Impact of surgery on immunologic function: comparison between minimally invasive techniques and conventional laparotomy for surgical resection of colorectal tumors

Background

Surgical trauma suppresses host immune function, potentially creating an environment vulnerable to tumor cell growth. This study compared immune function after laparoscopy, minilaparotomy, and conventional colorectal tumor resections.

Methods

Seventy-one patients underwent surgery (20 laparoscopy, 21 minilaparotomy, and 30 conventional). Blood samples were taken before surgery and at 3 hours, 24 hours, and 5 days after surgery. White blood cell constitution was determined using monoclonal antibodies. Levels of TH1 cytokines interferon-γ, tumor necrosis factor-α, and interleukin (IL)-2 and TH2 cytokines IL-10, -4, and -6 were measured in plasma and from supernatants of activated peripheral blood mononuclear cells.

Results

At 5 days after surgery, lymphocyte counts remained low in the conventional and minilaparotomy groups (P = .001 and P = .008) but had resolved in laparoscopic patients. Three-hour postoperative serum IL-6 concentrations were lower in laparoscopic than in conventional patients (P = .028). Production of TH1 cytokines 3 hours after surgery were significantly increased in laparoscopic patients (interferon-γ P = .018, tumor necrosis factor-α P = .011, and IL-2 P = .037).

Conclusions

TH1 lymphocyte function is improved transiently and immune homeostasis restored earlier in patients undergoing laparoscopic colorectal cancer resection, which may influence disease recurrence.     

Results of “Twinning Procedure” in Lung Transplantation: Experience in a Single Center

Introduction

The major limiting factor for lung transplantation (LT), both worldwide and in Spain, is the number of suitable lung donors. This, together with the increased demand for LT, led us to propose the performance of 2 single lung transplantations simultaneously using the same donor (the “twinning procedure”).

Objective

The objective of this study was to analyze the outcome of patients who underwent transplantation with this procedure, assessing differences between the first and the second transplant.

Patients and Methods

From November 2001 to August 2008, 46 single lung transplantations (SLTs) were performed with 23 donors.

Results

The mean ischemia time was 258 minutes (median, 265) for the first transplantation and 312 minutes (median, 320) for the second transplantation. Primary graft dysfunction occurred in 5 patients (24%) in the first group and 9 in the second group (39%; P = .27). The median intubation time was 8 hours for the first and 6.5 hours for the second group. The mean hospital stay was 39 and 31 days, respectively. Postoperative mortality was 2 (8.7%) and 3 (13%) patient, respectively (P = .99). There was no significant difference in the incidence of acute rejection episodes, infections, or chronic rejections. Five-year survival rates were 67.9% for the first and 61.5% for the second (Kaplan-Meier).

Conclusions

The performance of 2 SLTs using the same donor and in the same hospital was feasible with adequate planning, permitting better use of donors and reducing waiting list time and mortality. Our results showed no increased risk for recipients of the second transplant in the early postoperative and long-term periods.     

Management of chronic pancreatitis in the pediatric patient: endoscopic retrograde cholangiopancreatography vs operative therapy

Purpose

The management of chronic pancreatitis (CP) in children is challenging. We compare endoscopic retrograde cholangiopancreatography (ERCP) to operative therapy (OR).

Methods

The study involved review of patients younger than 18 years with CP who underwent ERCP or OR from 1973 to 2007. Follow-up was complete in 95% of patients (median, 6 years; range, 1-23 years).

Results

We identified 37 children with CP; 25 (68%) were managed by OR with 20 of these previously failing ERCP. Twelve (32%) were managed by ERCP alone. Mean follow-up was longer in the OR group (5.1 vs 2.1 years; P = .02). Patients with idiopathic pancreatitis (58% vs 13%; P = .04) and patients with a later onset of pancreatitis (12.0 vs 7.4 years; P = .002) were more likely to be managed with ERCP alone. The patients who underwent OR had a lower rate of recurrent pancreatitis (39% vs 75%; P < .0001), although this did not correlate to fewer hospitalizations or less narcotic use compared to ERCP alone. When patients who failed ERCP and progressed to OR were included in the ERCP alone group, ERCP was worse in recurrence (90% vs 39%; P < .0001) and rate of hospitalization (55% vs 33%; P = .04) compared to OR.

Conclusion

Patients with CP managed by OR have a lower rate of recurrent pancreatitis and hospitalization compared to ERCP.     

Prospective, nonrandomized comparison between right- and left-sided hand-assisted laparoscopic donor nephrectomy

Background

Despite technical improvements, laparoscopic living donor right nephrectomy can be associated with difficulties to obtain a sufficient lengths of right renal vessels. We report our experience with right-sided, hand-assisted, laparoscopic donor nephrectomy (HALDN).

Patients and methods

During a 7-year period (2003-2010), right HALDN was performed on 51 and left HALDN on 40 living kidney donors. We prospectively collected perioperative outcome data in donors and recipients including graft function and calculated 1-year graft survival according to the Kaplan-Meier-method.

Results

There were no conversions. The mean procedure time was 123 minutes versus 135 minutes for left HALDN (P = .09). Mean blood loss was 92 mL versus 101 mL in left HALDN (P = .09). There was no renal artery or vein thrombosis. The mean warm ischemia time was 47 seconds versus 41 seconds in left HALDN (P = .21). Hospital discharge was on an average at 3.4 days postoperatively. Delayed graft function occurred in two recipients: one in the left group and the other in the right group. Further, no significant difference in serum creatinine values was seen between the groups at 1 year after the transplantation. One-year graft survival rate was 97.5% in the left versus 98.1% in the right group.

Conclusion

Right HALDN is as safe and feasible as left HALDN. Hand-assistance results in a convenient length of right renal vessels without an increased incidence of vascular thrombosis.     

Lung transplantation in cystic fibrosis patients in the Czech Republic: initial single-center experience

Background

Lung transplantation is a well established treatment for advanced lung diseases.

Methods

We compared the clinical results of patients with cystic fibrosis (CF) entered into the waiting list with those of patients after lung transplantation.

Results

Among 36 patients with CF on the waiting list, 23 underwent lung transplantation, 8 died, 3 are still on the waiting list, and 2 were excluded from the waiting list. The median waiting list time of 0.48 years (range, 0.03-2.37) was insignificantly longer for patients who died compared with transplanted patients (0.97 vs 0.44 years). Mortality of waiting-list patients was 25.8%. The median survival of transplant patients of 7.48 years (range 0.00-10.85 years) was significantly lower among patients who were colonized (BCC) versus those who were not Burkholderia cepacia complex (0.19 vs 7.48 years; P = .041). The 1-, 3-, and 5-year patient survivals after lung transplantation were 72.9, 54.4, and 54.4, respectively.

Conclusion

The results of patients with cystic fibrosis on the waiting list versus after lung transplantation in our center were similar to those reported in the literature. We confirmed a less favorable prognosis of BCC-colonized patients.     

Hyperuricemia after renal transplantation

Background

Hyperuricemia is a common complication after kidney transplantation, and may adversely affect graft survival.

Objective

To assess the prevalence of and predictors for development of hyperuricemia after renal transplantation.

Materials and Methods

Hyperuricemia was defined as a serum uric acid concentration of at least 7.0 mg/dL in men and 6.0 mg/dL in women. From March 2008 to May 2010, uric acid concentration was measured in 12,767 blood samples from 2961 adult renal transplant recipients (64% male and 36% female patients).

Results

Hyperuricemia was observed in 1553 patients (52.4%). The disorder frequently occurred in women (P = .003) and in patients with impaired renal graft function (P = .00). After adjustment for sex, serum creatinine concentration, diabetes mellitus, cyclosporine concentration, and dyslipidemia, only female sex (P = .03) and renal allograft dysfunction (P = .05) were associated with hyperuricemia after kidney transplantation.

Conclusion

Hyperuricemia is a common complication after kidney transplantation, and renal allograft insufficiency predisposes to higher uric acid concentration.     

Tacrolimus Versus Cyclosporine for Adult Lung Transplant Recipients: A Meta-Analysis

Background

Tacrolimus and cyclosporine are the 2 major immunosuppressants for lung transplantation. Several studies have compared these 2 drugs, but the outcomes were not consistent. The aim of this meta-analysis of randomized controlled trials (RCTs) was to compare the beneficial and harmful effects of tacrolimus and cyclosporine as the primary immunosuppressant for lung transplant recipients.

Methods

We conducted searches of electronic databases and manual bibliographies. We performed a meta-analysis of all RCTs comparing tacrolimus with cyclosporine as primary immunosuppression for lung transplant recipients. Extracted, pooled data for mortality, acute rejection, withdrawals, and adverse events were analyzed using Mantel-Haenszel tests with a random effects model.

Results

Three RCTs including 297 patients were assessed in this study. Mortality at 1 year or more was comparable between lung recipients treated with tacrolimus and cyclosporine (odds ratio [OR], 0.94; 95% confidence interval [CI], 0.42-2.10; P = .88). Tacrolimus-treated patients experienced fewer incidences of acute rejection (MD = −0.14; 95% CI, −0.28 to −0.01; P = .04). Pooled analysis showed a trend toward a lower risk of bronchiolitis obliterans syndrome (BOS) among tacrolimus-treated patients, although it did not reach significances (OR, 0.53; 95% CI, 0.25-1.12; P = .10). Fewer patients stopped tacrolimus than cyclosporine (OR, 0.12; 95% CI, 0.03-0.48; P = .003). The rate of new-onset diabetes was higher among the tacrolimus group (OR, 3.69; 95% CI, 1.17-11.62; P = .03). The incidence of hypertension and renal dysfunction were comparable in these 2 groups (OR, 0.24; 95% CI, 0.03-1.70; P = .15; and OR, 1.67; 95% CI, 0.70-3.96; P = .25, respectively). There was a trend toward lower risk of malignancy in tacrolimus-treated patients, although it did not reach significance either (OR, 0.19; 95% CI, 0.03-1.13; P = .07). The incidence of infection was comparable in these 2 groups (MD = −0.29, 95% CI, −0.68 to 0.11; P = .16).

Conclusion

Using tacrolimus as primary immunosuppressant for lung transplant recipient resulted in comparable survival and reduction in acute rejection episodes when compared with cyclosporine.     

Lung transplantation for patients older than 65 years: is it a feasible option?

Background

Advanced age has been a relative contraindication to lung transplantation. However, the exact age limit for this procedure has not yet been established. The aim of this work is to present our experience with this particular group.

Methods

This retrospective review included medical charts of patients who underwent lung transplantation at our institution from January 2004 to February 2009: namely, 112 cadaveric lung transplants with 12 patients (10.7%) >65 years old.

Results

There were 9 male patients and the overall mean age was 68 years (range 66-72). The indications were pulmonary fibrosis in 8 and emphysema in 4 cases. Four patients had mild coronary artery disease and 4 systemic hypertension. All of the procedures were unilateral and only 2 required extracorporeal circulation. Only 5 patients received blood product transfusions intraoperatively; the mean ischemic time was 222 minutes. Four patients developed primary graft dysfunction, the mean requirement for mechanical ventilation was 30 hours, and the mean intensive care unit stay, 11 days. Postoperative complications were respiratory infections (n = 8), catheter-related infection (n = 1), atrial fibrillation (n = 2). The mean hospital stay was 28 days and the 1-year survival was 75%.

Conclusion

Lung transplantation is a feasible option for well-selected patients with end-stage pulmonary disease who are >65 years old. Our study reinforces the modern trend for unilateral procedures in this situation.     

Exogenous Biliverdin Improves the Function of Lung Grafts From Brain Dead Donors in Rats

Background

Biliverdin, a product of heme oxygenase-1 (HO-1), ameliorates the posttransplant functions of heart, kidney, and liver. In this study, we investigated the effects of biliverdin on lung grafts from brain dead (BD) rat donors.

Methods

Male Wistar rats were randomly divided into 3 groups. The sham group (n = 7), did not undergo BD. Both donor and recipient rats in the BD biliverdin group (n = 8) were injected with biliverdin (35 mg/kg in 1 mL) intraperitoneally after confirmed BD and transplantation. In the BD group (n = 8), both donor and recipient rats received the same volume of saline (35 mg/kg in 1 mL) as the BD biliverdin group. All donor rats were observed for 1.5 hours before undergoing lung transplantation. Two hours after transplantation, we obtained blood and lung graft samples.

Results

Biliverdin reversed the aggravation of Pao₂ in recipients, reduced the grafts wet/dry ratio, decreased the severity of lung injury measured by histologic examination, reduced serum tumor necrosis factor-α and interleukin-8 levels and inhibited myeloperoxidase activity (MPO) in the grafts. Furthermore, it significantly decreased malonaldehyde levels and increased superoxide dismutase levels. Biliverdin reduced cell apoptosis, activated protein expression of biliverdin reductase, and inhibited expression of HO-1 and nuclear factor (NF)-κB in lung grafts.

Conclusion

Biliverdin exerts protective effects on lung grafts from BD donors through anti-inflammatory, antioxidant, and anti-apoptotic mechanisms.     

Basiliximab or Antithymocyte Globulin for Induction Therapy in Kidney Transplantation: A Meta-analysis

Objective

To compare efficacy and safety of basiliximab versus antithymocyte globulin (ATG) for induction therapy in kidney transplantation.

Methods

A literature search of the MEDLINE, EMBASE, CBMdisc, and Cochrane databases was used to identify randomized controlled trials that compared basiliximab and ATG for induction therapy in kidney transplantation. Inclusion criteria comprised: prospective randomized controlled clinical trials, follow-up time ≥12 months, randomized comparisons of ATG versus basiliximab as induction therapy in kidney transplantation. Meta-analytical techniques were applied to identify differences in outcomes between the two agents.

Results

A total of six studies involving 853 patients were identified. No differences between ATG and basiliximab were seen in terms of biopsy-proven rejection (relative risk [RR] 1.15, 95% confidence interval [CI] 0.88-1.52, P = .31), delayed graft function (RR 1.02, 95% CI 0.69-1.51, P = .93), graft loss (RR 1.15, 95% CI 0.73-1.80, P = .55), and patient death (RR 1.22, 95% CI 0.65-2.30, P = .54). But basiliximab had a lower incidence of infection (RR 0.87, 95% CI 0.78-0.97, P = .02) and neoplasm (RR 0.29, 95% CI 0.09-0.97, P = .04).

Conclusions

Basiliximab is as effective as ATG for induction therapy in kidney transplantation, whereas basiliximab has a lower incidence of infection. Basiliximab may be a safer and preferable option for induction therapy in kidney transplantation.     

Hepaticoduodenostomy vs hepaticojejunostomy for reconstruction after resection of choledochal cyst

Purpose

Roux-en-Y hepaticojejunostomy (HJ) is currently the favored reconstructive procedure after resection of choledochal cysts. Hepaticoduodenostomy (HD) has been argued to be more physiologically and technically easier but is feared to have associated complications. Here we compare outcomes of the 2 procedures.

Methods

A retrospective chart review identified 59 patients who underwent choledochal cyst resection within our institution from 1999 to 2009. Demographic and outcome data were compared using t tests, Mann-Whitney U tests, and Pearson χ² tests.

Results

Fifty-nine patients underwent repair of choledochal cyst. Biliary continuity was restored by HD in 39 (66%) and by HJ in 20 (34%). Open HD patients required less total operative time than HJ patients (3.9 vs 5.1 hours, P = .013), tolerated a diet faster (4.8 days compared with 6.1 days, P = .08), and had a shorter hospital stay (7.05 days for HD vs 9.05 days for HJ, P = .12). Complications were more common in HJ (HD = 7.6%, HJ = 20%, P = .21). Three patients required reoperation after HJ, but only one patient required reoperation after HD for a stricture (HD = 2.5%, HJ = 20%, P = .037).

Conclusions

In this series, HD required less operative time, allowed faster recovery of bowel function, and produced fewer complications requiring reoperation.     

Comparison of volume-controlled and pressure-controlled ventilation in steep Trendelenburg position for robot-assisted laparoscopic radical prostatectomy

Study Objective

To compare the effects of volume-controlled ventilation (VCV) and pressure-controlled ventilation (PCV) on respiratory mechanics and hemodynamics in steep Trendelenburg position.

Design

Prospective, randomized clinical trial.

Setting

University hospital.

Patients

34 ASA physical status 1 and 2 patients undergoing RLRP.

Interventions

Patients were randomly allocated to either the VCV (n = 17) or the PCV group (n = 17). After induction of anesthesia, each patient's lungs were ventilated in constant-flow VCV mode with 50% O₂ and tidal volume of 8 mL/kg; a pulmonary artery catheter was then inserted. After establishment of 30° Trendelenburg position and pneumoperitoneum, VCV mode was switched to PCV mode in the PCV group.

Measurements

Respiratory and hemodynamic variables were measured at baseline supine position (T1), post-Trendelenburg and pneumoperitoneum 60 minutes (T2) and 120 minutes (T3), and return to baseline after skin closure (T4).

Main Results

The PCV group had lower peak airway pressure (AP_peak) and greater dynamic compliance (C_dyn) than the VCV group at T2 and T3 (P < 0.05). However, no other variables differed between the groups. Pulmonary arterial pressure and central venous pressure increased at T2 and T3 (P < 0.05). Cardiac output and right ventricular ejection fraction were unchanged in both groups.

Conclusions

PCV offered greater C_dyn and lower AP_peak than VCV, but no advantages over VCV in respiratory mechanics or hemodynamics.     

Induction of Tolerance in Renal Transplantation Using Splenic Transplantation: Experimental Study in a Canine Model

Objective

To evaluate in a canine model the induction of tolerance to renal transplantation after splenectomy and splenosis.

Materials and Methods

This prospective, experimental, comparative, longitudinal study included 4 experimental groups, each comprising 4 dogs. Group 1 (control group) underwent renal transplantation only; group 2 underwent renal transplantation and splenectomy; group 3 underwent renal transplantation and splenosis; and group 4 underwent renal transplantation, splenectomy, and splenosis. Survival and degree of rejection were compared between the 4 groups.

Results

Splenosis improved renal function after transplantation, as indicated by increased serum creatinine concentration (group 3, 6.2 mg/dL vs group 1, 12.9 mg/dL). Comparison of weighted survival curves (corrected for degree of rejection) demonstrated a significant difference between group 2 (66.0 days) and group 4 (66.2 days) vs group 1 (52.7 days) and group 3 (41.2 days) (P = .05, Wilcoxon rank sum test).

Conclusion

These results suggest that in this experimental model of renal transplantation, splenosis and splenectomy induce clinical tolerance, as indicated by improved renal function and prolonged recipient survival.     

Antithymocyte globulin induction therapy in heart transplantation: prospective randomized study of high vs standard dosage

Background

In cardiac transplantation, high-dose antithymocyte globulin (ATG) induction therapy as short-term rejection prophylaxis has not been used.

Objective

To evaluate the efficacy and safety of intraoperative use of single high-dose ATG induction therapy after heart transplantation.

Patients and Methods

Fourteen patients received single high-dose ATG therapy plus shortened standard therapy (group1), and 16 patients received ATG standard therapy (group2).

Results

No perioperative deaths were reported. During follow-up, 3 deaths were recorded. Five- year patient survival was 92.8% in groupl vs 85.7% in group2 (P = .34). The mean (SD) number of acute rejection episodes per patient was 2.5 (2.2) in the high-dose ATG group vs 2.7 (2.5) in the standard therapy group (P = .83), with 5-year freedom from acute rejection of 45.5% in group 1 vs 35.6% in group 2 (P = .85). Infections were observed in 6 patients in group1 and in 8 patients in group2 (P = .69). Malignant disease was diagnosed in 1 patient in the high-dose group and 3 patients in the standard therapy group (P = .35). Chronic allograft vasculopathy was recognized in 4 patients (28%) in group1 and 8 (50%) in group2 (P = .05). Five-year actuarial freedom from allograft vasculopathy was 69.2% in the high-dose ATG group vs 50.0%% in the standard therapy group (P = .35).

Conclusions

High-dose ATG for prevention of rejection episodes is safe and efficacious, with a lower rate of early and late complications, in particular, graft vasculopathy.     

Pancreata From Pediatric Donors Restore Insulin Independence in Adult Insulin-Dependent Diabetes Mellitus Recipients

Context

The use of pediatric donors can increase the number of donors available for pancreas transplantation.

Aim

The aim of this study was to verify if pancreas transplantation from pediatric donors is as effective as transplantation from adult donors to restore metabolic control in type 1 diabetic patients.

Materials and Methods

From 2000 to April 2009 we performed 17 pancreas transplantations from pediatric donors: 9 simultaneous kidney-pancreas (SPK), 6 pancreas transplantation alone (PTA), and 2 pancreas after kidney (PAK). All subjects received whole organs with enteric diversion of exocrine secretions; 11 underwent systemic and 6 underwent portal venous graft drainage. The immunosuppressive therapy was as follows: prednisone, mycophenolate mofetil, anti-thymocyte globulin (ATG), and cyclosporine or tacrolimus. The pediatric donor population had a mean age of 15.3 years (range, 12-17), a mean weight of 60.1 kg (range, 42-75), and a mean body mass index (BMI) of 21 (range, 17.9-23.4).

Results

After 9 years the overall patient survival rate was 94.12%, whereas the graft survival rate was 63.35%. Normal glucose and insulin levels were maintained either fasting or during oral glucose tolerance test (OGTT). The group of recipients of pediatric organs was compared with patients receiving organs from adult donors (n = 125); the mean glucose values were lower in the pediatric group, whereas insulin production was higher in the adult patients. Early venous thrombosis was 17.6% in the pediatric group and 20% in adult recipients (Fisher exact test, P = not significant [NS]).

Conclusion

Pediatric donors restored insulin independence in adult diabetic recipients, representing a valid source of organs for pancreas transplantation.     

Outcomes of pediatric ABO-incompatible kidney transplantations are equivalent to ABO-compatible controls

Background

Due to the profound shortage of suitable deceased allografts, much effort has been made to investigate whether successful kidney transplantation (KT) is possible across the ABO blood group barrier even for pediatric recipients.

Methods

We reviewed 52 consecutive ABO incompatible (ABOic) transplantation performed between September 1989 and March 2011. The mean age at transplantation was 10.6 ± 3.9 years (range, 4.4-19.7), with 35 boys and 17 girls. The donor-to-recipient ABO blood antigen incompatibility was as follows: A1/O (n = 17); B/O (n = 13); A1/B (n = 6); B/A1 (n = 1); A1B/B (n = 9); and A1B/A (n = 6). As a control group, data were collected from 271 pediatric ABO compatible (ABOc) living donor KT in the same period.

Results

Overall acute rejection episodes (ARE) among the ABOic group were significantly higher than those of the ABOc group (44% vs 26%; P < .02). However, there was no difference in glomerular filtration rate (GFR) at 1 year after transplantation: 86 ± 31 mL/min for ABOic vs 99 ± 37 mL/min for ABOic, respectively.The 1-y, 5-y, and 10-year patient survival rates were 98%, 92%, and 92% in the ABOic group, respectively, and 99%, 98%, and 97% in the ABOc group, respectively (P = not significant [NS]). The overall 1-, 5-, 10-, and 15-year graft survival rates were 94%, 88%, 86%, and 86% in the ABOic group, respectively, and 95%, 92%, 88%, and 78% in the ABOc group, respectively.

Conclusion

ABOic KT provided long-term allograft and patient survivals equivalent to ABOc live donor transplantations.     

Pediatric cardiac transplantation in children with high panel reactive antibody

Background

Elevated panel reactive antibody (PRA) may be considered a risk factor precluding pediatric orthotopic heart transplantation. We retrospectively reviewed our management strategy and outcome data for children undergoing heart transplantation with high PRA (> 10%).

Methods

Sixty consecutive children (median age = 130.5 days) underwent heart transplantation. Diagnoses included hypoplastic left heart syndrome (HLHS) (30 patients), cardiomyopathy (18 patients), and postoperative complex congenital heart disease (CCHD) (12 patients). Standard induction immunosuppressive therapy included pulse steroids, gamma globulin, and polyclonal rabbit antithymocyte globulin. Initial immunosuppression is a calcinurin inhibitor and an antiproliferative agent. Eight children exhibited elevated PRA (group P). Fifty-two exhibited nonelevated PRA (group N). Immunosuppression was modified in group P as follows: preoperative intravenous immunoglobulin G (IVIG) and/or cyclophosphamide or mycophenolate mofetil and preoperative and postoperative exchange transfusions or plasmapheresis. In group P, cyclophosphamide was the initial antiproliferative agent.

Results

Group P = 4 HLHS patients (all status post [s/p] prior cardiac surgery) and 4 postoperative CCHD patients. Group N = 26 HLHS patients (4 patients s/p prior cardiac surgery), 18 cardiomyopathy patients, and 8 postoperative CCHD patients. Group P patients were older and weighed more than group N patients. Waiting time for donor heart, cardiac ischemic time, and length of hospital stay were similar in both groups. Thirty-day mortality for group P was 25% and for group N it was 7.9% (p = 0.178). Overall mortality for group P was 50% and for group N it was 15.4% (p = 0.043).

Conclusions

Although heart transplantation can offer children with end-stage heart failure and elevated PRA their only chance of survival, these patients remain high risk despite aggressive immunosuppression.     

Transthoracic echocardiographic findings in patients with chronic kidney disease awaiting kidney transplantation

Background

The high prevalence of classic cardiovascular risk factors in patients undergoing dialysis therapy or transplantation is associated with a 3.5- to 50-fold higher risk than in the general population. The primary cause of death in transplant recipients is cardiovascular disease.

Objective

To report echocardiographic findings using a screening protocol to detect heart disease in candidates for kidney transplantation.

Methods

Between November 2005 and December 2009, we examined 356 patients using 2-dimensional color Doppler echocardiography.

Results

A high prevalence of left ventricular hypertrophy, left ventricular diastolic dysfunction, valvulopathy, and valve calcification was observed. There was a positive correlation between valve calcification and female sex, age (P < .001), duration of renal replacement therapy (P = .01), peripheral arterial disease (P = .02), cerebrovascular disease (P = .005), and high concentration of lipoprotein(a) (P = .02).

Conclusion

An echocardiographic study should be part of the initial evaluation in candidates for renal transplantation.     

Retrograde intrarenal surgery in infants and preschool-age children

Objectives

The objectives of this study are to present our experience with retrograde intrarenal surgery for management of renal calculi in children less than 7 years old and to determine its safety and efficacy in this age group.

Methods

Patient demographics, stone location and size, use of ureteral access sheath, stone-free status, complication rates, and follow-up were evaluated.

Results

A total of 16 patients (9 boys and 7 girls; mean age, 4.2 years) underwent 17 procedures. The mean stone size was 11.5 mm (8-17 mm). Flexible ureteroscopy and laser lithotripsy were performed in all cases regardless of stone location. Dilation of the ureteral orifice was required in 5 cases (29.4%), and ureteral access sheaths were placed in 3 patients (17.6%). With a mean follow-up of 10.3 months, 88% of the children were stone free. The success rate for stones less than 10 mm was 100% and 81.8% for stones 10 mm or more (P < .05). There were no major complications, but there was 1 case of perforation and extravasation at the ureterovesical junction after balloon dilation that was managed with stent placement.

Conclusions

Retrograde intrarenal surgery is a safe and effective method for the treatment of intrarenal calculi, and it achieves reasonable results with minimal complications in children less than 7 years old.