Can Preemptive Kidney Transplantation Guarantee Longer Graft Survival in Living-Donor Kidney Transplantation? Single-Center Study

Introduction

The benefit of preemptive kidney transplantation (KTx) for graft survival compared with nonpreemptive KTx is controversial.

Objective

To analyze the influence of preemptive KTx on graft survival.

Patients and Methods

The study included 476 of 531 patients who had undergone living-donor KTx between January 2000 and June 2007. Pediatric patients and those who had previously undergone KTx were excluded. Recipients were divided into 2 groups; group 1 included 413 patients (86.8%) who received grafts after institution of maintenance dialysis, and group 2 included 63 patients (13.2%) who underwent preemptive KTx.

Results

Donor type and HLA mismatch demonstrated significant differences between the 2 groups. Group 1 had more living donors and fewer HLA mismatches. Warm ischemia time in group 2 was significantly shorter than in group 1. The serum creatinine concentration in group 1 on postoperative day 7 was significantly higher than in group 2. Five- and 10-year graft survival in groups 1 and 2, respectively, were 95.3% and 81.3% vs 92.9% and 92.9%. Graft survival was not significant insofar as duration and method of dialysis. At our institution, independent risk factors for graft survival in living-donor KTx are primary end-stage renal disease, acute cellular rejection episodes, and recipient age.

Conclusion

We observed no benefit on graft survival in recipients of living-donor KTx insofar as whether they had undergone previous dialysis.     

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.     

Surgery for Hepatocellular Carcinoma: Does It Improve Survival?

Background: The incidence and mortality of hepatocellular carcinoma (HCC) are increasing in the United States. Whether surgery is associated with improved survival at the population level is relatively unknown. To address this question, we used a population-based cancer registry to compare survival outcomes between patients receiving and not receiving surgery with similar tumor sizes and health status.Methods: By using the Surveillance, Epidemiology, and End Results database, we identified HCC patients who had surgically resectable disease as defined by published expert guidelines. After excluding patients with contraindications to surgery, we performed both survival analysis and Cox regression to identify predictors of improved survival.Results: Of the 4008 patients diagnosed with HCC between 1988 and 1998, 417 were candidates for surgical resection. The mean age was 63.6 years; mean tumor size was 3.3 cm. The 5-year overall survival with surgery was 33% with a mean of 47.1 months; without surgery, the 5-year overall survival was 7% with a mean of 17.9 months (P < .001). In the multivariate Cox regression, surgery was significantly associated with improved survival (P < .001). Specifically, patients who received surgery had a 55% decreased rate of death compared with patients who did not have surgery, even after controlling for tumor size, age, sex, and race.Conclusions: This study shows that surgical therapy is associated with improved survival in patients with unifocal, nonmetastatic HCC tumors <5 cm. If this is confirmed in future studies, efforts should be made to ensure that appropriate patients with resectable HCC receive high-quality care, as well as the opportunity for potentially curative surgery.     

Will Incremental Hemodialysis Preserve Residual Function and Improve Patient Survival?

The progressive loss of residual renal function in peritoneal dialysis patients is associated with increased mortality. It has been suggested that incremental dialysis may help preserve residual renal function and improve patient survival. Residual renal function depends upon both patient related and dialysis associated factors. Maintaining patients in an over‐hydrated state may be associated with better preservation of residual renal function but any benefit comes with a significant risk of cardiovascular consequences. Notably, it is only observational studies that have reported an association between dialysis patient survival and residual renal function; causality has not been established for dialysis patient survival. The tenuous connections between residual renal function and outcomes and between incremental hemodialysis and residual renal function should temper our enthusiasm for interventions in this area.     

Does CT-Based Navigation Improve the Long-Term Survival in Ceramic-on-Ceramic THA?

Background  

Although navigated THA provides improved precision in implant positioning and alignment, it is unclear whether these translate into long-term implant survival.     

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.     

Can the Kidney Weight and Recipient Body Weight Ratio Predict Long-Term Graft Outcome in Living Donor Kidney Transplantation?

We investigated the effect of the donor kidney weight (Kw) to recipient body weight (Rw)ratio (Kw/Rw) on long-term graft function. To investigate the impact of the Kw/Rw ratio on the graft function, we retrospectively collected data from 213 kidney transplant recipients at least 5 years Post-transplantations. Renal function showed a positive correlation with the Kw/Rw ratio until 5 years after transplantation (at 60 months after transplantation, R = 0.158, P = .023); however, this ratio does not affect graft survival (P = .794). We used the mixed-effect model to identify the factors that affect the estimated glomerular filtration rate (eGFR) over time. In univariate analysis, donor age, BSA, kidney weight, and Kw/Rw ratio were associated with eGFR. To identify independent factors that affect to the eGFR, multivariate analysis using a mixed model was applied. Donor age (P < .001) and Kw/Rw ratio (P < .001) were independent factors that affected the eGFR. To identify the cutoff values of the Kw/Rw ratio and donor age that affect long-term graft function, multiple testing using a mixed model was applied. The cutoff value for the Kw/Rw ratio was 3.16 (P = .0104) and the cutoff value of donor age was 44 years (P = .0001). Based on our results, we conclude that the Kw/Rw ratio and donor age are important factors for the long-term function of graft.     

Can a Tissue-Engineered Skin Graft Improve Healing of Lower Extremity Foot Wounds after Revascularization?

p < 0.01) and the median time to complete wound closure (7 vs. 15 weeks, p= 0.0021, rank-sum test). There was no difference in the wound closure rate of meshed and unmeshed graft at 4, 8, 12, or 24 weeks (p > 0.05). Three indolent localized wound infections in the tissue-engineered skin graft group were the only complication. Tissue-engineered skin grafting can be used safely in previously ischemic wounds after lower extremity revascularization. Treatment with this graft promotes healing more rapidly and in more patients than standard moist dressings. It obviates the risk, inconvenience, and expense of donor skin harvesting, anesthesia, and hospitalization associated with autologous skin grafting. This graft may represent an advance in the treatment of previously ischemic lower extremity foot wounds.     

Does Surgical Resection of Pulmonary Metastases of Head and Neck Cancer Improve Survival?

Background  The prognosis of patients with metastasized head and neck cancer is poor. Limited experience exists with the benefit of resection of lung metastases and systematic mediastinal and hilar lymph node dissection on survival of patients with head and neck carcinoma. Methods  Eighty patients undergoing metastasectomy for pulmonary metastases of primary head and neck cancer entered the study. Multivariate analysis was performed by Cox regression analysis. Survival differences between patients operated and those not operated on were analyzed by matched pair analysis. Results  From 1984 until 2006, pulmonary metastases were diagnosed in 332 patients treated for head and neck cancer; 80 of these were admitted to our department for resection. Metastases of the primary head and neck tumor were confirmed histologically in 67 patients. The median overall survival after resection of lung metastases was 19.4 months and was statistically significantly better compared with patients who were not operated on (P < .001). The multivariate analysis after metastasectomy revealed that incomplete resection of pulmonary lesions, complications associated with surgery, and adjuvant therapy of the primary tumor are independent negative prognostic factors for survival. We observed a trend to improved survival in patients without hilar or mediastinal lymph node metastases. Conclusion  The survival rate of patients operated on was statistically significantly higher than that of patients with conservative treatment. Even patients with multiple or bilateral pulmonary lesions after curative treatment of a primary tumor should be operated on if there is no contraindication against an extended surgical procedure and a complete resection of the metastases seems achievable. The first two authors contributed equally to this work.     

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.     

Effects of Graft Quality on Non-Urgent Liver Retransplantation Survival: Should We Avoid High-Risk Donors?

Background

Few studies have studied the effects of graft quality on non-urgent liver retransplantation (ReLT) outcomes. We aimed to analyze graft characteristics and survival in non-urgent ReLT and the effect of using grafts with extended criteria on survival.

Methods

Eighty non-urgent ReLT were performed from June 1988 to June 2010. The whole series was divided by identical time periods to study time-related effects. We assessed graft quality with donor risk index (DRI) and Briceño scores and recipient status with the Model for End-stage Liver Diseases and Rosen scores. Low and high-risk grafts were defined by a DRI cutoff of 1.8.

Results

Graft survival was similar in both periods (1-, 5-, and 10-year graft survivals: 73.5, 46.9, and 40.8 versus 71, 47.7, and 47.7%, p = 0.935) although donor quality was worse in the second period (DRI: 1.35 ± 0.32 vs. 1.66 ± 0.34, p < 0.001). In the first period high-risk grafts did worse than low-risk grafts (5-year survival: 0 vs. 54.5%, p = 0.002) while in the second period outcomes were similar (5-year survival: 48.6 vs. 56.7 %, p = 0.660). Donor age was the only independent donor factor for graft survival, with lower survival when using grafts from donors over 60-years-old.

Conclusions

Graft quality in ReLT has worsened with time mainly because of older donors but nowadays the use of high-risk grafts in non-urgent ReLT is not associated with worse graft survival because of better perioperative management. Moreover of being selective on recipient conditions, care should be taken when using grafts from donors over 60-years-old for non-urgent ReLT.     

Potential Prophylactic Measures Against Postoperative Immunosuppression: Could They Reduce Recurrence Rates in Oncological Patients?

Background: Removing the primary tumor is indispensable for eliminating the major pool of metastasizing cells, but the surgical procedure itself is suspected of promoting metastases. This adverse effect is attributed to several mechanisms acting in synergy, including mechanical release of tumor cells, enhanced angiogenesis, secretion of growth factors, and immunosuppression. Here we provide new insights into mechanisms of postoperative immunosuppression and assess the assumptions underlying the hypothesis that, by suppressing cell-mediated immunity (CMI), surgery may render the patient vulnerable to metastases that otherwise could have been controlled.Methods: An extensive review of relevant articles in English identified by using the MEDLINE database and cross-referencing.Results: Current literature suggests that (1) CMI can control minimal residual disease, especially if surgery is performed early; (2) major surgery transiently but markedly suppresses CMI through multiple mechanisms now better understood; (3) surgical stress promotes experimental metastasis through immunosuppression, but the clinical evidence remains indirect because of ethical limitations.Conclusions: Minimizing postoperative immunosuppression seems feasible, may limit recurrence, and should be introduced into the broader array of considerations when planning oncological surgeries. In the short run, physicians could try to avoid immunosuppressive anesthetic approaches, inadvertent hypothermia, excessive blood transfusions, and untended postoperative pain. When feasible, minimally invasive surgery should be considered. In the long run, clinical trials should evaluate prophylactic measures, including perioperative immunostimulation and several antagonists to cytokines and hormones specified herein.