Ureteral Stenosis After Renal Transplantation—A Single-Center 10-Year Experience

Background

Kidney transplantation (KT) is the definitive treatment for ESRD. Ureteral stenosis (US) is one of the most common urologic complications and has been reported in 2.6%–15% of KTs.

Sexual Dysfunction in Patients With Chronic Renal Disease: Does It Improve With Renal Transplantation?

IntroductionCurrently in the medical literature there is controversy about the role and effects of renal transplantation (RTx) on the sexual functioning of patients with terminal chronic renal disease (TCRD). There is no clear evidence of the real impact of RTx on sexual functioning in these patients. This article makes a brief summary of the literature, describing the most important clinical concepts, evaluates results, and compares the impact of renal transplantation on sexual function before and after the procedure.Material and MethodsMedline and the Embase database were consulted; Medical Subject Headings used were “Kidney Failure, Chronic,” “Kidney Transplantation,” “Sexual Dysfunction,” “Pleasure,” “Sexual Behavior,” and “Quality of Life.” Search was limited to articles within the last 15 years.ResultsSexual dysfunction affects almost 87% of male and 60% to 80% of female patients; 40% to 78% of male patients with RTx report a sense of improvement on global sexual function, 25% to 30% of female patients of reproductive age with RTx report improvement in sexual performance and decreasing of menstrual cycle alterations. Fewer than 10% of patients receiving an RTx reported a decrease of sexual satisfaction.DiscussionDespite controversy, reviewed results show significant improvement of sexual functioning after receiving an RTx. Those who report no improvement of sexual functioning may have conditions attributable to implicit characteristics of TCRD (age, neuroendocrine/metabolic problems) and/or RTx (immunosuppressive therapy). RTx improves sexual functioning by improving sexual desire and overall sexual satisfaction.ConclusionIdentified determinants associated with improvement of sexual functioning are decreased prolactin serum level, age younger than 45 years, and onset of dialysis less than 6 months.     

Effect of Age on Liver Transplantation Recipient Outcomes: Two Centers’ Experience

BackgroundLiver diseases epidemiology has changed with advances in perioperative care. Transplantation at large centers is favorable among older and younger recipients. Local limitations on transplantation for recipients older than 65 years were cancelled in 2014. This study evaluates the effects of age on the transplantation outcome of Israeli patients in the era after removal of the limitations on recipient age.MethodsThis retrospective analysis examined prospective data on patients older than 18 years who underwent liver or liver–kidney transplantation between 2014 and 2019 at 2 transplantation centers. Patients were divided into 4 age groups (group 1: ≤59 years; group 2: 60–64 years; group 3: 65-69 years; and group 4: ≥70 years). Each group's associations of pretransplantation factors with outcome and survival were examined.ResultsTwo hundred sixty-one recipients underwent 269 transplantations (mean age: 53 ± 12.61 y). There were 181 male (67.8%) and 88 female recipients (67.28%). Overall, 207 patients (79.6%) survived ≥12 months. One-year survival rates were 82.9%, 73.2%, 71.4%, and 93.8% for groups 1 to 4, respectively (not statistically significant; P = .11). One-year graft survival was similar between groups. More patients with chronic obstructive pulmonary disease, diabetes mellitus, or ischemic heart disease tended to survive <12 months. Cardiovascular complication was more common in older groups and affected survival.ConclusionPatient age alone should not be used to deny access to transplantation, which could benefit older nonfrail individuals. However, risk factors such as male sex, chronic obstructive pulmonary disease, ischemic heart disease, diabetes mellitus, and concomitant kidney-liver transplantation should be carefully considered.     

Preemptive Kidney Transplantation—A Team Experience in Uruguay

Kidney transplantation is the best treatment for end-stage chronic renal disease. In Uruguay, the prevalence of patients on dialysis is 757 patients per millon inhabitants, plus 316 alive with a functioning renal graft. We install a preemptive renal transplantation program. Twenty-five patients received grafts without dialysis from 2004 to 2013, 5 receiving their 2nd transplantation and 17 from cadaveric donors, with 7.4 ± 7.7 months in the waiting list. At 24 months, patients' survival rate was 100% and the grafts' 97%, with a serum creatinine of 1.4 ± 0.6 mg%. The developed programs of dialysis and renal health care contributed install our preemptive kidney transplantation. Kidney transplantation should be proposed to selected patients with chronic renal failure as primary therapy of substitution of renal function.     

Outcomes of En Bloc Kidney Transplantation From Pediatric Donors: A Single-Center Experience

Background

To overcome a shortage of donors, cadaveric pediatric en bloc kidneys can be used to expand the donor pool. Recent evidence shows that en bloc kidney transplantation (EBKT) has better outcomes than standard-criteria deceased adult donor kidney transplantation. We reviewed our experiences of EBKT and their outcomes.

Should a Complex Uropathy Be a Contraindication for Renal Transplantation in Children?

Background

Anatomic and functional disorders of the lower urinary tract represent up to 40% of the causes of renal failure in children. Several centers avoid renal transplantation in these patients because of the high risk of complications and lower graft survival. The aim of this work was to determine the frequency of urinary tract abnormalities (UTAs) among our pediatric series, and to compare the frequency of complications, function, and long-term graft survival among patients without versus with UTA.

Methods

This single-center, retrospective study compared outcomes between pediatric recipients with versus without UTA. We analyzed demographic features, etiology, pretransplant protocol, urinary tract rehabilitation, incidence of complications, rejection events, as well as graft function and survival.

Results

Among 328 pediatric cases performed between 1998 and 2008, we excluded nine patients due to incomplete medical records, analyzing 319 procedures in 312 patients. Sixty-seven patients (21%) had UTA. The average age, weight, and height at the time of grafting were significantly lower in the urologic group: 11.1 versus 12.6 years, 28.8 versus 34.4 kg; 125.4 versus 138.4 cm, respectively. There were significantly higher frequencies of a transperitoneal approach and vena cavae and aortic anastomoses among patients with UTA (P < .001), posing a greater technical challenge in this population. No differences in creatinine levels were observed at 0.5, 1, 2, 5, and 10 years: 1.3 versus 1.6 at 5 years, and 1.4 versus 1.5 at 8 years. Urologic complications, including urinary tract infections (UTIs), occurred among 80.6% of patients with UTA versus 42.1% in the non-UTA group (P < .001). UTIs appeared predominantly in patients with UTA (62.7% vs 35.3%, P < .001), representing a 2.7-fold risk compared with those children transplanted for other reasons. Rejection incidence was similar in both groups (49.8%). There was no significant difference in 5-y (89.8% vs 85%) or 10-year (83% vs 67%) graft survivals between the groups (P = .162).

Conclusion

Our results demonstrated that with proper interdisciplinary care, graft and patient survivals of pediatric recipients with UTAs were not affected; therefore, these patients should not be rejected for transplantation.     

Renal Grafts With Multiple Arteries: A Relative Contraindication for a Renal Transplant?

Introduction

Advances in surgical techniques had achieved good outcomes in renal transplantation. There has been controversy with respect to the impact of multiple arteries on the outcome of the renal transplantations.

Objectives

The objectives of this study were to examine the renal function and incidence of complications among grafts with one versus two or more arteries.

Materials and methods

We evaluated 86 patients with renal transplantations between January 2006 and January 2008 as a retrospective comparative study. The patients were stratified according to the number of renal graft arteries: group 1 had one artery (n = 66); group 2, two or more arteries (n = 16).

Results

The warm ischemia time was shorter among group 1 compared with group 2 (P < .03). There were significant differences between the groups with respect to mean blood pressure at 1 year (P < .04). The kidney biopsies after 1-year follow-up did not show any difference.

Conclusion

We considered that the presence of anatomic variations was not a contraindication for renal transplantation, but that it is necessary to continue our follow-up to determine the real impact of these variations on graft and patient survivals.     

Does Tacrolimus Use Have a Sexual Dysfunctional Effect in Women After Renal Transplant?

BackgroundTacrolimus, one of the immunosuppressive agents, is used to prevent tissue rejection in renal transplant recipients, but the relationship between the plasma concentrations of tacrolimus and female sexual dysfunction has not yet been elucidated. The aim of this study was to determine the effect of tacrolimus use on sexual dysfunction of women after renal transplant.MethodsTwenty-one female patients who successfully underwent transplant and were treated with tacrolimus were enrolled as the patient group, while 21 patients presented to the obstetrics and gynecology clinic for different reasons were included in the study as the control group. The Beck Depression Inventory, Beck Anxiety Inventory, and Female Sexual Function Index were applied. Plasma concentrations of tacrolimus were simultaneously measured in transplant recipients.ResultsThe scores of all scales did not differ among groups in terms of depression, anxiety, and sexual dysfunction. All transplant recipients had a plasma concentration of tacrolimus in the range of 3 to 7 ng/L. When the patients were compared by the scores of depression and anxiety scales, the drug levels showed no effect on the depression, anxiety, and female sexual functions.ConclusionsSexual dysfunction appears to be ameliorated in women because of the hormone levels after renal transplant at the end of the dialysis process, hence enhancing the quality of life. Normal plasma levels of tacrolimus, which is known to cause sexual dysfunction, could not change this result.     

Kidneys With Small Renal Cell Carcinoma Used in Transplantation After Ex Vivo Partial Nephrectomy

Background

The increase in the prevalence of end-stage renal disease in developed countries and the shortage of deceased donors have made it necessary to increase the graft pool by means of several strategies, such as living donation, non–heart-beating organ donors, and expanded-criteria donors. This study aimed to assess the short-term outcomes of donor kidneys with small (≤3.5 cm) renal cell carcinoma (sRCC) and to evaluate the possibility of using marginal kidneys in renal transplantation.

Lipid Profile Before and After Renal Transplantation—A Longitudinal Study

Background. The data on lipid profile in renal transplant recipients from the Indian subcontinent is scant. Methods.?Lipid profile was studied in 30 consecutive patients of end stage renal disease before renal transplantation (0 month) and prospectively posttransplantation at 1, 3, and 6 months. The results were compared with 30, age and sex matched, healthy controls. All the patients received triple immunosuppression (prednisolone, azathioprine and cyclosporine). Results.?Pretransplantation, the hypertriglyceridemia and hypercholesterolemia was present in 20% and 7% of the patients and the difference (elevation) in the mean values of various lipid fractions was not significant compared to healthy controls except a fall in HDL (p<.01). After renal transplantation, there was a significant elevation in the mean values of total cholesterol, triglycerides, VLDL, and LDL cholesterol at 1, 3, and 6 months. HDL cholesterol levels remained significantly lower as compared to healthy controls. Although, the mean values of serum triglycerides and cholesterol were significantly higher in diabetic end stage renal disease compared to nondiabetic ESRD, however there was insignificant difference in the lipid profile amongst diabetic and nondiabetic renal allograft recipients. Conclusion.?Our data shows distinct elevation in the lipids and lipoproteins after renal transplantation and immunosuppressive drugs seem to be the culprit.     

Experience With the Use of Sirolimus in Liver Transplantation—Use in Patients for Whom Calcineurin Inhibitors Are Contraindicated

Sirolimus (SRL) provides effective immunosuppression for kidney transplantation and may be useful in patients with delayed allograft function after kidney transplantation. We review our experience with SRL in liver transplant recipients for whom calcineurin inhibitors are undesirable. Fourteen patients with renal insufficiency or acute mental status impairment were administered SRL after liver transplantation (5- to 10-mg load, 1 to 4 mg/d). Immunosuppression also consisted of mycophenolate mofetil and corticosteroids. On resolution of neurological or renal dysfunction (return to baseline mental status or serum creatinine level), tacrolimus (TAC) therapy was initiated. Twelve patients received primary transplants, 1 patient received a combined liver-kidney transplant, and 1 patient received a third transplant. Follow-up was 2 to 7 months. Calcineurin inhibitors were initially withheld in 9 patients, and therapy was aborted because of toxicity in the remaining 5 patients. Mean times to the initiation of SRL and TAC therapy were 5.4 ± 4.6 and 26.8 ± 24.4 days, respectively. Serum trough levels of SRL did not correlate with dose or other patient variables. Two patients died after prolonged pretransplantation hospital courses in the intensive care unit. Six patients experienced acute rejection, but only 1 patient required antilymphocyte therapy. Serum creatinine levels at the start of SRL therapy were 2.2 ± 1.1 and 1.2 ± 0.6 mg/dL at 3 months. All 3 patients with neurological indications for SRL had a return to their baseline mental status. All patients had improved liver function chemistry test results and prothrombin times. No patients developed leukopenia or thrombocytopenia. SRL is safe after liver transplantation in patients with acute neurological or renal impairment. SRL is an attractive alternative when calcineurin inhibitors are undesirable, but serum trough levels of SRL should be monitored. A prospective randomized study of an SRL-based calcineurin inhibitor–avoiding regimen compared with standard therapy in patients with renal insufficiency will further evaluate the role for SRL in liver transplantation. (Liver Transpl 2000;6:734-740.)     

Does Everolimus Associated With a Low Dose of Cyclosporine in Long-Term Cardiac Transplant Recipients Improve Renal Function? Initial Experience

Background

Cyclosporine (CsA) renal toxicity is a well-known side effect. Various immunosuppressive strategies have been developed to minimize renal insufficiency. The use of everolimus associated with low levels of CsA can be an alternative strategy.

Methods

From October 2007 to April 2008, everolimus was started with a lower dose of cyclosporine (trough levels from 109.3 ± 27.5 to 93.7 ± 30.1 ng/mL after 45 days) in 21 cardiac transplant recipients (18 male and 3 female patients, mean age 56.4 ± 10.7 years). Pre-everolimus therapy creatinine levels, creatinine clearances, and glomerular filtration rates were 1.9 ± 0.9 mg/dL, 54.2 ± 18.1 mL/mins and 44.3 ± 16.5 mL/min/m², respectively.

Results

We observed a significant reduction in creatinine levels (from 1.9 ± 0.9 to 1.4 ± 0.3 mg/dL, P = .022) as well as a significant improvement in creatinine clearances (from 54.2 ± 18.1 to 69.0 ± 19.0 mL/min, P = .020) and glomerular filtration rates (from 44.3 ± 16.5 to 57.1 ± 16.3 mL/min/m², P = .010) after 7 days of everolimus therapy. Upon univariate analysis patient age, pretransplantation creatinine clearance, creatinine clearance after everolimus introduction, glomerular filtration rate at 45 days, and time from transplantation were associated with renal improvement. Upon multivariate analysis, only creatinine clearance at 7 days was related to the renal improvement.

Conclusions

These preliminary data suggested that everolimus with a low dose of CsA may be safe and effective to reduce CsA-related renal insufficiency among selected, heart transplant patients.     

Post-Transplant Diabetes Mellitus: Is It Associated With Poor Allograft Outcomes in Renal Transplants?

Background

Post-transplant diabetes mellitus (PTDM) is a common metabolic complication whose incidence ranges from 2 to 50%, reflecting wide variations in population type, criteria for diagnosis, and immunosuppressive regimen. PTDM is associated with poor graft outcomes and increased infections and cardiovascular disease following renal transplants. Therefore, we assessed the incidence of PTDM and examined the association between PTDM and graft function after transplantation.

Materials and methods

We investigated 565 renal transplants in our center. The patients were divided into 2 groups, depending on the time of surgery: group 1 (n = 228, from January 1990 to December 1995) and group 2 (n = 377, from January 1996 to December 2011). In each group, patients were divided into no diabetes mellitus (non-DM), preexisting diabetes mellitus (pre-DM), and PTDM subgroups. PTDM was defined as fasting plasma glucose ≥126 mg/dL. We started treatment by modification of lifestyle and/or antidiabetic medication. All patients in group 1 received cyclosporine (CsA) and patients in group 2 received CsA or tacrolimus. We analyzed the clinical characteristics of recipients, serum creatinine levels, and long-term graft survival.

Results

The overall incidence of PTDM was 11.7% (n = 66); 9.2% (n = 21) in group 1, and 13.4% in group 2. There was a higher incidence of PTDM in the recipients who received tacrolimus than in those who received CsA (25.0% vs 9.5%, P < .001) and the delay before the appearance of PTDM was shorter (38.58 ± 6.94 vs 75.85 ± 7.67, P = .017). Also the tacrolimus dose (20.4l ± 4.28 ng/mL) at the time of PTDM diagnosis was above the therapeutic range (5–20 ng/mL). There were no significant differences in infection and cardiovascular complication rates between the non-DM, pre-DM, and PTDM patients in group 1. In group 2, the use of tacrolimus significantly increased the incidence of PTDM compared with CsA (P < .001). However, there were no significant differences between subgroups in other variables. Serum creatinine levels 10 years after renal transplantation (P = .756 in group 1 and P = .559 in group 2) and long-term graft survival in those groups were not significantly different (P = .067 in group 1 and P = .125 in group 2).

Conclusion

Renal function and allograft outcomes are more impaired in patients with PTDM than in either non-DM or pre-DM patients. However, if regular screening of plasma glucose levels, early diagnosis, and appropriate treatment of PTDM are carried out, the risk of complications can be minimized and the long-term allograft outcomes improved.     

Renal Transplantation in Patients With “Valve Bladder”: Is Bladder Augmentation Necessary?

Introduction

Posterior urethral valve is a common cause of renal failure in children. This disorder often results in small bladder and low compliance, which frequently requires bladder augmentation. Herein, we report our experience in 5 children with “valve bladder” who underwent renal transplantation without preliminary bladder enlargement.

Materials and Methods

Thirteen children with valve bladder undergoing renal transplantation were considered candidates for bladder augmentation. All had oligoanuria at transplantation. In 8 children, bladder augmentation was performed before renal transplantation; in the remaining 5, the decision was postponed until after transplantation. These children underwent transplantation with a ureteral reimplant, and a suprapubic catheter was in place for 2 months. Periodically, renal function, bladder capacity, and compliance were assessed, and renal ultrasonography was performed.

Results

At 1-, 2-, 4-, and 6-month follow-up, the 5 children who did not undergo bladder augmentation demonstrated normal renal function, with improved bladder capacity and absence of hydronephrosis. No significant difference was evident between the 2 groups (augmented vs nonaugmented) insofar as renal function, bladder capacity, or hydronephrosis. After transplantation, bladder augmentation was not deemed necessary in any of the 5 children because of complete restoration of clinical and urodynamic parameters.

Conclusion

Renal transplantation can be performed safely without preemptive bladder augmentation. Ureteral reimplantation is recommended, even in patients with small valve bladders. The decision about the need for bladder augmentation should be made only after normal diuresis is restored.     

Laparoscopic Repair of Incisional Hernia Following Liver Transplantation—Early Experience of a Single Institution in Taiwan

Background

Ventral incisional hernia (VIH) is not uncommon following liver transplantation. Open repair was traditionally adopted for its management. Laparoscopic repair of VIH has been performed successfully in nontransplant patients with evidence of reduced recurrence rates and hospital stay. However, the application of VIH in post-transplantation patients has not been well established. Herein, we provide our initial experience with laparoscopic repair of post-transplantation VIH.