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Contains fulltext : 229465.pdf (Publisher’s version ) (Closed access) BACKGROUND: Deceased donor kidneys are preserved in cold hypoxic conditions. Providing oxygen during preservation might improve post-transplant outcomes, particularly for kidneys subjected to greater degrees of preservation injury. This study aimed to investigate whether supplemental oxygen during hypothermic machine perfusion (HMP) could improve the outcome of kidneys donated after circulatory death. METHODS: This randomised, double-blind, paired, phase 3 trial was done in 19 European transplant centres. Kidney pairs from donors aged 50 years or older, donated after circulatory death, were eligible if both kidneys were transplanted into two different recipients. One kidney from each donor was randomly assigned using permuted blocks to oxygenated hypothermic machine perfusion (HMPO(2)), the other to HMP without oxygenation. Perfusion was maintained from organ retrieval to implantation. The primary outcome was 12-month estimated glomerular filtration rate (eGFR) using the Chronic Kidney Disease Epidemiology Collaboration equation in pairs of donated kidneys in which both transplanted kidneys were functioning at the end of follow-up. Safety outcomes were reported for all transplanted kidneys. Intention-to-treat analyses were done. This trial is registered with the ISRCTN Registry, ISRCTN32967929, and is now closed. FINDINGS: Between March 15, 2015, and April 11, 2017, 197 kidney pairs were randomised with 106 pairs transplanted into eligible recipients. 23 kidney pairs were excluded from the primary analysis because of kidney failure or patient death. Mean eGFR at 12 months was 50·5 mL/min per 1·73 m(2) (SD 19·3) in the HMPO(2) group versus 46·7 mL/min per 1·73m(2) (17·1) in HMP (mean difference 3·7 mL/min per 1·73m(2), 95% CI -1·0 to 8·4; p=0·12). Fewer severe complications (Clavien-Dindo grade IIIb or more) were reported in the HMPO(2) group (46 of 417, 11%, 95% CI 8% to 14%) than in the HMP group (76 of 474, 16%, 13% to 20%; p=0·032). Graft failure was lower with HMPO(2) (three [3%] of 106) compared with HMP (11 [10%] of 106; hazard ratio 0·27, 95% CI 0·07 to 0·95; p=0·028). INTERPRETATION: HMPO(2) of kidneys donated after circulatory death is safe and reduces post-transplant complications (grade IIIb or more). The 12-month difference in eGFR between the HMPO(2) and HMP groups was not significant when both kidneys from the same donor were still functioning 1-year post-transplant, but potential beneficial effects of HMPO(2) were suggested by analysis of secondary outcomes. FUNDING: European Commission 7th Framework Programme.

Background: The shortage of donor kidneys has led to the use of marginal donors, e.g., those whose kidneys are donated after circulatory death. Preservation of the graft by hypothermic machine perfusion (HMP) provides a viable solution to reduce warm ischemic damage. This pilot study was undertaken to assess the feasibility and patient safety of the AirdriveTM HMP system in clinical kidney transplantation. Methods: Five deceased-donor kidneys were preserved using the oxygenated Airdrive HMP system between arrival at the recipient center (Amsterdam UMC) and implantation in the patient. The main study end-points were adverse effects due to the use of Airdrive HMP. Secondary end-points were clinical outcomes and perfusion parameters. All events occurring during the transplantation procedure or within 1 month of follow-up were monitored. Results: Five patients were included in this pilot study. No technical failures were observed during the preservation period using the Airdrive HMP. Mean perfusion parameters were: duration 8.5 h (3–15 h), pressure 25 mm Hg (18–25 mm Hg), flow 49.77 mL/min (19–58 mL/min), resistance 0.57 mm Hg/min/mL (0.34–1.3 mm Hg/min/mL), and temperature 8.2 °C (2–13°C). Mean cold ischemia time (CIT) was 20.2 h (11–29.5 h). No adverse events or technical failures were observed during preservation and transplantation or during the 1-month follow-up. Conclusions: This pilot study showed the feasibility of the use of the Airdrive HMP system with no adverse events in clinical kidney transplantation.

Insufficient hemodynamics during agonal phase-i.e. the period between withdrawal of life-sustaining treatment and circulatory arrest-in Maastricht category III circulatory-death donors (DCD) potentially exacerbate ischemia/reperfusion injury. We included 409 Dutch adult recipients of DCD donor kidneys transplanted between 2006 and 2014. Peripheral oxygen saturation (SpO2-with pulse oximetry at the fingertip) and systolic blood pressure (SBP-with arterial catheter) were measured during agonal phase, and were dichotomized into minutes of SpO2>60% or SpO2 80 mmHg or SBP

Introduction: Creating functional arteriovenous fistulae (AVF) at the wrist is challenging in paediatric patients because of the small calibre of the blood vessels. Methods: We report our experience with AVF surgery in children younger than 15 years of age using microsurgical techniques. Twenty-five patients underwent AVF surgery between 2003 and 2015 (20 for haemodialysis, 4 for plasmapheresis and 1 for parenteral nutrition). Median (range) age was 9 (2-15) years and median weight was 24 (8-61) kg. Results: The one-month occlusion rate was 8%. The primary and secondary patency rates at 1, 2, 3 years were: 60%, 49%, 42%, and 82%, 72%, 54%, respectively. The median (range) maturation time was 4.53 (0.5-11.2) months. We found no statistically significant effect of patient age, body weight, type of AVF and indication for AVF creation on the primary and secondary patency rates. Conclusions: Microsurgical AVF creation at the wrist can be performed with satisfactory results and should be the preferred technique in the paediatric population.

Background: Vesicoureteral reflux (VUR) is frequently found after transplantation, but its impact on graft function, urine tract infection, and graft loss remains uncertain. Therefore our objective was to evaluate the effects of VUR on the outcome of renal transplantation. Material and Methods: We included 1008 adult renal transplant recipients of whom a 1-week posttransplant voiding cystourethrogram was available. Study end points included occurrence of bacteriuria, renal function, and graft survival. Results: In total, 106 (10.5%) of 1008 graft recipients had a diagnosis of VUR on voiding cystography. The incidence of bacteriuria was comparable in the reflux and nonreflux group (17% vs 17.4%, P = .91). There was no significant difference in renal function at 3 months and 1 year in patients with and without VUR. One- and 5-year graft survival in patients with VUR was 85.8% and 82.1% compared to 87.3% and 83.0% in patients without VUR ( P = .68 and P = .80). Conclusion: Posttransplant VUR has no correlations with early bacteriuria, renal function, and graft survival.

Context Wound morbidity is an important surgical complication after kidney transplant. Objective To assess risk factors for postoperative wound complications and the impact of such complications on outcomes of kidney transplant. Design and Patients Retrospectively, 108 consecutive kidney transplant patients between January 2010 and December 2010 were included in the analysis. Wound morbidity was defined as a surgical site infection or symptomatic lymphocele requiring intervention. Patient, donor, and surgical characteristics were reviewed. Results Eight lymphoceles and 5 surgical site infections occurred in 12 patients. Risk factors for wound complications were recipient's age ( P < .01), body mass index ( P = .01), urinary tract infection ( P = .01), and prolonged postoperative wound drainage ( P = .047). Wound morbidity did not increase the incidence of delayed graft function, acute rejection, graft failure, or mortality. Obesity, recipient's age, urinary tract infection, and prolonged wound drainage are risk factors for wound-related complications. Graft and patient survival rates are comparable between patients with and without wound-related complications.

BACKGROUND: The optimal immunosuppressive regimen in kidney transplant recipients, delivering maximum efficacy with minimal toxicity, is unknown.METHODS: The Amsterdam, LEiden, GROningen trial is a randomized, multicenter, investigator-driven, noninferiority, open-label trial in 305 kidney transplant recipients, in which 2 immunosuppression minimization strategies-one consisting of early steroid withdrawal, the other of tacrolimus minimization 6 months after transplantation-were compared with standard immunosuppression with basiliximab, corticosteroids, tacrolimus, and mycophenolic acid. The primary endpoint was kidney function. Secondary endpoints included death, primary nonfunction, graft failure, rejection, discontinuation of study medication, and a combined endpoint of treatment failure. An interim analysis was scheduled at 6 months, that is, just before tacrolimus minimization.RESULTS: This interim analysis revealed no significant differences in Modification of Diet in Renal Disease between the early steroid withdrawal group and the standard immunosuppression groups (43.2 mL/min per 1.73 m2 vs 45.0 mL/min per 1.73 m2, P = 0.408). There were also no significant differences in the secondary endpoints of death (1.0% vs 1.5%; P = 0.737), primary nonfunction (4.1% vs 1.5%, P = 0.159), graft failure (3.1% vs 1.5%, P = 0.370), rejection (18.6% vs 13.6%, P = 0.289), and discontinuation of study medication (19.6% vs 12.6%, P = 0.348). Treatment failure, defined as a composite endpoint of these individual secondary endpoints, was more common in the early steroid withdrawal group (P = 0.027), but this group had fewer serious adverse events and a more favorable cardiovascular risk profile.CONCLUSIONS: Based on these interim results, early steroid withdrawal is a safe short-term immunosuppressive strategy. Long-term outcomes, including a comparison with tacrolimus minimization after 6 months, will be reported in the final 2-year analysis.

In renal transplantation, use of calcineurin inhibitors (CNIs) is associated with nephrotoxicity and immunosuppression with malignancies and infections. This trial aimed to minimize CNI exposure and total immunosuppression while maintaining efficacy. We performed a randomized controlled, open-label multicenter trial with early cyclosporine A (CsA) elimination. Patients started with basiliximab, prednisolone (P), mycophenolate sodium (MPS), and CsA. At 6 months, immunosuppression was tapered to P/CsA, P/MPS, or P/everolimus (EVL). Primary outcomes were renal fibrosis and inflammation. Secondary outcomes were estimated glomerular filtration rate (eGFR) and incidence of rejection at 24 months. The P/MPS arm was prematurely halted. The trial continued with P/CsA (N = 89) and P/EVL (N = 96). Interstitial fibrosis and inflammation were significantly decreased and the eGFR was significantly higher in the P/EVL arm. Cumulative rejection rates were 13% (P/EVL) and 19% (P/CsA), (p = 0.08). A post hoc analysis of HLA and donor-specific antibodies at 1 year after transplantation revealed no differences. An individualized immunosuppressive strategy of early CNI elimination to dual therapy with everolimus was associated with decreased allograft fibrosis, preserved allograft function, and good efficacy, but also with more serious adverse events and discontinuation. This can be a valuable alternative regimen in patients suffering from CNI toxicity.

Living donor kidney transplant is the preferred treatment for end-stage renal disease; however, the shortage of kidney donors remains a big problem. One of the major reasons for the shortage of living donors is the risk of potentially serious surgical complications of a procedure in which the donor has no personal medical benefit. Therefore it is important to understand the risk factors for perioperative complications associated with donor nephrectomy. Hand-assisted laparoscopic donor nephrectomy is the preferred approach for kidney procurement in many medical centers. This review gives an overview of the risk factors in donor nephrectomy and more specifically in hand-assisted laparoscopic donor nephrectomy. (C) 2014 NATCO, The Organization for Transplant Professionals

Supplemental Digital Content is available in the text., Background. Cold ischemia time (CIT) is known to impact kidney graft survival rates. We compare the impact of CIT on graft failure and mortality in circulatory death versus brain death donor kidneys and how it relates to donor age. Methods. We used the prospective Dutch Organ Transplantation Registry to include 2153 adult recipients of brain death (n = 1266) and circulatory death (n = 887) donor kidneys after static cold storage from transplants performed between 2005 and 2012. CIT was modeled nonlinearly with splines. Associations and interactions between CIT, donor type, donor age, 5-year (death-censored) graft survival, and mortality were evaluated. Results. The median CIT was 16.2 hours (interquartile range 12.8–20), ranging from 3.4 to 44.7 hours for brain death and 4.7 to 46.6 hours for circulatory death donor kidneys. At >12 hours of CIT, we observed an increased risk of graft failure in kidneys donated after circulatory death versus after brain death. This risk rose significantly at >22 hours of CIT (hazard ratio 1.45; 95% confidence interval, 1.01-2.49; P = 0.043). Kidneys that came from 60-year-old circulatory death donors demonstrated elevated hazard risk at 19 hours of CIT, a shorter timeline than that for kidneys that came from brain death donors of the same age (hazard ratio 1.33; 95% confidence interval, 1.00-1.78; P = 0.045). The additional harmful effects of increased CIT in kidneys from circulatory-death donors were also found for death-censored graft failure but did not affect mortality rates in any significant way. Conclusions. The findings support the hypothesis that prolonged cold ischemia is more harmful for circulatory death donor kidneys that have already been subjected to a permissible period of warm ischemia. Efforts should be made to reduce CIT, especially for older circulatory death donor kidneys.

Postoperative surgical site infection (SSI) can be considered a frequent complication of hand-assisted laparoscopic donor nephrectomy (HALDN). Since 2007, our center used routinely a gentamicin-containing collagen sponge (GCCS) when closing the wound. The effect of GCCS on SSI is not elucidated clearly. In this retrospective cohort study, we assessed the effects of GCCS on SSI after HALDN. Between December 2004 and November 2007, we treated 100 patients without GCCS, and from November 2007 to July 2010, there were 100 patients with GCCS placed after HALDN. A SSI was defined as an incisional infection that required an intervention such as opening of the site or antibiotic treatment within 90 days after surgery. Implantation of a GCCS resulted in a statistically significant reduction in the SSI rate, from 6% to 0 (p=0.01). All infections occurred in the Pfannenstiel incision site. There was no significant difference between the groups in the creatinine concentration after three months. The use of gentamicin-containing collagen sponges reduces the risk of SSI significantly after HALDN without compromising kidney function

Item does not contain fulltext An increasing number of elderly patients (>/=65 years) receive a donor kidney from elderly donors after brain death (DBD) or after circulatory death (DCD). These organs are allocated within the Eurotransplant Senior Program, but outcomes must be evaluated. From the Dutch Organ Transplantation Registry, we selected 3597 recipients (>/=18 years) who received a first DBD or DCD kidney during 2002-2012, and categorized them as young or elderly recipients receiving a graft from either a young or elderly donor, stratified by donor type. In multiple logistic regression analysis, elderly recipients of elderly DCD kidneys experienced more delayed graft function and acute rejection than did elderly recipients of young DBD kidneys (odds ratios 10.43 [95% confidence interval (95% CI), 5.75 to 18.91] and 2.78 [95% CI, 1.35 to 5.73], respectively). In Cox regression analysis, elderly recipients of elderly DCD kidneys had a 5-year mortality risk higher than that of elderly recipients of young DBD kidneys (hazard ratio, 1.86; 95% CI, 1.15 to 3.02). Elderly recipients of elderly kidneys had a 5-year mortality rate comparable to that of waitlisted elderly patients remaining on dialysis. Among elderly recipients, 63.8% of those who received elderly DCD kidneys, 45.5% of those who received elderly DBD kidneys, and approximately 26% of those who received young DBD or DCD kidneys had an eGFR

Minnee RC, Lardy N, Ajubi N, Idu MM, Kock RV, Legemate DA, van Donselaar-van der Pant KAMI, Bemelman FJ. Ten-yr results of the trans-Atlantic kidney transplant airlift between the Dutch Caribbean and the Netherlands. Clin Transplant 2011: 25: 302–307. © 2010 John Wiley & Sons A/S. Abstract: The prevalence of end-stage renal failure in Curacao (Dutch Caribbean) is one of the highest in the world. In 1998, the St. Elisabeth Hospital started a unique trans-Atlantic collaboration with the Academic Medical Center in Amsterdam, the Netherlands, and the Eurotransplant Foundation. The partnership aimed to achieve a structured transplantation program for patients in the Dutch Caribbean, who otherwise would need lifelong dialysis. This study is an analysis of the 10-yr transplantation results of this trans-Atlantic program. In 41 consecutive transplantations performed between January 1998 and April 2007, one-yr graft survival and complication rates were retrospectively studied. Twenty-four men and 17 women with a median age of 54 were transplanted. The median dialysis period prior to transplantation was 6.8 yr. The one-yr graft survival rate was 69% (95% confidence interval: 52–80%). Initially 28 grafts functioned (68%); four grafts showed primary non-function (10%) and delayed graft function developed in nine patients (22%). Ten recipients had 16 post-operative complications. Our trans-Atlantic program affords patients with end-stage renal failure, who otherwise would need lifelong dialysis, a chance to be transplanted.

While the guidelines for vaccination in renal transplant recipients recommend the use of pneumococcal polysaccharide (PPS) and tetanus toxoid (TT), their efficacy in immunocompromised renal transplant recipients is not known. Here we tested the effect of everolimus on immune responses after vaccination by measuring the capacity of 36 stable renal transplant recipients to mount cellular and humoral responses after vaccination. Twelve patients in each treatment arm received immunosuppressive therapy consisting of prednisolone (P) plus cyclosporine (CsA), mycophenolate sodium (MPA), or everolimus. Patients were vaccinated with the T-cell-dependent antigens immunocyanin and TT, and the T-cell-independent PPS. Treatment with CsA partially inhibited and MPA completely abolished the capacity to mount a primary humoral response, whereas everolimus left this largely intact. Recall responses were inhibited by MPA only. All drug combinations inhibited cellular responses against TT. In patients treated with MPA, B-cell numbers were severely reduced. Thus, combined with P, treatment with MPA completely disturbed primary and secondary humoral responses. Everolimus or CsA allowed the boosting of T-cell-dependent and -independent secondary humoral responses. Treatment with everolimus allowed a primary response. Kidney International (2010) 78, 934-940; doi:10.1038/ki.2010.269; published online 11 August 2010

Item does not contain fulltext The continuing shortage of kidneys for transplantation requires major efforts to expand the donor pool. Donation after cardiac death (DCD) increases the number of available kidneys, but it is unknown whether patients who receive a DCD kidney live longer than patients who remain on dialysis and wait for a conventional kidney from a brain-dead donor (DBD). This observational cohort study included all 2575 patients who were registered on the Dutch waiting list for a first kidney transplant between January 1, 1999, and December 31, 2004. From listing until the earliest of death, living-donor kidney transplantation, or December 31, 2005, 459 patients received a DCD transplant and 680 patients received a DBD transplant. Graft failure during the first 3 months after transplantation was twice as likely for DCD kidneys than DBD kidneys (12 versus 6.3%; P=0.001). Standard-criteria DCD transplantation associated with a 56% reduced risk for mortality (hazard ratio 0.44; 95% confidence interval 0.24 to 0.80) compared with continuing on dialysis and awaiting a standard-criteria DBD kidney. This reduction in mortality translates into 2.4-month additional expected lifetime during the first 4 years after transplantation for recipients of DCD kidneys compared with patients who await a DBD kidney. In summary, standard-criteria DCD kidney transplantation associates with increased survival of patients who have ESRD and are on the transplant waiting list. 01 juni 2010

Background Cold storage using histidine–tryptophan–ketoglutarate (HTK) solution is used widely in clinical practice for the preservation of warm ischaemia-damaged kidney grafts. This study assessed the efficacy of pulsatile machine perfusion in combination with Polysol® for the preservation of warm ischaemia-damaged kidney grafts. Methods After induction of warm ischaemia by clamping of the left renal pedicle for 30 min, pigs were subjected to left nephrectomy. Thereafter, grafts were preserved for 20 h by cold storage with HTK (CS-HTK) or Polysol® (CS-PS), or machine preservation with Polysol® (MP-PS). Subsequently, contralateral kidneys were removed and preserved kidneys were transplanted. Control pigs underwent unilateral nephrectomy. Renal function was assessed daily for 1 week. Kidney biopsies were analysed for morphology and proliferative response. Results Renal function of warm ischaemia-damaged grafts preserved using MP-PS was comparable to that of non-ischaemic controls. MP-PS and CS-PS groups showed improved renal function compared with the CS-HTK group, with more favourable results for MP-PS than for CS-PS. The proliferative response of tubular cells in the CS-HTK group was higher than in all other groups. Conclusion This study demonstrated that the function of warm ischaemia-damaged kidney grafts after pulsatile perfusion preservation was comparable to that of non-ischaemic controls.

Background Forkhead box (FOXP3) is considered to be a specific marker for regulatory T cells. The aim of this study was to correlate intragraft FOXP3 at mRNA and cellular levels during renal allograft rejection to response to therapy and late clinical outcome. Methods Immunostainings and quantitative reverse-transcriptase polymerase chain reaction for FOXP3, CD3, and transforming growth factor (TGF)-beta were performed and results were related to histopathologic and clinical outcome. Results A good correlation between immunohistochemical analysis and mRNA levels for both CD3 and FOXP3 was observed. Intragraft FOXP3 was significantly related to tubulitis and interstitial fibrosis. A strong correlation was found between FOXP3 and CD3 mRNA and between FOXP3 and TGF-beta mRNA. No correlation was found between FOXP3 and response to therapy. Discussion In conclusion, intragraft FOXP3 at both cellular and molecular levels parallels T-cell infiltration during acute rejection. FOXP3 does not predict response to antirejection therapy. FOXP3 correlates with renal fibrosis, TGF-beta, and poor late renal outcome.

Background: Vascular transplantation has become an alternative for prosthetic grafts. Suitable storage methods for vascular allografts are therefore necessary. For small caliber arterial allografts, cryopreservation and cold storage showed discouraging results. Since glycerol preservation proved effective for the storage of skin allografts, this preservation method was investigated for vascular allografts using a rat aortic transplantation model. Methods: Glycerol-preserved allografts (GA) were transplanted to the infrarenal aorta (n = 18) in Wistar rats. A control group (n = 18) underwent immediate autotransplantation (AU) of an equal length of aorta. Results: Cumulative graft patency at 90 days’ follow-up was 93% for AU and 78% for GA (ns). No aneurysm formation was detected in both groups. Intraluminal endothelial cell coverage, integrity of the media and smooth muscle cell repopulation were comparable in both groups. Intimal thickness was less in GA than in AU and inflammatory reaction in the adventitia was diminished in GA. Conclusion: GA were successfully grafted with acceptable patency rates compared to autografts, while intima hyperplasia and adventitial inflammatory reaction were less.

Objectives: Although the advent of (hand-assisted) laparoscopic donor nephrectomy has had a positive effect on the donor pool, there is still some concern about the increased morbidity and safety of the laparoscopic donor nephrectomy. The aim of this study was to compare the results of hand-assisted laparoscopic donor nephrectomy (HALD) with open donor nephrectomy (ODN). Methods: A single-center non-randomized analysis of 202 living donor kidney transplantations (44 ODN, 158 HALD) between January 1995 and April 2006 was conducted. Results: The left kidney was harvested in 75% in the ODN group and 53% in the HALD group (P = 0.009). There was no conversion in the HALD group. Mean donor operative time for HALD (174 min) was longer than for ODN (124 min, P

Abstract The catastrophic antiphospholipid syndrome is characterised by rapid onset thromboses, often resistant to conventional anticoagulant treatment, and resulting in life threatening multiple organ dysfunction. The diagnosis of catastrophic antiphospholipid syndrome may be difficult, predominantly due to its frequently atypical presentation. We report a case of a 35-year-old female who presented with a pancreatic tumour and extensive thromboses. Following a storm of ischemic events due to thrombotic occlusions in spite of therapeutic heparin dose, the suspicion of catastrophic antiphospholipid syndrome emerged. The patient was successfully treated with anticoagulants, immunuglobulins, plasmapheresis and rituximab. The present report shows that the use of the diluted Russell’s viper venom time can be helpful in providing additional information on the lupus anticoagulans antibody status, allowing careful monitoring of lupus anticoagulans conversion and hence response to therapy.

Background Older living kidney donors remain controversial because of their physiological decline in glomerular filtration rate and their increased susceptibility of surgical complications. Little is known about the quality of life (QOL) of this elderly group. The purpose of this study is to examine surgical outcome and the QOL in older living donors. Patients and methods All 105 consecutive living donors who underwent a laparoscopic donor nephrectomy between June 2002 and February 2006 were prospectively included in the study. Intra- and postoperative complications were measured. Quality of life was recorded preoperatively and at several endpoints postoperatively. Older donors were defined as 55 years and older. Results There were no significant differences in intra- and postoperative complication rates and 1-year graft survival rate between both groups. Elderly donors (n=34) had both a significant lower postoperative pain at rest at day 1 compared with the younger group (P=0.019) and a lower total pain score in the analysis for the whole follow-up period (P=0.002). Although small solitary significant differences in Short Form-36 Health Survey, Multidimensional Fatigue Inventory-20 and visual analogue scale measuring pain, between both groups were detected, in general QOL of older donors was not different than of younger donors. Conclusion Although small solitary significant differences exist with respect to pain, social functioning and mental health older donors, in general, have similar surgical outcome and quality of life when compared with younger donors. There is no need to exclude older donors in screening programs for transplantation.

Background and Purpose— Evidence is accumulating that infection with influenza A virus contributes to atherothrombotic disease. Vaccination against influenza decreases the risk of atherosclerotic syndromes, indicating that inflammatory mechanisms may be involved. We tested the hypothesis that influenza A virus–specific T cells contribute to atherosclerotic plaque inflammation, which mediates the onset of plaque rupture. Methods— T-cell cultures were generated from atherosclerotic segments and peripheral blood of 30 patients with symptomatic carotid artery disease. The response of plaque and peripheral blood T cells to influenza A virus was analyzed and expressed as a stimulation index (SI). Selective outgrowth of intraplaque influenza A–specific T cells was calculated by the ratio of plaque T cell SI and peripheral blood T cell SI for each patient. Accordingly, the patients were categorized as high- (SI ratio ≥5), intermediate- (5 Results— High proliferative responses of plaque-derived T cells to influenza A virus were frequently observed. Among the 30 patients, 5 were categorized as high responders, 10 were intermediate responders, and 15 were nonresponders. Live influenza A virus could not be detected in the atherosclerotic plaques by polymerase chain reaction. Conclusions— Selective outgrowth of influenza A virus–specific T cells occurs within the microenvironment of human atherosclerotic plaques. Influenza virus–derived antigens or alternatively, mimicry antigens, appear to be potential candidates for triggering or sustaining plaque inflammation, which eventually leads to symptomatic plaque complications.

Contains fulltext : 171827.pdf (Publisher’s version ) (Open Access) INTRODUCTION: Informed consent is mandatory for all (surgical) procedures, but it is even more important when it comes to living kidney donors undergoing surgery for the benefit of others. Donor education, leading to informed consent, needs to be carried out according to certain standards. Informed consent procedures for live donor nephrectomy vary per centre, and even per individual healthcare professional. The basis for a standardised, uniform surgical informed consent procedure for live donor nephrectomy can be created by assessing what information donors need to hear to prepare them for the operation and convalescence. METHODS AND ANALYSIS: The PRINCE (Process of Informed Consent Evaluation) project is a prospective, multicentre cohort study, to be carried out in all eight Dutch kidney transplant centres. Donor knowledge of the procedure and postoperative course will be evaluated by means of pop quizzes. A baseline cohort (prior to receiving any information from a member of the transplant team in one of the transplant centres) will be compared with a control group, the members of which receive the pop quiz on the day of admission for donor nephrectomy. Donor satisfaction will be evaluated for all donors who completed the admission pop-quiz. The primary end point is donor knowledge. In addition, those elements that have to be included in the standardised format informed consent procedure will be identified. Secondary end points are donor satisfaction, current informed consent practices in the different centres (eg, how many visits, which personnel, what kind of information is disclosed, in which format, etc) and correlation of donor knowledge with surgeons' estimation thereof. ETHICS AND DISSEMINATION: Approval for this study was obtained from the medical ethical committee of the Erasmus MC, University Medical Center, Rotterdam, on 18 February 2015. Secondary approval has been obtained from the local ethics committees in six participating centres. Approval in the last centre has been sought. RESULTS: Outcome will be published in a scientific journal. TRIAL REGISTRATION NUMBER: NTR5374; Pre-results.

Background: Stenting of the ureterovesical anastomosis reduces the incidence of urological complications (UCs) after renal transplantation, but there are multiple stenting techniques, and there is no consensus regarding which technique is preferred. The aim of this study was to compare an internal versus an external stenting technique on the incidence of UCs. Methods: This is a retrospective analysis of 419 deceased donor renal transplantations performed between January 2008 and December 2013. Until 2011, 183 patients received an external stent through the ureterovesical anastomosis placed by suprapubic bladder puncture (SP stent). From 2011, 236 recipients received an internal double-J (JJ) stent. Results: The rate of UC was 3.8% in JJ stents, compared to 9.3% in SP stents (p = 0.021). No difference in surgical ureter revision rate was observed between the groups (2.1 vs. 5.5%; p = 0.068). Urinary tract infection (UTI) rate and graft function were comparable between both groups. Conclusions: Internal JJ stenting significantly decreased the incidence of UC compared to an external SP stent. There was no difference in surgical ureter revision rate, UTI or graft function.

A 25-year-old man underwent an autotransplantation of his right kidney because of fibromuscular dysplasia-induced renal artery stenosis and subsequent hypertension. Since transplantation results in complete kidney denervation, it enabled assessment of renal sympathetic nerve activity changes using renal I-MIBG scintigraphy. Before and 2 weeks after transplantation I-MIBG, scintigraphy was performed. Uptake of I-MIBG in the left (control) kidney increased after transplantation with 4% at 15 minutes and 5% at 4 hours postinjection images, whereas I-MIBG uptake in the right transplanted kidney decreased with 21% at 15 minutes and with 29% at 4 hours, demonstrating renal I-MIBG changes after denervation.

BACKGROUND The impact of allograft pyelonephritis (AGPN) on renal allograft function is controversial. In this study, we evaluated the incidence, risk factors, and the impact of AGPN on renal allograft function. METHODS Retrospective cohort study in adult renal allograft recipients with 1-year follow-up after transplantation (Tx). Renal allograft function was evaluated by estimated glomerular filtration rate (eGFR) (by Modification of Diet in Renal Disease formula) and 24-h urine protein excretion. RESULTS A total of 431 renal allograft recipients were analyzed; 57 (13.2%) developed AGPN within 1 year after Tx. Median time between Tx and AGPN was 50 days. Risk factors for AGPN were the presence of a urological catheter (odds ratio [OR] = 18.93, 95% confidence interval [CI] = 8.00-44.81, P < 0.001) and preceding asymptomatic bacteriuria (ASB) (OR = 2.16, 95% CI = 1.20-3.90, P = 0.009). In 72.7%, the causative microorganism of ASB was identical to that of the succeeding AGPN episode. Multivariable linear regression analysis showed that experiencing AGPN did not decrease the eGFR (P = 0.61) nor did increased proteinuria (P = 0.29) 1 year after Tx. For the eGFR, an interaction was found between AGPN/bacteriuria (BU) and acute rejection (AR): the group experiencing BU preceding AR had significantly (P < 0.001) lower eGFR compared with the group that experienced only AR (21 mL/min/1.73 m2 vs. 48 mL/min/1.73 m2 ), as a result of increased prevalence of combined rejections within the BU group. CONCLUSION Indwelling urological catheters and preceding ASB are associated with developing AGPN. An incident of AGPN itself does not impair renal allograft function 1 year after Tx. However, a relevant interaction occurs between BU and AR, in which the sequence of occurrence of these 2 events synergistically impairs the eGFR.

Objective We systematically reviewed clinical studies on the use of venous and arterial allografts for infrainguinal revascularization. We attempted to find evidence for the best infrainguinal vascular allograft by a systematic review of the available literature. Methods An electronic search of the MEDLINE, EMBASE, and Cochrane databases was used to determine key articles from studies on the different types of vascular allografts used in infrainguinal reconstruction from 1966 to 2004. Articles were independently reviewed by using previously defined inclusion and exclusion criteria. Study results were gathered with cumulative primary patency as the primary end point. Secondary end points were major complications, graft disintegration, and major limb loss. Quantitative analysis was performed on the prospective randomized trials, and linear regression analysis was performed on cumulative primary patency. Fontaine's classification system was applied. Results No systematic review of randomized controlled trials was found. Five randomized controlled trials, 3 prospective cohort or case series, and 15 retrospective case series with 3837 vascular allografts were found. Methods of allograft preservation were cryopreservation (5 studies), cold storage (3 studies), and glutaraldehyde preservation of human umbilical veins (15 studies). One-year cumulative primary patency rates were 13% to 79% for cryopreservation, 63% to 80% for cold storage, and 40% to 91% for glutaraldehyde. The weighted mean 1-year cumulative primary graft patency rate was 41% for cryopreservation, 71% for cold storage, and 70% for glutaraldehyde allografts. Four randomized trials on femoropopliteal bypasses demonstrated higher patency rates of glutaraldehyde-preserved human umbilical veins than polytetrafluoroethylene grafts. Statistical heterogeneity between studies (I 2 = 91.4%) was too high to perform a formal meta-analysis. The rate of major limb loss was 20% to 58% for cryopreservation, 10% to 69% for cold storage, and 0% to 65% for glutaraldehyde, and the percentage of graft disintegration was 2% to 6% for cryopreservation, 4% to 15% for cold storage, and 0% to 11% for glutaraldehyde. Conclusions A firm conclusion could not be made because there were no studies available in which direct comparison was performed between different preservation methods of vascular allografts. In addition, heterogeneity of the individual studies hampered direct comparison of different types of vascular allografts. However, the overall graft performance of glutaraldehyde-preserved human umbilical vein allografts may be superior to that of other vascular allografts.

Routine splinting of the ureterocystostomy during renal transplantation lowers the urological complication rate but increases patient's morbidity. The number needed to treat to prevent one urological complication is high. The aim of this study was to identify risk factors, which can be used in the implementation of a selective splinting ureterocystostomy protocol. Retrospective analysis of 475 consecutive renal transplantations performed between January 1999 and December 2004. Donor, surgical-technical and recipient factors were assessed. Urological complications occurred in 62 (13%) patients. In 29 of these 62 patients (6.1%), only a temporary percutaneous nephrostomy catheter was necessary and in 33 (6.9%) surgical revision was required. Episodes of acute rejection and delayed graft function were identified as the only independent risk factors for a urological complication: odds ratio 2.62 [95% confidence interval: (CI) 1.38-4.97] and 2.22 (95% CI: 1.14-4.33), respectively. None of the risk factors for urological complications after renal transplantation that are known at the time of performing the ureterocystostomy are useful for the implementation of a selective splinting protocol.

Purpose: To report a collapsed stent-graft used to treat a traumatic aortic rupture. Case Report: A Gore TAG stent-graftwas placed in a 20-year-old man with multiple injuries. Postimplantation computed tomographic angiography (CTA) demonstrated no contrast extravasation and total exclusion of the traumatic rupture. Routine CTA 3 months after implantation revealed a collapsed stent-graft located in the outer curve of the distal aortic arch. A Talent stent-graft was placed successfully within the collapsed prosthesis. Postimplantation CTA demonstrated no contrast extravasation and good apposition of the endograft to the aortic wall. At 6 months, the repair remains secure; there is no sign of graft collapse or endoleak. Conclusions: Collapse of stent-grafts can occur after treatment for traumatic aortic ruptures; endovascular methods can be used to restore a satisfactory luminal contour

Purpose Protein adsorption, cell adhesion and graft patency was compared in hydrophilic versus hydrophobic polymer-coated prosthetic vascular grafts. We hypothesize that in vivocompatibility of hydrophilic polymer-coated prosthetic vascular grafts is superior to in vivo compatibility of hydrophobic grafts. Methods A pairwise side-to-side common carotid artery interposition graft was placed eight female landrace goats (mean weight 55 kg). Protein adsorption was assessed using Western Blot in two hydrophilic and two hydrophobic grafts harvested after three days. Graft patency was monitored for 28 days in six goats with continuous wave Doppler ultrasonography. Adherence of endothelial cells, leukocytes and platelets was determined with ELISA and compared between the two graft types after 28 days. Results After three days, more ApoA-l, albumin and VEGF and less fibrin adsorbed to hydrophilic grafts. After 28 days, compared to hydrophobic grafts, higher numbers of endothelial cells were present on hydrophilic grafts (P=0.016), and less thrombocytes and leukocytes (P=0.012 and 0.024, respectively). Two out of eight hydrophobic grafts lost patency, while none of the hydrophilic grafts failed (P=0.157). Conclusions Hydrophilic polymer-coated vascular grafts have superior in vivo compatibility when compared to hydrophobic grafts as characterized by reduced platelet and leukocyte adherence as well as higher endothelialization.

Objectivesto assess the influence of clinical and graft factors on the development of stenotic lesions. In addition the implications of any significant correlation for duplex surveillance schedules or surgical bypass techniques was examined.Patients and methodsin a prospective three centre study, preoperative and peroperative data on 300 infrainguinal autologous vein grafts was analysed. All grafts were monitored by a strict duplex surveillance program and all received an angiogram in the first postoperative year. A revision was only performed if there was evidence of a stenosis of 70% diameter reduction or greater on the angiogram.Resultsthe minimum graft diameter was the only factor correlated significantly with the development of asignificant graft stenosis(PSV-ratio ≥2.5) during follow-up (p=0.002). Factors that correlated with the development ofevent-causing graft stenosis, associated with revision or occlusion, were minimal graft diameter (p=0.001), the use of a venovenous anastomosis (p=0.005) and length of the graft (p=0.025). Multivariate regression analysis revealed that the minimal graft diameter was the only independent factor that significantly correlated with anevent-causing graft stenosis(p=0.009). The stenosis-free rates for grafts with a minimal diameter

Objectives:To investigate the effectiveness of two alternative vein-graft surveillance strategies. In the first strategy surveillance was restricted to patients with a possible higher risk of significant stenosis development, i.e. those with a moderate stenosis identified early after the operation. In the second strategy the effects of reducing the number of duplex tests per patient was examined.Patients and Methods:In a prospective study in three vascular surgical departments 300 patients (300 femoropopliteal or distal grafts) underwent duplex surveillance during the first year after the operation. The duplex-derived PSV-ratio was considered to represent the degree of stenosis. Arteriographic confirmation of suspected stenoses was routinely obtained, and patients without a suspected graft stenosis underwent a consented arteriogram during the first postoperative year. The decision to perform a graft revision was taken on the basis of an arteriographic stenosis of at least 70% diameter reduction. In the first strategy graft categories were defined on the basis of the first postoperative duplex examination: grafts with a PSV-ratio 3.0. The primary patency rate at 12 months was compared for these categories. In the second alternative strategy the number of examinations and the percentage of event causing de novo stenoses were analysed per surveillance interval.Results:The presence of moderate abnormalities at the initial duplex scan did not identify patients with a high risk of an event, as initial PSV-ratios of 1.5–2.0 and 2.0–2.5 (early mild-moderate lesions) had comparable 12-month primary patencies to patients with a PSV-ratio

A 37-year-old male patient received a kidney transplant from his brother as treatment for end-stage renal failure due to immunoglobulin-A nephropathy. The procedure was uncomplicated, and his serum creatinine stabilized at 1.7 mg/dl (150 μmol/l). However, 18 months after transplantation, his serum creatinine increased to 2.5 mg/dl (220 μmol/l). He developed hypertension, which could not be adequately controlled by four antihypertensive drugs prescribed in high doses. In addition, he complained of headaches and pain in the lower limbs during physical exercise. Physical examination revealed bilateral absence of femoral arterial pulsations. These findings raised the suspicion of diminished perfusion of the lower body. Magnetic resonance arteriography revealed a severe aortic stenosis just below the origin of the native renal arteries, causing hypoperfusion of the lower limbs and the allograft (Figure 1). Hypertrophied collaterals had developed via the arc of Riolan. The inferior mesenteric artery was hypertrophic, resulting from retrograde flow from the arc of Riolan into the distal aorta (Figure 2). Abdominal aortic stenosis, middle aortic syndrome, or coarctatio aortae abdominalis is characterized by segmental narrowing of the abdominal aorta. This rare entity affects mostly children and adolescents. It often presents as treatment-resistant hypertension, reduced or absent femoral arterial pulsations, intermittent claudication, and/or abdominal angina. A diagnostic delay is common. Middle aortic syndrome can be congenital or result from vasculitis. We successfully performed a vascular bypass from the suprarenal to the infrarenal abdominal aorta. The role for endovascular therapy for aortic stenoses close to the origin of major side branches is limited, as peri-procedural side-branch occlusion and peripheral embolization may occur. The perfusion of the graft and the iliac arteries, as well as the blood pressure, normalized postoperatively. In our patient, we postulate that the stenosis was of congenital origin.

No consensus exists about which ureterovesical anastomosis technique to use for kidney transplantation. The aim of this systematic review was to compare the existing techniques in relation to the risk of urological complications. All studies that compared ureterovesical anastomotic techniques in kidney transplantation were included. Study endpoints were urinary leakage, ureteral stricture, vesicoureteral reflux and hematuria. Subanalyses of stented and nonstented techniques were performed. Two randomized clinical trials and 24 observational studies were included. Meta-analyses were performed on the Lich-Gregoir (LG) versus Politano-Leadbetter (PL) techniques and LG versus U-stitch (U) techniques. Compared with the PL technique, the LG technique had a significantly lower prevalence of urinary leakage (risk ratio (RR): 0.47, 95% confidence interval (CI): 0.30 to 0.75) and a significantly lower prevalence of hematuria when compared with both PL and U techniques (RR: 0.28, 95% CI: 0.16 to 0.49 and RR: 0.23, 95% CI: 0.11 to 0.50, respectively), regardless of ureteral stenting. There was no difference in the prevalence of ureteral strictures or vesicoureteral reflux between the various techniques. Of the three most frequently used ureterovesical anastomotic techniques, the LG technique results in fewer urological complications than the PL and U techniques.

Objectives Patients with critical limb ischemia (CLI) have a poor life expectancy, and aggressive revascularization is accepted as a means to maintain their independence in the end stage of life. The goal of this case-control study was to evaluate the clinical outcome of distal venous arterialization and compare this with pedal bypass surgery in patients with CLI, and to identify potential risk factors that could be used to effectively identify patients at high risk of graft occlusion and amputation. Methods A retrospective cohort of patients was treated for CLI using venous arterialization or pedal bypass between 2007 and 2012. Kaplan-Meier and Cox regression analyses were used to evaluate predictors for limb salvage and patency. Results In 40 patients with CLI, 21 venous arterializations and 19 pedal bypasses were performed. In the venous arterialization group, early occlusion was 15%, 1-year patency was 71%, and limb salvage was 53%. In the PB group, early occlusion was 23%, one-year patency was 75% and limb salvage was 47%. The only independent risk factor for limb salvage in multivariate analysis was bypass occlusion ( P Conclusions Limb salvage after venous arterialization was equal to limb salvage after pedal bypass surgery in this clinical comparative study.

Introduction Complications of the transplant ureter are the most important cause of surgical morbidity after renal transplantation. The presence of ureteral duplication in the renal graft might result in an increased complication rate. We analyzed our data of double-ureter renal transplantations using a case-control study design. Additionally, we performed a review of the literature. Methods From January 1995 to April 2012, 12 patients received a donor kidney with a double ureter (0.8%). We created a control group of 24 patients matched in age, sex, donor type, and ureteral stenting. Patient charts and surgical reports were reviewed retrospectively. Results In 7 patients both ureters were separately anastomosed to the bladder. In 4 patients a common ostium was created. In 1 patient 1 of the 2 ureters was ligated. No postoperative urologic complications occured. In the single-ureter group, the urologic complication rate was 17% (P = .71). Mean creatinine levels after transplantation were comparable between both groups. Discussion A double-ureter donor kidney is not associated with an increased complication rate after renal transplantation and yields equal outcomes as compared to single-ureter donor kidneys. We conclude that transplantation of a kidney with a duplicated ureter is safe.

Pre-existing occlusion of the inferior vena cava may complicate renal transplantation. Suppurative abdominal wall phlebitis following renal transplantation was diagnosed in a patient with pre-existing thrombosis of the inferior vena cava of unknown cause. The phlebitis developed in the subcutaneous collateral veins of the abdominal wall contra-laterally to the renal transplant. Cultures from abdominal wall micro-abscesses yielded Prevotella bivia as the causative agent. This complication has not been described before in the context of renal transplantation. The pathogenesis and management of this serious complication are discussed in this paper.

Background Whether or not to remove a failed renal graft has been the subject of much debate. One reason for a cautious approach to graft removal is its high morbidity and mortality rates. We analyzed the morbidity, mortality, and risk factors of transplant nephrectomy at our center. Material and methods We included 157 cases of transplant nephrectomy in 143 patients, performed between January 2000 and May 2012 at the Academic Medical Center, Amsterdam. Patient data were collected retrospectively. Results A total of 32 surgical complications occurred after transplant nephrectomy (20%) and 16 patients needed surgical re-intervention (10%). Hemorrhage and infection are the most frequent causes of surgical complications (14%). The mortality rate was 3.2%. There were no significant differences in characteristics and timing of transplant nephrectomy between the group with surgical complications and the group without. A total of 59 re-transplantations were performed in 57 patients (38%). Conclusions Transplant nephrectomy is associated with high morbidity and mortality rates. We found no significant risk factors for surgical complications following transplant nephrectomy and no significant association between timing of transplant nephrectomy and surgical complications. Steps to reduce these complications need further investigation.

In this study, we assessed the safety of the new organ preservation solution polysol solution in the clinical setting of living kidney transplantation. We conducted a prospective pilot study in nine adult donor-recipient couples using polysol solution for washout and cold storage of kidney grafts. Adverse reactions possibly related to the use of polysol solution as well as renal function at 1, 6, and 12 months after transplantation were monitored. All living kidney transplantation performed in adults in our center within 2002 to 2008 using the University of Winconsin solution served as controls (n = 190). The use of polysol solution was associated with a higher acute rejection rate compared to University of Wisconsin solution at all time points. Also, antibody-mediated rejection occurred more frequently in the polysol group. Renal function at all time points was also comparable between the groups. This pilot study in living kidney transplantation is the first clinical study on the use of polysol solution. Although the study was not powered on the endpoint rejection, we observed a high number of acute rejection and antibody-mediated rejection episodes in recipients of polysol solution preserved grafts as compared to University of Wisconsin solution controls. As a consequence the study was terminated prematurely.

Introduction: The incidence of urological complications after renal transplantation ranges from 2.5 to 30%. Often surgical revision is necessary. The risk factors for surgical revision and which surgical techniques to apply are not elucidated. This study investigates the outcome and risk factors for surgical revision of the ureterocystostomy. Materials and Methods: Between January 1995 and March 2009, 1,157 consecutive kidney transplantations were performed. All patient charts and surgical reports were reviewed. Results: Urological complications occurred in 142 (12.3%) patients. In 60 patients (5.2%) surgical revision was necessary. Of these 60 patients, 43 (71.7%) received neoureterocystostomy, 10 (16.7%) ureteropyelostomy reconstruction and 7 (11.7%) other techniques. Independent risk factors for surgical revision were donor ureteral reconstruction (odds ratio (OR) 48.66, 95% confidence interval (CI) 5.01–472.97), recipient age Conclusions: Ureteral stenting, recipient age, delayed graft function and perioperative ureteral reconstruction are significant factors associated with surgical revision of the ureterocystostomy. Surgical revision of the ureterocystostomy is a successful therapy with a low recurrence rate.

Background: Prosthetic grafts have poor patency rates in peripheral arterial reconstructions. Glycerol (GL)-preserved grafts are an alternative. The aim of this study was to examine patency, graft morphology and function of GL-preserved allografts in a goat carotid artery animal model. Methods: The first group (n = 7) underwent bilateral replacement of the carotid artery by a carotid allograft that was preserved in GL for 1 week. In the second group (n = 5), a carotid artery allograft that was preserved in University of Wisconsin solution (UW) for 48 h was used. In the third group (n = 5), the jugular vein (autologous vein, AU) was used. The follow-up was 3 months. Results: One UW graft and 1 GL graft occluded in the first 24 h postoperatively. Three-month primary patency rates for GL, UW and AU grafts were 93, 100 and 80%, respectively (p = 0.39). Graft diameter was increased in UW allografts (p < 0.005), whereas GL allografts remained unchanged. After explantation, GL allografts demonstrated contraction and relaxation capacity and lower intimal thickness (p < 0.001). Conclusion: GL preservation has proven to be a feasible method for arterial allograft transplantation in a large animal model with decreased intimal hyperplasia and renewed functional capability.

It is believed that the size of the CD8+ T-cell pool is fixed and that with every new viral challenge, the size of the pre-existing memory-cell population shrinks to make way for the new virus-specific cells. CMV-seropositive individuals have high numbers of CMV-specific resting-effector type CD8+ T cells in their peripheral blood (PB). This prompted us to investigate whether CMV infection limits immunologic space at sites where immune reactions are initiated, such as in the lymph nodes (LNs). LN and paired PB samples were analyzed for CMV-, EBV-, and influenza-specific CD8+ T cells. In marked contrast to blood, LNs contained significantly lower numbers of CX3CR1-expressing effector-type CD8+ T cells, whereas the CMV-specific cells that were found in the LNs resembled polyfunctional memory-type cells. In contrast, EBV- and influenza-specific CD8+ T cells were highly similar between PB and LNs both in number and function. Therefore, it is unlikely that CMV-specific CD8+ T cells in the LNs restrain the immunologic space of other virus-specific cells.

Purpose and Methods: The contribution of color-flow duplex surveillance to improving vein graft patency was evaluated in two patient groups after 201 infrainguinal bypass procedures were performed during a 5-year period. Incidence of revision procedures and the primary and assisted primary patency rates were compared for 160 bypass grafts monitored during the first 2 years by use of color-flow duplex scanning of the vein graft and adjacent arterial segments (color-flow surveillance group) versus 41 bypass grafts monitored by use of clinical assessment alone (clinical follow-up group). Only grafts that were patent after the first postoperative month are considered. Results: The two groups were comparable with regard to most of the pertinent clinical factors. Stenotic lesions were identified in 58 bypass grafts, and severity was determined by use of intraarterial digital subtraction angiography. Eighteen bypass grafts with stenoses did not undergo a revision for reasons that were determined by the doctor, the hospital, or the patient. The occlusion rates of revised and nonrevised stenotic grafts were compared for lesions of different severity. None of the grafts for stenoses with 30% to 49% diameter reduction (DR) failed during follow-up. Occlusion occurred in 57% of the nonrevised and 9% of revised grafts ( p = 0.047) for stenoses with 50% to 69% DR. Stenoses with 70% or greater DR were associated with graft failure in 100% of nonrevised bypasses and in 10% of revised grafts ( p = 0.004). The assisted primary patency rate was higher in grafts that underwent color-flow surveillance compared with grafts with that underwent clinical follow-up (3-year patency rates of 91% and 72%, respectively; p = 0.004). The independent correlation of color-flow surveillance with higher patency rates was demonstrated in a proportional hazard analysis. The relative risk (probability of occlusion) in color-flow surveillance grafts is less than one third of the relative risk in bypass grafts that underwent clinical follow-up. Conclusions: We conclude that revision procedures were more optimally used during color-flow surveillance, whereas asymptomatic stenotic graft lesions are missed with clinical follow-up, which results in a higher percentage of graft failures. Overall graft patency rates can be improved with use of color-flow duplex surveillance and repair of significant stenotic lesions. (J VASC SURG 1993;17:42-53.)

Background. Delayed graft function (DGF) has a negative effect on the results of living-donor kidney transplantation. Objective. To investigate potential risk factors for DGF. Methods. This prospective study included 200 consecutive living donors and their recipients between January 2002 and July 2007. Delayed graft function was defined as need for dialysis within the first postoperative week. Results. Delayed graft function was diagnosed in 12 patients (6%). Intraoperative complications occurred in 10 donors (5%), and postoperative complications in 24 donors (13.5%). One-year kidney graft survival with vs without DGF was 52% and 98%, respectively (P

Contains fulltext : 89902.pdf (Publisher’s version ) (Closed access) BACKGROUND: Treatment safety and effectiveness of total parathyroidectomy and autotransplantation for secondary and tertiary hyperparathyroidism have been extensively proven in adults; the evidence for children, however, is scarce. Children and adolescents cannot simply be seen as young adults in the case of chronic kidney disease and hyperparathyroidism. The aim of this retrospective study was therefore, to evaluate whether parathyroidectomy with forearm autograft is as effective and safe in children and adolescents as in adults. METHODS: A group of 64 adults and 8 children and adolescents treated for secondary or tertiary hyperparathyroidism were retrieved from our database. The outcomes were compared on patient demographics, operation results, and blood parameters consisting of parathyroid hormone (PTH) and calcium levels. Our results were compared with all currently available articles on parathyroidectomy in children with secondary or tertiary hyperparathyroidism (n = 11). RESULTS: For adults, preoperative mean serum calcium was 2.67 +/- 0.29 mmol/l and mean parathyroid hormone (PTH) level was 120 +/- 86 pmol/l. For children, preoperative mean serum calcium was 2.62 +/- 0.20 mmol/l and mean parathyroid hormone (PTH) level was 80 +/- 38 pmol/l. Postoperative calcium and parathyroid hormone levels for adults dropped to 2.39 +/- 0.23 mmol/l and 30 +/- 53 pmol/l, respectively. Postoperative calcium and parathyroid hormone levels for children dropped to 2.41 +/- 0.16 mmol/l and 26 +/- 33 pmol/l, respectively. The effectiveness of parathyroidectomy with autotransplantation was 75% in children and 72% in adults. Thus, effectiveness did not differ significantly between children and adults. CONCLUSIONS: Combining the results of our own study with a literature review on pediatric parathyroidectomy, we conclude that parathyroidectomy and forearm autograft is as effective a treatment for secondary and tertiary hyperparathyroidism in children and adolescents as it is in adults. 01 mei 2010

Development of stenosis in lower extremity vein grafts or its anastomotic segments is responsible for most graft failures. While these lesions can be treated by minor procedures, timely identification may improve long-term graft patency. In this review, diagnostic methods that are currently applied for vein graft surveillance, criteria for stenosis and recommendations for intervention are discussed.

BACKGROUND: Ureteral stents are successful in reducing urological complications after renal transplantation. However, the optimal duration and method of stenting have not yet been clarified. The objective of the present study was to investigate the frequency of urological complications when a 5-day external stented ureterocystostomy protocol was followed. METHODS: A single-center nonrandomized analysis of 392 kidney transplantations between June 2003 and June 2007 was conducted. From July 2005 all 196 renal transplant recipients received a 5-day external stented ureterocystostomy. A urological complication was defined as any cause leading to the placement of a percutaneous nephrostomy catheter and/or surgical revision of the ureterocystostomy. RESULTS: In the non-stented group, 21 of the 196 patients (10.7%) developed a urological complication compared to 13 patients (6.6%) in the stented group (p = 0.151). In the stented group, 2 of the 66 recipients of a living donor transplant (3.0%) developed a urological complication compared to 8 of the 59 recipients (13.6%) in the non-stented group (P = 0.030). Eleven of 130 recipients of a deceased donor transplant (8.5%) in the stented group developed a urological complication, compared to 13 of the 137 recipients (9.5%) in the non-stented group (P = 0.769). The surgical revision rate of the stented and the non-stented group was 5/13 39% and 6/21 29%, respectively. CONCLUSIONS: A 5-day routine external stent protocol is efficacious in living donor renal transplantation in preventing early postoperative ureter obstruction, but this stenting period seems inadequate for deceased donor renal transplantation

Objective We sought to assess the efficacy of POLYSOL, a low-viscosity, colloid-based organ preservation solution, for the preservation of warm ischemically damaged kidney grafts compared with histidine-tryptophane-ketoglutarate (HTK) solution. Methods Pigs (25–30 kg) underwent a left nephrectomy after clamping the renal vessels for 30 minutes. Kidney grafts washed out with Polysol ( n = 6) or HTK ( n = 6) were cold stored (CS) for 20 hours at 4°C. After the preservation period, the contralateral kidney was removed and the preserved kidney implanted heterotopically. Renal function was assessed daily for 7 days. Thereafter, animals were killed and the kidney grafts removed for histologic analysis. Results All animals survived for 7 days. All Polysol CS–preserved grafts showed immediate function, as demonstrated by urine production within 24 hours after reperfusion as compared with 3/6 grafts in the HTK CS group. Overall, the Polysol CS group showed improved renal function compared with HTK CS. Also, peak serum creatinine and blood urea values were lower in the Polysol CS group compared with HTK-preserved grafts. Histologic evaluation of warm ischemically damaged grafts showed less glomerular shrinking, less tubular damage, less edema, less inflammatory infiltration, and less necrosis in Polysol compared with HTK-preserved grafts. Conclusion Application of Polysol solution for washout and CS preservation of warm ischemically damaged kidney grafts resulted in improved renal function and structural integrity when compared with HTK.