Catheter management related to radical retropubic prostatectomy

The clinical course of 108 consecutive radical retropubic prostatectomy (RRP) patients with regards to postoperative cystograms and suprapubic cystostomy was retrospectively reviewed. All patients had a urethral Foley (UF), suprapubic catheter (SP) and were discharged with both catheters in place. Two of 9 patients who had excessive drainage had biochemical evidence of urine. Cystogram on these 2 patients, deferred till days 19 and 27, was normal. Among the other 7 patients with excessive JP drainage, only 1 showed a minor anastomotic look on day 15, necessitating catheter drainage for 1 additional week, with uneventful Foley removal then. Ten patients showed some degree of extravasation on the initial cystograms, 6 patients were judged to be insignificant and the catheter was removed the same day, 4 patients had extravasation (performed days 7, 13, 15, 22) which warranted repeat cystogram 1 week later, which then turned out to be normal. Five patients experienced problems with the UF early in the postoperative period and the SP served as a backup for bladder drainage. The SP entails negligible morbidity and may serve a useful function in the most critical early postoperative period. Based on our data, routine cystogram prior to catheter removal did not appear to alter the management of the catheters significantly and appears unnecessary, especially if the catheter is left in situ for close to 3 weeks prior to removal. In selected cases where technical anastomotic problems were encountered or if delayed healing was anticipated, a c;ystogram prior to catheter removal would still be available.     

Living donor renal transplant recipients tolerate early removal of bladder catheters

Recipients of living donor renal grafts enjoy numerous benefits compared with deceased donor kidney recipients. Bladder catheterization allows for the continuous determination of urinary output and, theoretically, may prevent urinary leaks. A series of 25 consecutive renal transplants was reviewed to evaluate the timing of removal of bladder catheters after transplantation. Removing urinary catheters as early as 24 h to 48 h post-transplant showed no increase in undesirable outcomes. More than 50% of the patients had invasive bladder catheters in place for only one or two days. Early removal was associated with a lower rate of urinary tract infections, decreased length of hospitalization and possibly less discomfort, in the absence of detrimental effects.     

Ratio of donor kidney weight to recipient bodyweight as an index of graft function

Reduced renal mass or mismatching kidney size are risk factors for chronic allograft nephropathy. We assessed the effect of mismatching donor kidney weight and recipient bodyweight on renal graft function in 82 live donor kidney transplant recipients who did not have acute rejection. We calculated the donor kidney weight to recipient bodyweight ratio, and established the relation between this ratio and renal indices with a mixed model regression. We showed that recipients with a high ratio had better graft function.     

Managing indwelling urethral catheters

An indwelling urethral (Foley) catheter is a closed sterile system that is inserted through the urethra to allow for bladder drainage. In the 1930's Frederick Foley designed a rubber tube with a separate lumen used to inflate a balloon which holds the catheter in place in the bladder. Historically, indwelling catheters primarily have been used in chronic, medically compromised elderly patients. As the number of elderly patients continues to increase, particularly in such settings as home care, the use of indwelling catheters is increasing. Nurses caring for patients with urinary incontinence, neurogenic bladder, and/or urinary retention manage these catheters. However, most nurses will agree that managing this type of system poses multiple medical and nursing care problems. In fact, Foley catheters are associated with several complications and side effects that increase patient morbidity and mortality. This article reviews current strategies for providing good catheter management as well as steps for retraining the patient following catheter removal.     

Recipient Criteria Predictive of Graft Failure in Kidney Transplantation

Several classifications systems have been developed to predict outcomes of kidney transplantation based on donor variables.This study aims to identify kidney transplant recipient variables that would predict graft outcome irrespective of donor characteristics.All U.S. kidney transplant recipients between October 25,1999 and January 1, 2007 were reviewed. Cox proportional hazards regression was used to model time until graft failure. Death-censored and nondeath-censored graft survival models were generated for recipients of live and deceased donor organs. Recipient age, gender, body mass index (BMI), presence of cardiac risk factors, peripheral vascular disease, pulmonary disease, diabetes, cerebrovascular disease, history of malignancy, hepatitis B core antibody, hepatitis C infection, dialysis status, panel-reactive antibodies (PRA), geographic region, educational level, and prior kidney transplant were evaluated in all kidney transplant recipients.Among the 88,284 adult transplant recipients the following groups had increased risk of graft failure: younger and older recipients, increasing PRA (hazard ratio [HR],1.03–1.06], increasing BMI (HR, 1.04–1.62), previous kidney transplant (HR, 1.17–1.26), dialysis at the time of transplantation (HR, 1.39–1.51), hepatitis C infection (HR, 1.41–1.63), and educational level (HR, 1.05–1.42).Predictive criteria based on recipient characteristics could guide organ allocation, risk stratification, and patient expectations in planning kidney transplantation.     

Clinical complications of urinary catheters caused by crystalline biofilms: something needs to be done

This review is largely based on a previous paper published in the journal Spinal Cord. The care of many patients undergoing long‐term bladder catheterization is complicated by encrustation and blockage of their Foley catheters. This problem stems from infection by urease‐producing bacteria, particularly Proteus mirabilis. These organisms colonize the catheter forming an extensive biofilm; they also generate ammonia from urea, thus elevating the pH of urine. As the pH rises, crystals of calcium and magnesium phosphates precipitate in the urine and in the catheter biofilm. The continued development of this crystalline biofilm blocks the flow of urine through the catheter. Urine then either leaks along the outside of the catheter and the patient becomes incontinent or is retained causing painful distension of the bladder and reflux of urine to the kidneys. The process of crystal deposition can also initiate stone formation. Most patients suffering from recurrent catheter encrustation develop bladder stones. P. mirabilis establishes stable residence in these stones and is extremely difficult to eliminate from the catheterized urinary tract by antibiotic therapy. If blocked catheters are not identified and changed, serious symptomatic episodes of pyelonephritis, septicaemia and endotoxic shock can result. All types of Foley catheters including silver‐ or nitrofurazone‐coated devices are vulnerable to this problem. In this review, the ways in which biofilm formation on Foley catheters is initiated by P. mirabilis will be described. The implications of understanding these mechanisms for the development of an encrustation‐resistant catheter will be discussed. Finally, the way forward for the prevention and control of this problem will be considered.     

Sources of urinary catecholamines in renal denervated transplant recipients

When a human kidney is transplanted, sympathetic nerves to that kidney are cut. We infused 3H-noradrenaline and then measured noradrenaline, dopamine and 3H-noradrenaline levels in the plasma and urine of renal transplant recipients and uninephrectomized control subjects. Less than 10% of 3H-noradrenaline cleared from the plasma appeared in the urine. Noradrenaline and dopamine appeared in the urine of transplant recipients at one-third the rate of control subjects, even though 3H-noradrenaline levels were slightly higher in the urine of transplant recipients. Transplant patients had a noradrenaline clearance of 128 +/- 50 ml/min, compatible with simple glomerular filtration, while controls had a higher calculated clearance of 229 +/- 41 ml/min. Plasma dopamine levels were very low compared with urinary dopamine. These results suggest that two-thirds of renal noradrenaline and dopamine depend on the presence of renal nerves. Almost all urinary dopamine comes from the kidney. For noradrenaline, urinary excretion is a very minor pathway for clearance from the plasma.     

Cadaveric renal transplant recipients can safely tolerate removal of bladder catheters within 48 h of transplant

The ideal time to remove urinary catheters after renal transplantation has not been thoroughly established. It remains unclear whether the anastomosis is actually protected with prolonged bladder catheterization. In addition, the incidence of urinary tract infections may increase with prolonged catheterization. A series of 57 consecutive deceased donor renal transplants was retrospectively reviewed for outcomes associated with duration of bladder catheterization. Removing urinary catheters within 48 h post-transplant showed no increase in undesirable outcomes, and very likely improved patient satisfaction.     

Emphysematous pyelonephritis in renal allograft related to antibody‐mediated rejection: A case report and literature review

Emphysematous pyelonephritis (EPN) is a rare condition which can rapidly progress to sepsis and multiple organ failure with high mortality. We experienced a rare case of EPN in a renal allograft related to antibody‐mediated rejection (AMR). The patient received a deceased donor kidney transplant due to end‐stage renal disease secondary to diabetes mellitus. Cross‐match test was negative but she had remote history of anti‐HLA‐A2 antibody corresponding with the donor HLA. Surgery concluded without any major events. Anti‐thymoglobulin was given perioperatively for induction. She was compliant with her immunosuppressive medications making urine of 2 L/d with serum creatinine of 1.9 mg/dL at discharge on post‐operative day (POD) 6. She did well until POD 14 when she presented to the clinic with features of sepsis, pain over the transplanted kidney area and decline in urine volume with elevated serum creatinine. CT revealed extensive gas throughout the transplanted kidney. Renal scan revealed non‐functional transplant kidney with no arterial flow. Based on these findings, a decision to perform transplant nephrectomy was made. At laparotomy, the kidney was completely necrotic. Pathology showed non‐viable kidney parenchyma with the tubules lacking neutrophilic casts suggestive of ischemic necrosis. Donor‐specific antibody (DSA) returned positive with high intensity anti‐HLA‐A2 antibody. This is the first case of early EPN in allograft considered to have occurred as a result of thrombotic ischemia secondary to AMR. This case suggests consideration of perioperative anti‐B‐cell and/or anti‐plasma cell therapies for historical DSA and strict post‐operative follow‐up in immunologically high‐risk recipients to detect early signs of rejection and avoid deleterious outcomes.     

Steroid use in kidney transplant recipients presented with acute myocardial infarction

Suppression of the hypothalamic-pituitary-adrenal axis due to chronic exogenous steroid use is the most common cause of secondary adrenal insufficiency. Most kidney transplant recipients receive steroid therapy for immunosuppression; they are also at high risk for acute coronary events which can increase their physiological stress. Use of steroids early in the course of acute myocardial infarction (MI) raises concerns about the possibility of an increased risk of aneurysm formation and myocardial rupture. We present six case reports of kidney transplant recipients. Two of these recipients developed adrenal insufficiency after acute anterior MI; the life-threatening situation was successfully managed with corticosteroid administration. Four of these kidney transplant recipients presented with acute anterior MI; in these patients prophylactic steroid therapy prevented adrenal insufficiency, without any complication of the MI. We recommend the use of prophylactic corticosteroids for kidney transplant recipients to prevent adrenal insufficiency in the early course of acute MI.     

Kluyvera co‐infection in two solid organ transplant recipients: an emerging pathogen or a colonizer bystander?

Kluyvera species are opportunistic, gram-negative bacilli in the family Enterobacteriaceae. Ordinarily occurring as a commensal, Kluyvera have been reported to cause serious infections in immunosuppressed and immunocompetent hosts, causing diarrhea, urinary infections, peritonitis, and cholecystitis. We report Kluyvera infections in 2 solid organ transplant recipients. An 18-year-old female with alpha-1 antitrypsin deficiency underwent living donor liver transplantation and presented 6 months later with a liver abscess. The abscess aspirate grew mixed organisms including Kluyvera cryocrescens. A 22-year-old female with renal failure secondary to focal segmental glomerulosclerosis underwent a deceased donor kidney transplant and presented 3 months later with pyelonephritis; the urine culture grew Kluyvera ascorbata. Both patients improved only when their antibiotic coverage was broadened to include Kluyvera. The isolation of Kluyvera as a pathogen in transplant patients emphasizes that this commensal organism may be virulent in this patient population.     

Foreign body stone in the urinary bladder: a case report

Bladder calculi rarely form spontaneously and are usually a manifestation of an underlying pathologic condition of the lower urinary tract, including voiding dysfunction, urinary infection, obstruction, or foreign body retention. However, a ruptured Foley balloon-induced bladder stone is an unusual complication of an indwelling Foley catheter. We report a case of spinal cord injury with paraplegia and bladder stone induced by a fragment of a ruptured Foley balloon. The bladder stone and the Foley balloon fragment were successfully removed by cystoscopy. The stone was composed of calcium oxalate and calcium phosphate. We report this unusual case to raise awareness that it is important to check the integrity of the Foley catheter after removal of the tube.     

Indications and contraindications of living-donor kidney transplantation

Kidney transplant is the best therapy to manage end-stage kidney failure. The main barriers limiting this therapy are scarcity of cadaveric donors and the comorbidities of the patients with end-stage kidney failure, which prevent the transplant. Living kidney donor transplant makes it possible to obviate the problem of scarcity of cadaveric donor organs and also presents better results than the cadaveric transplant. The principal indication of living kidney donor transplant is preemptive transplant. This will allow the patient to avoid the complications of dialysis and it has also been demonstrated that it has better results than the transplant done after dialysis has been initiated. Priority indications of living donor transplant are also univitelline twins and HLA identical siblings. We will also have very favorable conditions when the donor is young and male. On the contrary, the living donor transplant will have worse results if the donors are over 60-65 years and the recipients are young, this possibly being a relative contraindication. There is an absolute contraindication for the living donation when the recipient has diseases with high risk of aggressive relapse in the grafts: focal and segmental hyalinosis that have had early relapse in the first transplant; atypical hemolytic uremic syndrome due to deficit or malfunction of the complement regulatory proteins; early development of glomerulonephritis due to anti-glomerular basement membrane antibody in patients with Alport Syndrome; primary hyperoxaluria.     

Efficacy of ganciclovir against cytomegalovirus nephropathy after kidney transplantation

A 32-year-old man who had received a kidney transplant from a living related donor, contracted cytomegalovirus (CMV) pneumonitis in the 8th month. He was treated with human interferon-beta and cured of the pneumonitis. After that, his serum creatinine value increased gradually. Renal biopsy revealed the cells with intranuclear inclusion bodies in the renal tubulus and the cells were positive for CMV antigens by direct immunofluorescence test using FITC-labeled mouse monoclonal antibody against an early antigen. He was hospitalized with persistent CMV viruria and treated with ganciclovir. Ganciclovir was administered daily in doses of 3 mg per kg per day for 32 days by intravenous drip infusion and thereafter the same dose was given 3 times weekly for 8 weeks. His urine was positive for CMV before the ganciclovir treatment and became negative on the 31st day after the treatment. The anti-CMV effect of ganciclovir was evidenced by gradual decrease in titer (PFU) of infectious CMV in the urine samples. His serum creatinine value decreased from 3.2 mg/dl to 2.8 mg/dl, and no adverse effect was noticed. Thus, ganciclovir is considered to be efficacious against CMV infections in kidney transplant recipients.     

High clinical suspicion of donor‐derived disease leads to timely recognition and early intervention to treat solid organ transplant‐transmitted lymphocytic choriomeningitis virus

Despite careful donor screening, unexpected donor‐derived infections continue to occur in organ transplant recipients (OTRs). Lymphocytic choriomeningitis virus (LCMV) is one such transplant‐transmitted infection that in previous reports has resulted in a high mortality among the affected OTRs. We report a LCMV case cluster that occurred 3 weeks post‐transplant in three OTRs who received allografts from a common organ donor in March 2013. Following confirmation of LCMV infection at Centers for Disease Control and Prevention, immunosuppression was promptly reduced and ribavirin and/or intravenous immunoglobulin therapy were initiated in OTRs. The liver recipient died, but right kidney recipients survived without significant sequelae and left kidney recipient survived acute LCMV infection with residual mental status deficit. Our series highlights how early recognition led to prompt therapeutic intervention, which may have contributed to more favorable outcome in the kidney transplant recipients.     

Spontaneous rupture of ileal neobladder: a case report

A 63-year-old male patient suffered from diabetes, hypertension, and a bladder tumor. He had undergone radical cystectomy and ileal neobladder construction 1 year prior to this admission. He came to our emergency room complaining of abdominal pain after recent alcohol consumption. Muscle guarding and abdominal rebounding pain developed after conservative treatment for 1 day. The next day, emergency laparotomy for acute peritonitis revealed two small perforations in the neobladder and calculus formation within it. In addition, severe intraperitoneal adhesion was noted. After removing the neobladder stone and repairing the neobladder, a Foley catheter was inserted for urine drainage. The patient's postoperative recovery was excellent.     

Successful Voiding After Trial Without Catheter Is Not Synonymous With Recovery of Bladder Function After Colorectal Surgery

Purpose The need for monitoring postoperative urine output and the possibility of lower urinary tract dysfunction following colorectal surgery necessitates temporary urinary drainage. Current practice assumes recovery of lower urinary tract function to coincide with successful micturition after removal of urethral catheter. The aim of this study was to analyze the recovery of bladder function following colorectal surgery. Methods Patients undergoing colorectal operations underwent preoperative and postoperative uroflowmetry and residual urine estimation. All patients were catheterized suprapubically at surgery. Uroflowmetry and postvoid residual volumes were recorded postoperatively until recovery of bladder function was complete. Results Thirty consecutive patients underwent suprapubic catheterization, 25 of whom completed the study. Seventeen (68 percent) patients were able to pass urine within 72 hours of surgery. Recovery of lower urinary tract function was delayed in patients undergoing rectal vs. colonic resections (median, 6 vs. 3 days, P = 0.0015). Postvoid residual volumes greater than 200 ml were noted in three (20 percent) patients following rectal resections beyond the tenth postoperative day, with complete emptying achieved by six weeks. Conclusions Apparent successful micturition following rectal resections does not always indicate recovery of bladder function. The use of suprapubic catheters, in addition to being safe and effective, allows assessment of residual volumes postoperatively and smoothes the path to full recovery of lower urinary tract function. Presented at the Tripartite Colorectal Meeting, Melbourne, Australia, October 27 to 30, 2002.     

Coccidioidomycosis in healthy persons evaluated for liver or kidney donation

Coccidioidomycosis is a fungal infection caused by Coccidioides species endemic to the southwestern United States, where it poses unique challenges for transplant recipients. Donor-derived coccidioidomycosis has been documented, but its risk of transmission is not known. We prospectively screened 568 healthy persons requesting evaluation for possible liver or kidney donation. Twelve (2.1%) of the 568 donor candidates were seropositive (11 initially and 1 with seroconversion and symptomatic illness within 1 week after negative screening). Three of these 12 patients proceeded to kidney donation, and a fourth patient proceeded to liver donation. None of the 4 transplant recipients received special coccidioidal prophylaxis, although all were administered fluconazole according to standard antifungal prophylaxis protocols. At follow-up (7-54 months), no coccidioidomycosis was identified in any recipient. The prevalence of coccidioidal antibodies was low among potential organ donor candidates, but the risk of donor-derived coccidioidomycosis remains unknown and further study is warranted.     

Factors prompting early central venous catheter removal from cancer patients with candidaemia

We evaluated clinical factors associated with early central venous catheter (CVC) removal in cancer patients with candidaemia who survived >3 days after the index blood culture. This was a retrospective cohort study from a previous candidaemia database conducted between January 2001 and June 2005. Eligible patients were those whose catheters were removed. Those who died in the first 72 h were excluded. Early CVC removal was defined as withdrawal in the first 72 h. We enrolled 164 patients with a 10.4% mortality rate. Multivariate analysis showed temporary non-tunnelled catheter type (odds ratio 5.06; 95% confidence interval 2.16-11.83) as the only variable associated with early removal. Among the 84 episodes judged not catheter-related, 52 CVCs were removed due to the need for further cancer treatment. No differences in mortality were seen among patients with early or late catheter removal. Stratified analysis showed a survival benefit (p = 0.04) of early removal among patients with a Karnofsky performance status score >60. The study shows a propensity to immediately remove short-term catheters and a tendency for early removal in patients undergoing active cancer treatment. There was no benefit of early catheter removal with regard to overall mortality. The favourable impact of early over late removal on survival among patients without significant illness merits further investigation.     

Bacteremia in transplant recipients: a prospective study of demographics, etiologic agents, risk factors, and outcomes.

BACKGROUND: Bacteremic infections are a major cause of death among organ transplant recipients. We sought to identify the risk factors associated with death and examine the timing of the bacteremic episode after operation to recognize patients who may benefit from perioperative prophylactic antibiotic therapy. METHODS: A total of 125 episodes of bacteremia or fungemia in 16 heart, 26 kidney, and 70 liver recipients were monitored prospectively in 1 year. RESULTS: The urinary tract was the most frequent portal for kidney recipients, the gastrointestinal and biliary tracts were frequent for liver recipients, and the lung was frequent in heart recipients. Heart and liver recipients were more severely ill at the time of bacteremia and had bacteremia sooner after operation. Death at 14 days after onset of bacteremia was 33% in heart recipients, 24% in liver recipients, and 11% in kidney recipients. Risk of death was associated with the severity of the underlying condition of the transplant recipient, the source of the bacteremia, and the microbial agent. Pseudomonas aeruginosa and Enterobacter species had fatality rates of 47% and 63%, respectively. P. aeruginosa and Enterobacter were also most commonly associated with failures of perioperative antibiotic prophylaxis. CONCLUSIONS: There are distinct clinical patterns of bacteremia in transplant recipients. The emergence of P. aeruginosa and Enterobacter species in the immediate postoperative period appeared to be a significant cause of morbidity and death among transplant recipients.