845 provided written informed consent, and 729 completed CSS questionnaire. Constipation was prevalent in the PD population (13%), particularly among older patients, those who were caregiver dependent, had diabetes and poorer nutritional status (indicated by lower time-averaged serum albumin, potassium, creatinine and phosphate concentrations). Twenty-seven percent of which experiencing symptoms of constipation for over a year. Notably, self-reported constipation at baseline was significantly associated with a shorter time to first peritonitis and higher rates of peritonitis and death. However, no significant association was found between constipation and HD transfer after adjusting for various factors, including age, gender, PD vintage, comorbidities, shared frailty by study sites and serum albumin.

Conclusion

Patient-reported constipation independently correlated with increased risks of peritonitis and all-cause mortality, though no such correlation was observed with HD transfer. These findings underscore the need for further investigation to identify effective interventions for constipation in PD patients.     

Impact of failed allograft nephrectomy on initial function and graft survival after kidney retransplantation

The management of an asymptomatic failed renal graft remains controversial. The aim of our study was to explore the effect of failed allograft nephrectomy on kidney retransplantation by comparing the outcome of recipients who underwent graft nephrectomy prior to retransplantation with those who did not. Retrospective comparison of patients undergoing kidney retransplantation with (group A, n = 121) and without (group B, n = 45) preliminary nephrectomy was performed, including subgroup analysis with reference to patients with multiple (≥2) retransplantations and patients of the European Senior Program (ESP). Nephrectomy leads to increased panel reactive antibody (PRA) levels prior to retransplantation and is associated with significantly increased rates of primary nonfunction (PNF; P = 0.05) and acute rejection (P = 0.04). Overall graft survival after retransplantation was significantly worse in group A compared with group B (P = 0.03). Among the subgroups especially ESP patients showed a shorter graft survival after previous allograft nephrectomy. On the multivariate analysis, pretransplant graft nephrectomy and PRA >70% were independent and significant risk factors associated with graft loss after kidney retransplantation. Nephrectomy of the failed allograft was not beneficial for retransplant outcome in our series. Patients with failed graft nephrectomy tended to have a higher risk of PNF and acute rejection after retransplantation. The possibility that the graft nephrectomy has a negative impact on graft function and survival after retransplantation is worth studying further.     

Analysis of the factors conditioning the diffusion of peritoneal dialysis in Italy.

BACKGROUND: The diffusion of peritoneal dialysis (PD) in Italy is lower than expected on the basis of indications and contraindications reported in literature. METHODS: To analyse the factors influencing the use of PD in Italy, we used data from the first National Census of the Italian Society of Nephrology relating to 9773 incident patients (Incid(HD + PD)) in 2004 and 43 293 prevalent patients dialysed in 658 centres at 31/12/2004 (337 public centres, 286 private centres, 12 paediatric centres, 15 research or religious institutions and 8 unspecified). RESULTS: The percentages on PD of total incident (Inc(PD)%) and prevalent dialysis patients (Prev(PD)%) were 15.9% and 10.3%, respectively with considerable variations from region to region and from centre to centre. The Inc(PD)% was higher in regions with fewer patients on dialysis in private centres. In the private centres, the Inc(PD)% was 0.4%. Of the 325 non-paediatric public centres, 116 (35.7%) do not use PD: compared with the 209 centres which do, these centres have a lower mean Inc(HD + PD) and Prev(HD + PD) per centre (13.0 +/- 12.3 vs 28.6 +/- 18.0 - 51.8 +/- 35.7 vs 117.3 +/- 66.4 patients, P < 0.0001), and more haemodialysis (HD) stations available (3.0 vs 3.5 patients per HD station, P < 0.0001). However, the significant influence of cultural and motivational factors on the use of this method is demonstrated by the fact that it is used by 34% of the smaller non-paediatric public centres, and is not used by 19% of the larger non-pediatric public centres.     

How great is the survival advantage of transplantation over dialysis in elderly patients?

BACKGROUND: Patients >60 years old represent 66% of all new patients starting renal replacement therapy in Scotland. The aim of this study was to investigate whether or not transplantation provides any survival benefit in this group of patients. METHODS: 325 patients >60 years old listed for transplantation in Scotland between 1 January 1989 and 31 December 1999 were followed up until 31 December 2000. Sociodemographic, comorbidity, listing and transplant data were obtained from the national renal and transplant databases and case-notes review. Survival was compared between those who received a transplant and those who were listed but did not receive a transplant by the end of the follow-up period. Mann-Whitney, chi(2), Fisher's exact and log-rank tests were used where appropriate. RESULTS: Of the 325 patients listed, 128 (39.4%) received a first transplant within the study period and the remaining 197 (60.6%) continued to undergo dialysis. The transplant recipients were younger at listing (P<0.0001), lived closer to the transplant centre (P = 0.043) and spent less time on the active waiting list (P<0.0001) than patients who remained on dialysis. They had less ischaemic heart disease (P = 0.024), cerebrovascular disease (P = 0.03) and arrhythmias (P = 0.016). The overall mortality rate was 0.16 per patient-year for dialysis and 0.10 for transplantation. There was a significantly lower risk of death (RR = 0.35, 95% CI 0.22--0.54; P<0.0001, log-rank) and a longer life expectancy after listing with a transplant (8.17 vs 4.32 years). CONCLUSIONS: Renal transplantation offers a significant survival advantage over dialysis in elderly patients with end-stage renal failure who are considered suitable for transplantation.     

Comparing long-term outcomes between early and delayed initiation of peritoneal dialysis following catheter implantation

Aim: The aim of this study was to compare peritonitis rates, peritoneal dialysis technique survival and patient survival between patients who started peritoneal dialysis earlier than 14 days (early starters) and 14 days or more (delayed starters) after insertion of a Tenckhoff catheter. Methods: Observational analysis was performed for all patients who underwent insertion of a Tenckhoff catheter at Far Eastern Memorial Hospital between 1 January 2006 and 31 December 2012. The patients were divided into two groups: early and delayed starters. The rate and outcomes of peritonitis were recorded. Peritoneal dialysis technique survival and patient survival were analyzed using the Kaplan–Meier method. Cox regression analysis was performed for peritoneal dialysis technique failure and patient mortality. Results: There were 80 early starters and 69 delayed starters. The peritonitis rate was 0.18 episodes per year in early starters and 0.13 episodes per year in delayed starters. There was no significant difference of peritonitis free survival (p?=?0.146), peritoneal dialysis technique survival (p?=?0.273) and patient survival (p?=?0.739) at 1, 3, 5 years between early starters and delayed starters. After adjustment with age, albumin and diabetes, early starters did not have an increased risk of peritonitis, technique failure and mortality compared to delayed starters. Conclusion: Compared to the patients who started peritoneal dialysis 14 days or more after catheter implantation, the patients who started earlier did not have an increased risk of peritonitis, peritoneal dialysis technique failure and mortality.     

Calcification of end-stage renal allograft in a peritoneal dialysis patient.

A 40-year-old female with end-stage renal disease received acadaveric renal transplant with prednisolone and cyclosporinA in 1990. Chronic rejection developed and continuous ambulatoryperitoneal dialysis (CAPD) was     

The influence of obesity on short- and long-term graft and patient survival after renal transplantation

To determine short- and long-term patient and graft survival in obese [body mass index (BMI) >or= 30 kg/m(2)] and nonobese (BMI < 30 kg/m(2)) renal transplant patients we retrospectively analyzed our national-database. Patients 18 years or older receiving a primary transplant after 1993 were included. A total of 1,871 patients were included in the nonobese group and 196 in the obese group. In the obese group there were significantly more females (52% vs. 38.6%, P < 0.01) and patients were significantly older [52 years (43-59) vs. 48 years (37-58); P < 0.05]. Patient survival and graft survival were significantly decreased in obese renal transplant recipients (1 and 5 year patient survival were respectively 94% vs. 97% and 81% vs. 89%, P < 0.01; 1 and 5 year graft survival were respectively 86% vs. 92% and 71% vs. 80%, P < 0.01). Initial BMI was an independent predictor for patient death and graft failure. This large retrospective study shows that both graft and patient survival are significantly lower in obese renal transplant recipients.     

Obesity is associated with worse peritoneal dialysis outcomes in the Australia and New Zealand patient populations

Although obesity is associated with increased risks of morbidity and death in the general population, a number of studies of patients undergoing hemodialysis have demonstrated that increasing body mass index (BMI) is correlated with decreased mortality risk. Whether this association holds true among patients treated with peritoneal dialysis (PD) has been less well studied. The aim of this investigation was to examine the association between BMI and outcomes among new PD patients in a large cohort, with long-term follow-up monitoring. Using data from the Australia and New Zealand Dialysis and Transplant Registry, an analysis of all new adult patients (n = 9679) who underwent an episode of PD treatment in Australia or New Zealand between April 1, 1991, and March 31, 2002, was performed. Patients were classified as obese (BMI of >/=30 kg/m(2)), overweight (BMI of 25.0 to 29.9 kg/m(2)), normal weight (BMI of 20 to 24.9 kg/m(2)), or underweight (BMI of <20 kg/m(2)). In multivariate analyses, obesity was independently associated with death during PD treatment (hazard ratio, 1.36; 95% confidence interval, 1.14 to 1.54; P < 0.05) and technique failure (hazard ratio, 1.17; 95% confidence interval, 1.07 to 1.26; P < 0.01), except among patients of New Zealand Maori/Pacific Islander origin, for whom there was no significant relationship between BMI and death during PD treatment. A supplementary fractional polynomial analysis modeled BMI as a continuous predictor and indicated a J-shaped relationship between BMI and patient mortality rates and a steady increase in death-censored technique failure rates up to a BMI of 40 kg/m(2); the mortality risk was lowest for BMI values of approximately 20 kg/m(2). In conclusion, obesity at the commencement of renal replacement therapy is a significant risk factor for death and technique failure. Such patients should be closely monitored during PD and should be considered for early transfer to an alternative renal replacement therapy if difficulties are experienced.     

A prospective study of anaemia and long-term outcomes in kidney transplant recipients.

BACKGROUND: Anaemia is prevalent in kidney transplant recipients (KTR), and only few KTR with anaemia receive treatment with erythropoietin. Some have claimed that this undertreatment might contribute to suboptimal outcomes such as mortality and cardiovascular events in these patients. However, no evidence is currently available that anaemia is actually associated with such risks in KTR. METHODS: We merged two cohorts of KTR to study the associations between anaemia and two outcomes: all-cause mortality and kidney allograft loss. Detailed information on the demographic and clinical characteristics of these 825 patients was available at baseline. As recommended by the American Society of Transplantation, anaemia was considered present if the haemoglobin concentration was < or =13 g/dl in men or < or =12 g/dl in women. Patients were followed using the Austrian Dialysis and Transplant Registry. RESULTS: After 8.2 years of follow-up, 251 patients died and 401 allografts were lost. In multivariate analyses, anaemia was not associated with all-cause mortality (HR: 1.08; 95% CI: 0.80-1.45), but it was associated with 25% greater risk of allograft loss (HR = 1.25; 95% CI: 1.02-1.59). This association was even more pronounced in death-censored analyses. Analyses using haemoglobin as a continuous variable or in categories also found no association with mortality. CONCLUSIONS: Anaemia may not be associated with mortality in KTR. In light of the recent findings of increased mortality in chronic kidney disease patients with higher haemoglobin treatment target, further evidence is needed to guide clinicians in the treatment of anaemia in these patients.     

Higher peritoneal transport status is associated with higher mortality and technique failure in the Australian and New Zealand peritoneal dialysis patient populations

Although early studies observed that peritoneal membrane transport characteristics were determinants of morbidity and mortality in peritoneal dialysis (PD) patients, more recent investigations, such as the Ademex trial, have refuted these findings. The aim of this study was to determine whether baseline peritoneal transport status predicted subsequent survival in Australian and New Zealand PD patients. The study included all adult patients in Australia and New Zealand who commenced PD between April 1, 1999, and March 31, 2004, and had a peritoneal equilibration test (PET) performed within 6 mo of PD commencement. Times to death and death-censored technique failure were examined by Kaplan-Meier analyses and multivariate Cox proportional hazards models. PET measurements were available in 3702 (72%) of the 5170 individuals who began PD treatment in Australia or New Zealand during the study period. In these patients, high transporter status was found to be a significant, independent predictor of death-censored technique failure (adjusted hazard ratio [AHR] 1.23; 95% confidence interval [CI] 1.02 to 1.49; P = 0.03) and mortality (AHR 1.34; 95% CI 1.05 to 1.79, P = 0.02) compared with low-average transport status. High-average transport class was also associated with mortality (AHR 1.21; 95% CI 1.00 to 1.48; P = 0.047) but not death-censored technique failure (AHR 1.04; 95% CI 0.90 to 1.21) compared with low-average transport status. When transport status was alternatively analyzed as a continuous variable, dialysate:plasma creatinine ratio at 4 h was independently predictive of both death-censored technique failure (AHR 1.07; 95% CI 1.01 to 1.295; P = 0.031) and death (AHR 1.09; 95% CI 1.01 to 1.373; P = 0.036 per 0.1 change in dialysate:plasma creatinine). Peritoneal transport rate is a highly significant risk factor for both mortality and death-censored technique failure in the Australian and New Zealand incident PD patient populations.     

Outcomes of renal transplantation in patients with autosomal dominant polycystic kidney disease: a nationwide longitudinal study

Renal transplantation in patients with autosomal dominant polycystic kidney disease (ADPKD) is a medical and surgical challenge. Detailed longitudinal epidemiological studies on large populations are lacking and it is mandatory to care better for these patients. The success of such a project requires the development of a validated epidemiological database. Herein, we present the results of the largest longitudinal study to date on renal transplant in patients with ADPKD. The 15‐year outcomes following renal transplantation of 534 ADPKD patients were compared with 4779 non‐ADPKD patients. This comprehensive, longitudinal, multicenter French study was performed using the validated database, DIVAT (Données Informatisées et VAlidées en Transplantaion). We demonstrate that renal transplantation in ADPKD is associated with better graft survival, more thromboembolic complications, more metabolic complications, and increased incidence of hypertension, whereas the prevalence of infections is not increased. This study provides important new insights that could lead to a better care for renal transplant patients with ADPKD.     

亲属活体肾移植受者术后新发代谢综合征对移植肾功能的影响

目的 研究肾移植术后新发代谢综合征(metabolic syndrome,MS)对移植肾功能的影响.方法 回顾性分析2012年8月1日至2014年8月1日郑州人民医院器官移植中心的120例亲属活体肾移植受者资料,分为MS组和非MS组,对患者术后3个月、6个月、1年、3年和5年的血肌酐值采用SPSS 16.0统计学软件进...