Kidney transplant complications and obesity

Objective

To determine the rate of graft failure and complications secondary to morbid obesity in kidney transplant patients at our institution.

Methods

A retrospective study involving recipients renal transplants from 2002 to 2007. Patients were divided into 3 groups: group 1, body mass index (BMI) >35 underwent a diet plan and gained weight posttransplant; group 2, BMI >35 underwent successful diet modifications posttransplant; and group 3, BMI <35 did not undergo a diet regimen.

Results

Sixty-six patients were studied. Group 1 patients, (n = 21, BMI >35) had higher postoperative complications, longer operative time, and longer hospital stay when compared with their obese counterparts group 3 (n = 23, BMI <35). We saw no significant change in postoperative complications between group 2 and group 3 (n = 22, BMI > 35).

Conclusions

Worse graft function and complications were seen with patients who gained weight post operatively. Conversely, a good outcome was seen with those patients that lost weight pre and post operatively. The results of this study may open the field for pretransplant weight loss procedures to improve quality of life, nutrition, and overall health of transplant candidates.     

Management of the obese kidney transplant candidate

Obesity is an increasingly common condition that can exclude end stage renal disease patients from consideration of kidney transplantation. The optimal management of obese transplant candidates is uncertain, especially the use of pharmacologic therapies or bariatric surgery. We review the rationale to consider transplantation in obese patients, the impact of obesity on access to kidney transplantation, the evidence for obese patients to lose weight loss prior to kidney transplantation, peri-operative management considerations and specific weight loss strategies prior to transplantation. We also propose an algorithm for pre-transplant management of obese transplant candidates that takes into consideration the patient's peri-operative risk, the anticipated time to transplantation and the risk of delayed graft function. Finally, we suggest a number of areas in need of further research as well as health policy considerations to improve the care of obese kidney transplant candidates.     

Portopulmonary hypertension and the liver transplant candidate

The management of the liver transplant (OLT) candidate with portopulmonary hypertension (PPHTN) has dramatically changed in the past 3 years. Careful preoperative evaluation with functional characterization of right ventricular function plays a critical role. The pulmonary vascular response to epoprostenol infusion serves as a deciding factor for OLT candidacy. Careful perioperative attention to avoid right ventricular failure from acutely elevated pulmonary artery pressures or sudden increases in right ventricular preload is a key physiologic tenet of management. With increased surgical expertise, anesthetic sophistication, and availability of epoprostenol, PPHTN is no longer considered an absolute contraindication for OLT.     

Management of the sensitized adult heart transplant candidate

Eckman PM, Hanna M, Taylor DO, Starling RC, Gonzalez‐Stawinski GV. Management of the sensitized adult heart transplant candidate.
Clin Transplant 2010: 24: 726–734. © 2010 John Wiley & Sons A/S. Abstract: Heart transplant recipients sensitized to human leukocyte antigens comprise a challenging subgroup of patients. Sensitization has been associated with a variety of effects that determine short‐term and long‐term outcomes. These include a higher rate of acute rejection and graft loss, and a heightened risk for developing cardiac allograft vasculopathy. Because of improvements in both tissue typing and immunomodulatory therapies coupled with the growing population receiving mechanical circulatory support/LVAD, the percent of sensitized patients listed for heart transplantation has increased, inflicting a greater burden to the already scarce donor pool. Despite these potentially adverse developments, pre‐transplant immunologic management has resulted in decreased waiting times and outcomes that were not possible over 10 yr ago. The following review will focus on the contemporary management of the sensitized heart transplant candidate and highlight therapies that have allowed the successful transplantation of this growing and challenging patient population, including several approaches in development.     

Kidney transplant performed after liver transplant: a single center experience

Changes in liver allocation due to institution of the model for end-stage liver disease/PELD criteria have led to an increase in the number of patients receiving liver transplants who have elevated creatinine. Whether these patients' renal dysfunction is reversible or not and whether they should receive combined liver and kidney transplants (KTXs) are individualized decisions, although some criteria are becoming clearer. A part of this decision must consider the outcomes of patients who have liver transplants alone but later require KTXs. We herein describe our single-center experience with this patient population. Our data show that KTX subsequent to liver transplantation (TX) is generally safe and effective, with a possibly higher surgical complication rate than standard KTX. Outcomes analysis showed not statistically different patient survival of KTXs performed after liver transplant (KALT) compared with KTX alone. Death censored graft survival was statistically lower in the KALT group but this largely accrued in the first three yr after transplant and was nearly equivalent by 10 yr.     

Kidney transplant options for the diabetic patient

For patients with diabetes and progressive chronic kidney disease, kidney transplantation is the optimal mode of renal replacement therapy, with or without a pancreas transplant. Additional benefits of pancreas transplant have become increasingly apparent due to advances in surgical outcomes and immunosuppression, and may be reasonably considered even in selected patients with type 2 diabetes. In general, pancreas transplantation is associated with long-term survival advantages despite an increased short-term morbidity and mortality risk. This is true with simultaneous pancreas kidney transplantation or pancreas after kidney transplantation compared to kidney transplantation alone, regardless of kidney donor status (living or deceased). Individual patient preferences, comorbidities, and expected waiting time influence selection of transplant modality, rather than a clear survival benefit of one strategy versus the other. In selected patients with type 2 diabetes, recent outcomes data support cautious utilization of simultaneous pancreas kidney transplantation when a living kidney donor transplant is not an option. The purpose of this review is to summarize current data regarding kidney and pancreas transplant treatment options in patients with both type 1 and 2 diabetes and the influence of current organ allocation policies to better understand the advantages and disadvantages of each of these strategies.     

Kidney transplant program waitlisting rate as a metric to assess transplant access

Kidney transplant program performance in the United States is commonly measured by posttransplant outcomes. Inclusion of pretransplant measures could provide a more comprehensive assessment of transplant program performance and necessary information for patient decision-making. In this study, we propose a new metric, the waitlisting rate, defined as the ratio of patients who are waitlisted in a center relative to the person-years referred for evaluation to a program. Furthermore, we standardize the waitlisting rate relative to the state average in Georgia, North Carolina, and South Carolina. The new metric was used as a proof-of-concept to assess transplant-program access compared to the existing transplant rate metric. The study cohorts were defined by linking 2017 United States Renal Data System (USRDS) data with transplant-program referral data from the Southeastern United States between January 1, 2012 and December 31, 2016. Waitlisting rate varied across the 9 Southeastern transplant programs, ranging from 10 to 22 events per 100 patient-years, whereas the program-specific waitlisting rate ratio ranged between 0.76 and 1.33. Program-specific waitlisting rate ratio was uncorrelated with the transplant rate ratio (r = −.15, 95% CI, −0.83 to 0.57). Findings warrant collection of national data on early transplant steps, such as referral, for a more comprehensive assessment of transplant program performance and pretransplant access.     

Pulmonary hypertension: considerations in the liver transplant candidate

Pulmonary hypertension is a potentially lethal complication of end-stage liver disease with a prevalence of 2%. In the setting of liver transplantation, the prevalence may be as high as 12%. Given the potential importance of this syndrome to the transplantation community, the purpose of this review is to summarize the current state of understanding of portopulmonary hypertension and to suggest potential management strategies for (1) liver transplant candidates with suspected pulmonary hypertension and (2) intraoperative pulmonary hypertension following liver allograft reperfusion.     

Transportation for a pediatric heart transplant candidate to Germany

A 8-year-old girl who underwent a total cavopulmonary connection as an one-staged repair for tricuspid atresia (Ic) had had a progressive dilated cardiomyopathy. Despite of any medical support, her left ventricular ejection fraction had been ranged from 10% to 20% since 4 months after Fontan operation. This patient was decided to apply for a heart transplantation in Germany 17 months after Fontan operation. An administration of the sufficient amount of inotropics and oxygen, volume resuscitation, reduction of the peripheral circulation at the time of take-off, and a meticulous monitoring may contribute to the successful transportation of the critically ill patient.     

Kidney transplant monitoring by anti donor specific antibodies

Donor-specific anti-HLA antibodies were studied by cytotoxicity crossmatching (CTXM) and flow cytometry crossmatching (FCXM) in 117 kidney transplant candidates; the same study was carried out in 33 cadaver-donor kidney recipients, during the first 3 post-transplant months, for which donor cells were available. Pre-transport evaluation showed that 82.9 % of subjects were CTXM negative/FCXM negative, 6.8 % of patients were positive in both tests, and 10.3 % were CTXM negative/FCCM positive. Post-transplant monitoring for donor-specific antibodies (Abs-DS) showed that nine recipients (27.3 %) were FCXM positive; six of them were IgG + and three IgM +. In comparing these results with the clinical course, a significant association between FCXM IgG + and rejection episodes was observed (P < 0.01).     

Kidney function in cyclosporine-treated paediatric pulmonary transplant recipients

BACKGROUND: Lung or heart-lung transplantation is a useful therapy in life-threatening pulmonary disorders during childhood. Cyclosporine A is a major immunosuppressive treatment but has a number of adverse effects including nephrotoxicity. There have been no reports on the long-term evolution of renal function in a large series of paediatric pulmonary transplantation recipients. METHODS: We examined 19 patients followed up for at least 3 years after pulmonary transplantation. The mean time of follow-up was 5.36 years. Kidney function was evaluated by calculation of glomerular filtration rate (GFR) according the Schwartz formula. RESULTS: The GFR was normal before transplantation in all patients. The short-term evolution of GFR was marked by a significant drop during the first and until the 6th month. Then, regardless of the level reached at the end of the 6th month, the GFR remained stable in all patients except one until the end of follow-up. At the end of follow-up, 31% had normal GFR, 57% had mild chronic renal failure, and 5% had advanced renal failure. Hypertension was frequent and associated with renal failure. CONCLUSIONS: Paediatric pulmonary recipients showed evidence of long-term cyclosporine A-associated nephrotoxicity. Most of this toxicity occurred during the first 6 months.