Operative Strategies in Aortic Graft Infections: Is Complete Graft Excision Always Necessary?

The classic approach to aortic graft infections involves complete excision of the graft material with remote reconstruction of the distal circulation. Certain patients may not be well suited for this approach for physiologic or anatomic reasons. This study was undertaken to determine the outcome of partial graft excision in selected patients with aortic graft infection who were not felt to be candidates for complete graft excision. Retrospective analysis of 30 consecutive patients treated with infected grafts arising from the aorta over the past 10 years was performed. Mean interval between graft placement and infection was 5.5 years. Complete graft excision with bypass via clean tissue planes was achieved in 15 patients (group A), and partial or complete graft salvage or in situ graft replacement was performed at the discretion of the surgeon in 15 patients (group B). Perioperative mortality occurred in eight subjects (27%), including six in group A (40%) and two in group B (13%; p=NS). Six patients (20%) developed recurrent infection following graft excision, two (13%) in group A and four (27%) in group B (p=NS). Microorganisms were recovered from 24 of 30 (80%) graft cultures: 13 (43%) were gram positive, 4 (13%) were gram negative, and both gram-positive and gram-negative organisms were recovered from 7 (23%). Identification of culture isolates did not influence either perioperative mortality or the development of recurrent infection. Long-term survival was no different between the groups. We conclude that in certain high-risk patients who may not tolerate complete graft excision, local resection of infected graft segments may be preferable and leads to similar short- and long-term outcome.Presented at the 29th Annual Meeting of the Peripheral Vascular Surgery Society, Anaheim, CA, June 4-5, 2004.     

Complement Polymorphisms in Kidney Transplantation: Critical in Graft Rejection?

The complement system, as part of the innate immune system, plays an important role in renal transplantation. Complement is involved in the protection against foreign organisms and clearance of apoptotic cells but can also cause injury to the renal allograft, for instance, via antibody binding or in ischemia–reperfusion injury. Numerous polymorphisms in complement factors have been identified thus far; some of them result in different functionalities or alter complement levels. In this review, we provide an overview of the literature on the role of complement polymorphisms in renal transplantation. Furthermore, we discuss functional complement polymorphisms that have not yet been investigated in kidney transplantation. By investigating multiple polymorphisms both in donor and recipient at the same time, a complotype can be constructed. Because the combination of multiple polymorphisms is likely to have a greater impact than a single one, this could provide valuable prognostic information.     

Borderline Changes in Renal Transplantation: Are We Aware of the Real Impact in Graft Survival?

BackgroundBorderline changes suspicious for acute T-cell–mediated rejection (BC) are frequently seen on biopsy specimens, but their clinical significance and clinical management are still controversial. Our goal was to compare clinical outcomes of kidney transplant recipients with biopsy-proven BC vs acute T-cell–mediated rejection (aTCMR) and the influence of treating BC on graft outcomes.MethodsA retrospective cohort study was performed in all kidney transplant recipients with biopsy-proven BC and aTCMR between January 2012 and December 2018, according to Banff 2017 criteria; patients with concomitant antibody-mediated rejection were excluded.ResultsWe included 85 patients, 30 with BC (35.3%) and 55 with aTCMR (64.7%). There was no difference between groups regarding demographics, HLA matching and sensitization, immunosuppression, or time of transplant. Treatment with steroids was started in 15 patients with BC (50%) and in all patients with aTCMR, with 4 of the latter additionally receiving thymoglobulin (7.2%). At 1 year post biopsy, overall graft survival was 71%, and despite presenting better estimated glomerular filtration rate (eGFR) at biopsy (33.3 ± 23.4 vs 19.9 ± 13.2 mL/min/1.73 m², P = .008), patients in the BC group presented the same graft survival as the aTCMR group according to Kaplan-Meyer survival curves. When analyzing the BC group (n = 30) and comparing the patients who were treated (n = 15) vs a conservative approach (n = 15), graft survival at 1 year was 87% for treated patients and 73% for nontreated patients (P = .651), with no difference in eGFR for patients with functioning graft. However, at longer follow-up, survival curves showed a trend for better graft survival in treated patients (70.2 ± 9.2 vs 38.4 ± 8.4 months, P = .087).ConclusionOur study showed that patients with BC did not present better graft survival or graft function at 1 year after biopsy or at follow-up compared with the aTCMR group, despite better eGFR at diagnosis. We found a trend for better graft survival in patients with BC treated with steroids compared with a conservative approach. These results reinforce the importance of borderline changes in graft outcomes and that the decision to treat can influence long-term outcomes.     

The Vascularized Fibular Graft in Precollapse Osteonecrosis: Is Long-term Hip Preservation Possible?

Background  

Osteonecrosis of the femoral head (ONFH) is a debilitating condition affecting primarily young patients. Free vascularized fibular grafting (FVFG) may provide a durable means to preserve the femoral head. When used in the precollapse stages of ONFH, this treatment may alter the course of disease.     

Lung Transplantation From Donors After Previous Cardiac Surgery: Ideal Graft in Marginal Donor?

Lung transplantation is a limited by donor pool shortage. Despite the efforts to extend the graft acceptability with recurrent donor criteria reformulations, previous cardiothoracic surgery is still considered a contraindication. A donor who underwent cardiac surgery could potentially provide an ideal lung but high intraoperative risks and intrinsic technical challenges are expected during the graft harvesting. The purpose of this study is to present our dedicated protocol and four clinical cases of successful lung procurements from donors who had a previous major cardiac surgery. One donor had ascending aortic root (AAR) substitution, another had mitral valve substitution, and two had coronary artery bypass surgery. The others' eligibility criteria for organ allocation, such as ABO compatibility, PaO₂/FiO₂ ratio, absence of aspiration, or sepsis were respected. In one of the cases with previous coronary bypass grafting, the donor had a veno-arterial extracorporeal membrane oxygenation support. Consequently, the grafts required an ex vivo lung perfusion evaluation. We report the technical details of procurement and postoperative courses of recipients. All procurements were uneventful, without lung damage or waste of abdominal organs related to catastrophic intraoperative events. All recipients had a successful clinical outcome. We believe that successful transplantation is achievable even in a complicated setting, such as cases involving donors with previous cardiac surgery frequently are. Facing lung donor shortage, we strongly support any effort to avoid the loss of possible acceptable lungs. In particular, previous major cardiac surgery does not strictly imply a poor quality of lungs as well as unsustainable graft procurement.     

Perioperative Fluid Management in Kidney Transplantation: Is Volume Overload Still Mandatory for Graft Function?

Kidney transplantation is now recognized as the treatment of choice for patients with chronic renal failure. Despite the extension of indications to patients suffering severe hypertension, ischemic heart disease, and chronic heart failure, the worldwide results are superb. However, perioperative cardiac complications occur in 6% to 10% of transplanted patients. Aggressive intraoperative volume expansion is still recommended to maximize graft functional recovery (up to 30 mL/kg/h, central venous pressure [CVP] > 15 mm Hg), but patients with preexistent cardiac disease or poor myocardial function are exposed to the risk of fluid overload, acute respiratory failure, and prolonged ventilation. Among the last 90 cases performed at our institution, good functional recovery of the graft was present in 94% of the patients within 2 weeks, despite a much more conservative intraoperative hydration policy (crystalloids 2400 +/- 1000 mL, 15 mL/kg/h, CVP 7-9 mm Hg). Graft failure which occurred in 5 patients was significantly correlated only with donor age, while perioperative cardiovascular complications had been present in 9 cases (10%) who were coronary artery disease patients (55%). Age above 50 years was the only significant risk factor. Supranormal volume loading is probably not always warranted in kidney transplantation.     

Enterobacter cloacae–Related Necrotizing Fasciitis After Peritoneal Dialysis in Delayed Graft Function: A Case Report

Introduction

Necrotizing fasciitis is an uncommon soft-tissue infection that involves the superficial fascia, subcutaneous fat, and deep fascia. Herein, we report the first case of Enterobacter cloacae–related necrotizing fasciitis after peritoneal dialysis in delayed graft function.

Low Body Mass Index in Kidney Transplant Recipients: Risk or Advantage for Long-Term Graft Function?

OBJECTIVES: Nutritional status is known to be a marker of overall health status and a strong predictor of patient survival in several diseases. Whereas obesity is suspected to have a negative influence on general renal transplantation outcomes, the relationship between impaired nutritional status and long-term kidney graft survival is not yet clear. METHODS: We retrospectively analyzed graft survival with a follow-up time of 5 to 12.5 years among 224 kidney transplantations. A Cox proportional hazards model was applied to estimate risk factors for loss of graft function. RESULTS: The Cox model initially showed no significant influence of the body mass index (BMI) at 1 year after transplantation on the risk of transplant failure (relative risk 0.97 per BMI unit, P = .34). When the patients were divided into two groups according to BMI, a clear disadvantage was shown in terms of long-term graft survival for the groups with a low BMI. The risk of loss of transplant function increased by a factor of 1.85 (relative risk) if the BMI 1 year after kidney transplantation was less than 23 (P = .035). CONCLUSIONS: These findings suggested impaired long-term kidney graft survival among patients with reduced nutritional status. This result is assumed to reflect improved immune function due to reduced nutrient availability, thus leading to reinforcement of chronic rejection processes. This assumption is consistent with the already known immunomodulatory effect of caloric restriction to mitigate T-cell activation.     

Is the Visual Examination of LIMA Graft Sufficient for the Decision Reusing of This Graft in Redo Coronary Bypass Surgery?

Redo coronary artery bypass grafting (CABG) compromises a growing proportion of CABG in the current era of revascularization. Intimal hyperplasia at the site of anastomosis between left internal mammary artery (LIMA) and left anterior descending artery (LAD) is not infrequently reported causing severe ischemic symptoms in some patients. An additional grafting to distal LAD territory is a proper decision for the surgical strategy in most of the cases. Radial artery or venous grafts have been used for this purpose. Shortage of arterial grafts is the major concern in redo coronary surgery. Whether the previously anastomosed LIMA can be used is a major question in decision-making process. In this case report, we presented a complicated patient in whom LIMA was not reused although visual or angiographical examination was normal.     

Editorial Commentary: Is the Capsulodesis the Solution to Reduce Graft Extrusion in Meniscal Allograft Transplantation?

The causes of graft extrusion after lateral meniscus allograft transplantation seem to be a multifactorial problem. A recent study shows that the lateral capsulodesis technique could result in better results relative to the degree of meniscal extrusion compared with the bone-bridge fixation technique. Long-term comparative clinical studies are needed to confirm the efficacy of this procedure.     

Does Contrast Medium Administration in Organ Donors Affect Early Kidney Graft Function?

Since the upper age for organ donors has been raised, a higher incidence of preexistent organ damage and functional impairment is to be expected. Coronary artery sclerosis increases with age. It can only be diagnosed with certainty by coronary angiography. Since contrast medium administration may cause renal damage when risk factors are present, this study sought to establish whether angiography negatively influenced the early postoperative function of kidney grafts. We compared the clinical courses of 36 recipients of kidneys from donors in whom coronary angiography or levography had been performed with 36 recipients of kidneys from donors who had not been subjected to contrast medium. The results showed that the administration of contrast medium had no influence on renal function at 3 or 6 months after transplantation. In conclusion, fears that donor kidneys might be harmed by contrast medium appeared to therefore be unfounded.     

BK Virus–Associated Urothelial Carcinoma of a Ureter Graft in a Renal Transplant Recipient: A Case Report

Background

Urothelial carcinomas of ureter grafts in renal transplant patients are rare. Here we report our experience with a case of BK virus–associated urothelial carcinoma in a ureter graft.

Case Report

A 47-year-old man developed chronic renal failure secondary to diabetes mellitus and started maintenance hemodialysis in September 2007. Two months later, the patient received a renal transplant from his 70-year-old mother. The patient developed BK virus–associated nephropathy 1 year after transplantation and presented with a decline in renal function and hydronephrosis in the transplanted kidney 4 years 6 months after transplantation. Cystoscopy and retrograde pyelography revealed an irregular filling defect in the ureter graft. Cytologic diagnosis of his urine revealed a high-grade urothelial carcinoma. Computerized tomography showed a cT2 ureteral tumor and no involvement of other organs. The patient subsequently underwent a transplant nephroureterectomy with bladder cuff resection. Histopathologic findings revealed a high-grade urothelial carcinoma, pT2, in the ureter graft with SV40-positive staining. The patient was closely observed without adjuvant chemotherapy therapy and remained disease free 1 year after surgery. Renal transplant recipients with BK virus infection are at high risk of developing urologic malignancies. Close attention is necessary to diagnose post-transplantation urologica malignancies as early as possible.     

Does Procurement Technique Affect Posttransplant Graft Function in Deceased Donor Liver Transplantation?

Introduction

Various techniques have been described deceased donor liver transplantation (DDLT) procurement. One is a technique whereby almost total dissection is done in the porta hepatis and perihepatic detachment is carried out before cross-clamping the donor aorta. In another approach, after the donor aorta is cross-clamped, rapid and minimal en bloc dissection is performed with minimal manipulation. We evaluated early posttransplant graft function among liver procurement techniques.

Method

Between January 2008 and August 2012, we performed 45 consecutive adult DDLTs. One patient was excluded from this analysis due to early death from sepsis after transplantation. The 44 included patients were divided into two cohorts according to the procurement technique: A warm dissection (n = 23; 52%) and a cold dissection group (n = 21; 48%). We compared early posttransplant graft function using the aspartate aminotransferase (AST), alanine aminotransferase (ALT), total bilirubin (T-bil), and prothrombin time (PT) values of the two groups from the first to seventh postoperative day.

Result

The AST values in the warm group were significantly greater than those in the cold group on postoperative days 3 and 5. In addition, the ALT values in the warm group were greater than those in the cold group on postoperative days 4, 5, and 6. Moreover, the T-bil values in the warm group were greater than those in the cold group on postoperative days 2, 3, 4, 5, 6, and 7. However, there were no differences in PT values.

Conclusion

During liver procurement for DDLT, rapid en bloc procurement with minimal manipulation after clamping the donor aorta achieved better early graft function posttransplantation.     

Preischemic Iloprost Application for Improvement of Graft Preservation: Which Route is Superior in Experimental Pig Lung Transplantation: Inhaled or Intravenous?

BACKGROUND: Optimal allograft protection is essential in lung transplantation to reduce postoperative organ dysfunction. Although intravenous prostanoids are routinely used to ameliorate reperfusion injury, the latest evidence suggests a similar efficacy of inhaled prostacyclin. Therefore, we compared donor lung-pretreatment using inhaled lioprost (Ventavis) with the commonly used intravenous technique. METHODS: Five pig lungs were each preserved with Perfadex and stored for 27 hours without (group 1) or with (group-2, 100 prior aerosolized of iloprost were (group 3) or iloprost (IV). Following left lung transplantation, hemodynamics, Po(2)/F(i)o(2), compliance, and wet-to-dry ratio were monitored for 6 hours and compared to sham controls using ANOVA analysis with repeated measures. RESULTS: The mortality was 100% in group 3. All other animals survived (P < .001). Dynamic compliance and PVR were superior in the endobronchially pretreated iloprost group as compared with untreated organs (P < .05), whereas oxygenation was comparable overall W/D-ratio revealed significantly lower lung water in group 2 (P = .027) compared with group 3. CONCLUSION: Preischemic alveolar deposition of iloprost is superior to IV pretreatment as reflected by significantly improved allograft function. This strategy offers technique to optimize pulmonary preservation.