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To understand Black men's healthcare and social needs and determine if the resources that healthcare systems offer meet expectations. We surveyed men who had previously participated in at least one Minority Men's Health Fair in Cleveland, Ohio. In this descriptive study, we spoke with men up to three times (i.e., phases) between May and October 2020 by email and/or telephone. Phase 1 was a needs assessment survey. Phase 2 involved outreach to those who identified a need to provide a resource. Phase 3 determined whether the resource met individuals' needs. We described the demographic characteristics of the survey respondents, the percentage of men reporting a need and wanting a resource, and whether the resource resolved their need. Of the 768 men contacted, 275 completed the survey (36% response rate). The majority of respondents were 50-69 years old, identified as Black, and had at least a bachelor's degree. Eighty-five percent reported a need, of which wellness, financial, and healthcare access were among the top-reported needs. Among the men identifying a need, 35% were interested in a resource. Resources that were provided for employment, behavioral health, oral health, vision, or wellness needs were deemed insufficient. A few individuals reported that resources for food/personal hygiene, financial support, health care access, annual health screening, and medication met their needs. Among men with healthcare and social needs, only a fraction were interested in a resource, and fewer reported that the resource met their needs. These results warrant a greater understanding of what constitutes a resolution of healthcare and social needs from patients' perspectives., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Advance directives documentation can increase the likelihood that patient's wishes are respected if they become incapacitated. Unfortunately, completion rates are suboptimal overall, and disparities may exist, especially for vulnerable groups. We assessed whether implementing an initiative to standardize advance directives discussions during preanesthesia visits was associated with changes in rates of advance directives completion over time, and whether the association depends on race, insurance type, or income., Methods: We conducted a before-after interrupted time series evaluation between January 1, 2015 and June 30, 2019 in a single-center, outpatient preanesthesia clinic. Participants were adults who visited the preanesthesia clinic at Cleveland Clinic and had >1 comorbidity before a noncardiac surgery of either medium or high risk. The intervention in March of 2017 consisted of training staff to help patients complete and witness advance directives documents during visits. We measured advance directives completion, by race, payor, and income (using the 2019 Federal Poverty Line). We assessed the confounder-adjusted association between intervention (pre versus post) and proportion of patients completing advanced directives over time using segmented regression to compare slopes between periods and assess changes at start of the intervention. We used similar models to assess whether changes depended on race, insurance type, or income level., Results: We included 26,368 visits from 22,430 patients. We analyzed financial status for 16,788 visits from 14,274 patients who had address data. There were 11,242 (43%) visits preintervention and 15,126 (57%) visits postintervention. Crude completion rates for advance directives increased from 29% to 78%, with odds of completion an estimated 18 times higher than preintervention (odds ratio [95% CI] of 18 [16-21]; P < 0.001). Regarding race, Black patients had lower completion rates preintervention than White patients, although the gap steadily closed after the intervention ( P = .001). Postintervention, both race groups immediately increased, with no difference in amount of increase ( P = .17) or postintervention change in slope difference ( P = .17). Regarding insurance, patients with Medicaid had lower preintervention completion rates than those with private. Intervention was associated with increases in both groups, but the difference in slopes ( P = .43) or proportions ( P = .23) between the groups did not change after intervention. Regarding the Federal Poverty Line, the completion rate gap between those below (<100%) and above (139%-400%) narrowed by approximately half (0.51: 95% CI, 0.27-0.98; P = .04)., Conclusions: Standardizing advance directives discussions during preanesthesia visits was associated with more patients completing advance directives, particularly in vulnerable patient groups., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2023 International Anesthesia Research Society.)

Minority groups continue to suffer disproportionately from COVID-19's impact, with Blacks and Hispanics three times more likely to die from the disease than their White counterparts. The COVID-19 vaccine roll out has the potential to provide relief to these most adversely impacted communities. However, historic mistrust within racial minority communities threatens to derail the effective implementation of a vaccination program. The origin of this mistrust is multifactorial. Current day experience with structural racism and research abuses like Tuskegee Study collectively influence our perception of biased healthcare system. We outline issues and propose solutions that must be addressed to achieve a successful vaccination agenda. Mishandling of public expectations at any point may lead to an avalanche of vaccine opposition which might be unrecoverable., (Copyright © 2021. Published by Elsevier Inc.)

To combat racial/ethnic and socioeconomic health disparities associated with COVID-19 in our surrounding communities, the Cleveland Clinic Community Health & Partnership team developed a comprehensive program focused on connecting and communicating with local officials, faith-based organizations, and individual community members. Since March of 2020, our team has donated resources (e.g., personal protective equipment) to local organizations, referred thousands of community members to community or clinical resources, and partnered with federally-qualified health centers to support community COVID-19 testing. Future work will include the use of these networks to deploy the COVID-19 vaccine., (Copyright © 2021 The Cleveland Clinic Foundation. All Rights Reserved.)

Background: African American (AA) male survivors of strokes or transient ischemic attacks (TIA) have the highest risk of recurrent stroke when compared to other racial-ethnic men. However, there is a paucity of evidence-based strategies, including organizational, educational, or behavioral interventions, that targets secondary stroke risk reduction in AA men., Methods: Targeted Management for Reducing Stroke Risk (TEAM) is an ongoing, 6-month prospective, randomized controlled trial that will determine whether a curriculum-guided self-management approach, using peer dyads (men who had a stroke or TIA and their care partners) will improve post-stroke care in AA men., Results: The study sample will consist of 160 AA men who have experienced a stroke or TIA within 5 years, randomized to TEAM or Wait-list control group. The primary outcome changes in systolic blood pressure (BP) and high-density lipoprotein (HDL), while secondary outcomes include diastolic BP, total cholesterol, low-density lipoprotein, triglycerides, and glycemic control for diabetics. We hypothesize that AA men in TEAM will have significantly lower systolic BP and higher HDL when compared to AA men in the Wait-list control group at 6-month., Conclusion: Persistent disparities for stroke burden in AA men highlight the need for novel interventions to promote secondary stroke-risk reduction. Building on promising pilot data, TEAM uses a group format, with a nurse and patient co-led intervention focused on AA men and family needs, practice in problem-solving, and attention to emotional and role management. In addition, the TEAM approach may help reduce stroke risk factors and health disparities in AA men., Clinicaltrialsgov Identifier: NCT04402125., Competing Interests: Dr Martha Sajatovic reports grants from the National Institute of Nursing Research to institution, during the conduct of the study; grants from Nuromate, Otsuka, Alkermes, International Society for Bipolar Disorders (ISBD), National Institutes of Health (NIH), Centers for Disease Control and Prevention (CDC), and Patient-Centered Outcomes Research Institute (PCORI); personal fees from Alkermes, Otsuka, Janssen, Neurocrine, Bracket, Health Analytics, and Frontline Medical Communications; publication royalties from Springer Press, Johns Hopkins University Press, Oxford Press, and UpToDate; compensation for the preparation of continuing medical education materials from American Physician’s Institute, MCM Education, CMEology, Potomac Center for Medical Education, Global Medical Education, Creative Educational Concepts, and Psychopharmacology Institute, outside the submitted work. The authors have no other conflicts of interest., (© 2021 Still et al.)

Health and healthcare disparities are variances in the health of a population or the care rendered to a population. Disparities result in a disproportionately higher prevalence of disease or lower standard of care provided to the index group. Multiple theories exist regarding the genesis of this disturbing finding. The COVID-19 pandemic has had the unfortunate effect of amplifying health inequity in vulnerable populations. African Americans, who make up approximately 12% of the US population are reportedly being diagnosed with COVID-19 and dying at disproportionately higher rates. Viewed holistically, multiple factors are contributing to the perfect storm: 1) Limited availability of public testing, 2) A dramatic increase in low wage worker unemployment/health insurance loss especially in the service sector of the economy, 3) High rates of preexisting chronic disease states/reduced access to early healthcare and 4) Individual provider and structural healthcare system bias. Indeed, COVID-19 represents a pandemic superimposed on a historic epidemic of racial health inequity and healthcare disparities. Therapeutic solutions are not expected in the near term. Thus, identifying the genesis and magnitude of COVID-19's impact on African American communities is the requisite first step toward crafting an immediate well designed response. The mid and long term approach should incorporate population health based tactics and strategies., (Copyright © 2020 National Medical Association. Published by Elsevier Inc. All rights reserved.)

Purpose: African American men are more likely to be diagnosed with, die of and experience decisional regret about their prostate cancer than nonAfrican American men. Although some clinical discrepancies may be attributed to genetic risk and/or access to care, explanations for racial discrepancies in decisional regret remain largely speculative. We aim to identify sources of prostate cancer decisional regret with a focus on racial disparities., Materials and Methods: A cohort of 1,112 patients with localized prostate cancer treated at the Cleveland Clinic between 2010 and 2016 were matched by race, Gleason score, treatment (external beam radiation, brachytherapy, prostatectomy, active surveillance), prostate specific antigen at diagnosis, age at treatment and time since treatment. All patients received 4 surveys, including the Expanded Prostate Cancer Index Composite (EPIC) 26, the Decisional Regret Scale, our novel Prostate Cancer Beliefs Questionnaire and a modified EPIC demographics form. Descriptive and comparative statistics and multivariable logistic regression were used to compare survey outcomes by race and treatment method., Results: Of 1,048 deliverable surveys 378 (36.07%) were returned. African American men had worse decisional regret than nonAfrican American men even after adjusting for relevant covariates (OR 2.46, p <0.0001). African American men also had higher Prostate Cancer Beliefs Questionnaire medical mistrust and masculinity scores, both of which predicted worse decisional regret independent of race (1.415 and 1.350, p=0.0001, respectively)., Conclusions: African American men suffer worse decisional regret than nonAfrican American men, which may be partially explained by higher medical mistrust and concerns about masculinity as captured by the Prostate Cancer Beliefs Questionnaire. This novel survey may facilitate identifying targets to reduce racial disparities in prostate cancer.

The exquisite structure-function correlations observed in filamentous protein assemblies provide a paradigm for the design of synthetic peptide-based nanomaterials. However, the plasticity of quaternary structure in sequence-space and the lability of helical symmetry present significant challenges to the de novo design and structural analysis of such filaments. Here, we describe a rational approach to design self-assembling peptide nanotubes based on controlling lateral interactions between protofilaments having an unusual cross-α supramolecular architecture. Near-atomic resolution cryo-EM structural analysis of seven designed nanotubes provides insight into the designability of interfaces within these synthetic peptide assemblies and identifies a non-native structural interaction based on a pair of arginine residues. This arginine clasp motif can robustly mediate cohesive interactions between protofilaments within the cross-α nanotubes. The structure of the resultant assemblies can be controlled through the sequence and length of the peptide subunits, which generates synthetic peptide filaments of similar dimensions to flagella and pili.

Objective: The aim of this study was to provide a contemporary analysis of longitudinal kidney transplant outcomes and to evaluate potential causes of ethnic disparities among African American (AA) and Caucasian American (CA) patients undergoing kidney transplantation at our institution., Patients and Methods: 1400 patients were identified who underwent kidney transplantation from 2003 to 2013 from a large, academic institution in Cleveland, OH. Relevant recipient and donor demographic and clinical covariates were obtained from an institutional transplant database. Simple descriptive statistics and comparative survival analyses were performed to assess overall survival and graft survival., Results: The final cohort was comprised of 341 AA and 1059 CA patients. AAs were less likely to receive a living donor transplant (27.6% vs. 57.2%, p < 0.001) compared to CAs. Overall patient survival did not significantly differ between the two groups even when stratified by ethnicity. However, AAs had a significantly lower rate of graft survival (p < 0.001). On stratified analysis, there was no difference in the rate of graft survival among AAs and CAs who received living donor grafts. On univariate analysis, AAs demonstrated higher rates of immunosuppression non-compliance and chronic rejection (both p < 0.05). On multivariate analysis, AA recipient ethnicity (HR 1.56, p = 0.047), recipient history of diabetes (HR 1.67, p < 0.001), and AA donor ethnicity (HR 1.56, p = 0.047) were significantly associated with graft failure., Conclusion: AAs undergoing deceased donor renal transplantation demonstrated lower graft survival compared to CAs. Conversely, this disparity did not exist among AAs undergoing living donor transplantation. AAs had higher rates of deceased donor transplantation, immunosuppression non-compliance, chronic rejection, and diabetes. Opportunities exist to use patient education, alternative immunosuppression regimens, and living transplantation to close the ethnic disparity in renal allograft survival., (Copyright © 2018 National Medical Association. Published by Elsevier Inc. All rights reserved.)

Due to the increasing diversity within the United States population, there is an ever-increasing need for increased education on cultural literacy and tolerance in medical schools and residency programs. The purpose of this article was to review how a person's culture can play a substantive role in effecting and influencing (1) medical diagnosis, (2) patient and health provider medical decision-making, (3) the patient's perception of disease, and (4) the doctor-patient relationships. Many of the decisions we make as orthopedic surgeons must account for the patient's cultural needs, as much of our work impacts patients' daily activities and function. When considering the patient's perception of disease, validated tools have been developed, such as the Patient-Specific Index, which can be used to assess the feelings, goals, and expectations of patients. Cultural competency should be a part of curricula at every level of medical education.

Health literacy remains a key factor in the continuance of health disparities in our society as health related quality of life can be negatively affected by limited health literacy. This study explores how limited health literacy among minority men, attending a community health fair, correlates with their health related quality of life. Findings reflect that minority men who possess lower levels of health literacy experience lower self-reported quality of life. Directions for healthcare providers, community health educators and future research approaches are provided., (Copyright © 2018 National Medical Association. Published by Elsevier Inc. All rights reserved.)

Purpose: This study compared a novel self-management (TargetEd MAnageMent Intervention [TEAM]) versus treatment as usual (TAU) to reduce stroke risk in African American (AA) men., Design: Six-month prospective randomized controlled trial with outcomes evaluated at baseline, 3 months, and 6 months., Setting: Academic health center., Participants: Thirty-eight (age < 65) AA men who had a stroke or transient ischemic attack and a Barthel index score of >60 were randomly assigned to TEAM (n = 19) or TAU (n = 19)., Intervention: Self-management training, delivered in 1 individual and 4 group sessions (over 3 months)., Measures: Blood pressure, glycosylated hemoglobin (HbA 1c ), lipids, medication adherence, weight, and standardized measures of health behaviors (diet, exercise, smoking, substances), depression, and quality of life. Qualitative assessments evaluated the perspectives of TEAM participants., Analysis: T tests for paired differences and nonparametric tests. Thematic content qualitative analysis., Results: Mean age was 52.1 (standard deviation [SD] = 7.4) and mean body mass index was 31.4 (SD = 7.4). Compared to TAU, TEAM participants had significantly lower mean systolic blood pressure by 24 weeks, and there was also improvement in HbA 1c and high-density lipoprotein cholesterol ( P = .03). Other biomarker and health behaviors were similar between groups. Qualitative results suggested improved awareness of risk factors as well as positive effects of group support.

We describe the co-assembly of two different building units: collagen-mimetic peptides and DNA origami. Two peptides CP ++ and sCP ++ are designed with a sequence comprising a central block (Pro-Hyp-Gly) and two positively charged domains (Pro-Arg-Gly) at both N- and C-termini. Co-assembly of peptides and DNA origami two-layer (TL) nanosheets affords the formation of one-dimensional nanowires with repeating periodicity of ∼10 nm. Structural analyses suggest a face-to-face stacking of DNA nanosheets with peptides aligned perpendicularly to the sheet surfaces. We demonstrate the potential of selective peptide-DNA association between face-to-face and edge-to-edge packing by tailoring the size of DNA nanostructures. This study presents an attractive strategy to create hybrid biomolecular assemblies from peptide- and DNA-based building blocks that takes advantage of the intrinsic chemical and physical properties of the respective components to encode structural and, potentially, functional complexity within readily accessible biomimetic materials.

Health self-efficacy, a measure of one's self-assurance in taking care of their own health, is known to contribute to a range of health outcomes that has been under examined among African American men. The purpose of this investigation was to identify and contextualize predictors of general health self-efficacy in this population. A cross-sectional sample of surveys from 558 African American was examined. These men were older than 18 years, could read and write English, and attended a hospital-based community health fair targeting minority men in 2011. The outcome of interest was health self-efficacy, which was assessed by asking, "Overall, how confident are you in your ability to take good care of your health?" Responses ranged from 1 ( not confident at all) to 5 ( completely confident). Covariates included age, self-rated health, health insurance status, having a regular physician, and being a smoker. The mean age of participants was 54.4 years, and 61.3% of participants indicated confidence in their ability to take good care of their health. Older age and being a smoker were inversely associated with the outcome. Good self-rated health, having health insurance, and having a regular doctor were positively associated with reports of health self-efficacy. Findings suggest that multiple points of connection to the health care system increase the likelihood of health self-efficacy for this sample and interventions to support older African American men who may evaluate their own health status as poor and who may face barriers to health care access are implicated.

African Americans comprise 11 % of living organ donors, yet constitute 34 % of the kidney transplant waiting list. There are many barriers to organ donation among minorities that include decreased awareness of transplantation, cultural mistrust of the medical community, financial concerns, and fear of the transplant operation. This study investigates the societal misconceptions and demographic health factors that correlate with minority participation in organ and tissue donation. A 57 question Health and Wellness survey was designed to assess participants' demographic information, medical history, professional background, and opinions regarding organ transplantation. Participants were also asked to complete Quality Metric's Short Form-8 (SF-8) survey to assess physical health, mental health, and quality-of-life. Three hundred twenty-six surveys were administered to minority men. The majority of men were identified as African American, and 55 % were below the age of 40. Though 44 % of participants were willing to donate, only 27 % were registered as organ and tissue donors. Minorities who held misconceptions about organ donation-including the belief that they were too old or unhealthy to donate, for example-had lower general, physical, and mental health scores than those who did not (p = <0.0001). Minorities aware of the shortage for organs or who know a registered donor, an organ recipient, a dialysis patient, or someone on the waiting list were more willing to donate organs. Improving the general, physical, and mental health of minorities, coupled with an active educational outreach program, could result in a greater percentage of minorities registering and willing to be organ and tissue donors.

Health-related quality of life (HRQOL) measures among the African American populations have previously been inadequately studied. This study sought to further analyze the quality of life of African American men at the Cleveland Clinic Minority Men's Health Center and Cleveland Clinic Minority Men's Health Fair. Subjects were randomly selected at the Minority Health Fair and Minority Men's Health Center clinics over the duration of 2 weeks to participate in the anonymous survey with the help of independent surveyors. Convenience sampling was done at the Minority Men's Health Fair and at the Minority Men's Health Clinics. Participants were administered in-person Short Form-36 (SF-36v2). A total of 83 participants were surveyed, and the response rate from the surveyed population was 100%. The only exclusion criterion for the study was the refusal to participate ( n = 0). As compared with healthy U.S. norms, African American men reported lower HRQOL across six health domains: physical functioning (60.69 ± 2.82 vs. 84.2), general health (57.56 ± 2.41 vs. 72), social functioning (72.65 ± 3.17 vs. 83.3), role-emotional (55.89 ± 3.02 vs. 81.3), mental health (61.23 ± 2.34 vs. 74.7), and role-physical (62.5 ± 2.88 vs. 81). The largest difference between the health domains was reported in role limitations due to emotional problems (55.89 ± 3.02 vs. 81.3, 25.4). Marital analysis revealed clinically significant lower HRQOL in married African Americans as compared with nonmarried, statistically significant in physical functioning and physical health component ( p < .05). African Americans disproportionally face pervasive disparities in health, as supported by extensive quality of life impairment. No other study, to our knowledge, has used quality of life assessment in African Americans to quantitate how such disparities are affecting important domains in their lives.

The development of biomaterials designed for specific applications is an important objective in personalized medicine. While the breadth and prominence of biomaterials have increased exponentially over the past decades, critical challenges remain to be addressed, particularly in the development of biomaterials that exhibit highly specific functions. These functional properties are often encoded within the molecular structure of the component molecules. Proteins, as a consequence of their structural specificity, represent useful substrates for the construction of functional biomaterials through rational design. This chapter provides an in-depth survey of biomaterials constructed from coiled-coils, one of the best-understood protein structural motifs. We discuss the utility of this structurally diverse and functionally tunable class of proteins for the creation of novel biomaterials. This discussion illustrates the progress that has been made in the development of coiled-coil biomaterials by showcasing studies that bridge the gap between the academic science and potential technological impact.

To explore the potential effects of race on pathological outcomes of renal tumor and on kidney function preservation in the patients undergoing robotic partial nephrectomy (RPN) at our center. Retrospective review of our institutional review board approved database for African-American (AA) patients undergoing RPN from 2006 to 2014 was performed. AA and non-AA groups were compared with regards to demographics, tumor characteristics, functional data and, oncological outcomes. For functional outcomes, groups were matched (1:1) in terms of age, preoperative estimated glomerular filtration rate (eGFR) and R.E.N.A.L score. From the total of 1005 patients, 84 were AA. Age and the tumor size were comparable between the two groups (2.7 vs. 3 cm; p = 0.29). Proportion of patients with papillary RCC was higher among AAs compared to non-AAs (43.3 vs. 19.4 %; p < 0.001). After matching AA patients with non-AA counterparts (1:1 matching), eGFR preservation at latest follow up after surgery was comparable between groups (84.3 vs. 85 %; p = 0.25). AA race (OR 3.62, p < 0.001), male gender (OR 2.05, p < 0.001) and low preoperative eGFR (OR 0.97, p < 0.001) were predictors of papillary RCC on multivariate analyses. The incidence of papillary RCC is higher in AA patients undergoing RPN. There was no difference in kidney function recovery after robotic partial nephrectomy in both AA and non-AA groups. AA race itself is not a significant factor in determining renal malignancy. Further studies are needed to clarify the impact of higher prevalence of papillary tumors in AA group in terms of long-term oncological and functional outcomes.

Background: Health self-efficacy (the confidence to take care of one's health) is a key component in ensuring that individuals are active partners in their health and health care. The purpose of this study was to determine the association between financial hardship and health self-efficacy among African American men and to determine if unmet medical need due to cost potentially mediates this association., Method: Cross-sectional analysis was conducted using data from a convenience sample of African American men who attended a 1-day annual community health fair in Northeast Ohio (N = 279). Modified Poisson regression models were estimated to obtain the relative risk of reporting low health self-efficacy. After adjusting for sociodemographic characteristics, those reporting financial hardship were 2.91 times, RR = 2.91 (confidence interval [1.24, 6.83]; p < .05), more likely to report low health self-efficacy. When unmet medical need due to cost was added to the model, the association between financial hardship and low health self-efficacy was no longer statistically significant., Conclusion: Our results suggest that the association between financial hardship and health self-efficacy can be explained by unmet medical need due to cost. Possible intervention efforts among African American men with low financial resources should consider expanding clinical and community-based health assessments to capture financial hardship and unmet medical need due to cost as potential contributors to low health self-efficacy., (© 2014 Society for Public Health Education.)

Objective: To report a single-center 10-year experience of outcomes of kidney transplantation in African Americans (AAs) vs Caucasian Americans (CA) and to propose ways in which to improve kidney transplant outcomes in AAs, increased access to kidney transplantation, prevention of kidney disease, and acceptance of organ donor registration rates in AAs., Methods: We compared outcomes of deceased donor (DD) and living donor (LD) renal transplantation in AAs vs CAs in 772 recipients of first allografts at our transplant center from January 1995 to March 2004. For DD and LD transplants, no significant differences in gender, age, body mass index, or transplant panel reactive antibody (PRA) existed between AA and CA recipients., Results: Primary diagnosis of hypertension was more common in AA, DD, and LD recipients. Significant differences for DD transplants included Medicaid insurance in 23% AA compared with 7.0% CA (P<.0001) and more frequent diabetes mellitus type 2 in AAs (15% vs 4.1%, P=.0009). Eighty-three percent of AAs had received hemodialysis compared with 72% of CAs (P=.02). AAs endured significantly longer pretransplant dialysis (911±618 vs 682±526 days CA, P=.0006) and greater time on the waiting list (972±575 vs 637±466 days CA, P<0001). In DD renal transplants, AAs had more human leukocyte antigen (HLA) mismatches than CAs (4.1±1.4 vs 2.7±2.1, P<.0001). Mean follow-up for survivors was 7.1±2.5 years. Among LD transplants, graft survival and graft function were comparable for AAs and CAs; however, among DD transplants, graft function and survival were substantially worse for AAs (P=.0003). In both LD and DD transplants, patient survival was similar for AAs and CAs., Conclusion: Our data show that AAs receiving allografts from LDs have equivalent short- and long-term outcomes to CAs, but AAs have worse short- and long-term outcomes after DD transplantation. As such, we conclude that AAs should be educated about prevention of kidney disease, the importance of organ donor registration, the merits of LD over DD, and encouraged to seek LD options., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Given the benefits of health-related Internet use, we examined whether sociodemographic, medical, and access-related factors predicted this outcome among African American men, a population burdened with health disparities. African American men (n = 329) completed an anonymous survey at a community health fair in 2010; logistic regression was used to identify predictors. Only education (having attended some college or more) predicted health-related Internet use (P < .001). African American men may vary in how they prefer to receive health information; those with less education may need support to engage effectively with health-related Internet use.

Background: African-American men are disproportionately burdened with colorectal cancer (CRC). Research is scarce on the social determinants that may influence CRC screening as the primary strategy for early detection among African-American males., Methods: African-American men over the age of 18 years ( n = 558) were recruited from a community health fair and anonymously surveyed about their health and cancer screening behaviors. A social ecological theoretical framework was utilized to identify intrapersonal, interpersonal, organizational, and community predictors of CRC screening, which may be associated with social determinants of health and health behaviors. Analysis included correlations and logistic regression., Results: The mean age of participants was 54.3 years with 85.8% of men being over 40 years of age. Regarding CRC screening: 50.5% ( n = 282) of African-American male participants had received any type of CRC screening at any time. Positive predictors of CRC screening included: health insurance status, older age, having spoken with a health provider about family cancer risk, and having a regular doctor. However, employment status and poor self-rated health were negative predictors of the outcome., Conclusions: Social determinants of health, such as healthcare access and interactions with health systems, along with employment play a critical role in facilitating CRC screening completion in high-risk underserved populations such as African-American men.

Objective: To report a novel surgical approach of transvaginal hybrid natural orifice transluminal surgery (NOTES) living donor nephrectomy. We conceptualized this approach by incorporating 2 existing concepts: laparoendoscopic single-site surgery and NOTES., Materials and Methods: After thorough consent and under institutional review board approval, a 61-year-old woman volunteered to donate her kidney through hybrid transvaginal NOTES. Under general anesthesia, she was placed in a modified right lateral decubitus position. A SILS port and an 8-mm trocar were placed through the same umbilical incision. The GelPoint port was placed transvaginally via the posterior fornix, and the robot was docked. After dissection of the left kidney in preparation for extraction, the robot was undocked, and the retrieval bag was inserted through the GelPoint port. The graft was bagged before vessel stapling and extracted without breaching the bag. The kidney was delivered to the perfusion table with a clean pair of gloves without contamination with the bag exterior., Results: Donor nephrectomy was successfully completed without conversion or perioperative complications. The total operative time was 240 minutes, the warm ischemic time was 5.8 minutes, and the estimated blood loss was 75 mL. No complications occurred and extra ports were not needed. The patient was discharged after an uneventful 48-hour stay. Her creatinine was 1.0 mg/dL at 4 weeks of follow-up. The recipient was given pulse steroids for biopsy-proven acute rejection, and her serum creatinine was 1.16 mg/dL at 4 weeks postoperatively., Conclusion: Transvaginal hybrid NOTES robotic donor nephrectomy is feasible. Additional advances in robotic technology are awaited for development of this approach and to foster its clinical application., (Copyright © 2012 Elsevier Inc. All rights reserved.)

African American men have a higher incidence of prostate cancer than white men, and also a higher rate of death due to prostate cancer. Although both biologic and socioeconomic factors may be to blame, better screening in this population may help to close the gap.

Background: Prostate cancer is the most frequently diagnosed malignancy in men in the United States, with even higher prevalence and death rates among black men. The authors sought to compare trends in prostate-specific antigen (PSA), age, and prostate-cancer detection among black and white men in our region during a 16-year period., Methods: This was a retrospective study of patient archives between 1990 through 2006. Data collection was accomplished by examining patients' charts and electronic medical records. Data from 5570 patients, of whom 911 were black, were analyzed statistically by testing and comparing parameters over time., Results: During this 16-year period, mean age at the time of initial diagnostic prostate biopsy did not change in either group, despite what we had believed about the effects of patient education and screening campaigns. However, prostate-cancer detection rates did decrease during the time period studied. Over time, the authors also observed significant decreases in the sensitivity and specificity of PSA as a screening tool. Indeed, analysis of more recent cases demonstrated a positive predictive value comparable to a coin toss. While Gleason scores remained relatively stable over time, reporting of prostate intraepithelial neoplasia (PIN) and inflammation increased., Conclusions: Using lower PSA thresholds, promoting younger screening age, and increasing efforts to educate the public have not seemed to influence age at time of diagnostic testing, which may reflect other factors such as usefulness of screening, physician referral patterns, patient compliance, and other sociodemographic issues. The usefulness of PSA as a screening tool appears to be diminishing., (Copyright (c) 2010 American Cancer Society.)

In the United States, disparities in health care delivery and access are apparent between different racial and ethnic groups. Minorities, including African Americans, often suffer disproportionately from disease compared to Caucasians. In the urologic arena, this is apparent in urologic cancer screening, treatment choices, and survival, as well as in the arena of chronic kidney disease, transplant allocation, and transplant outcomes. Latino men also seem to be affected more often by erectile dysfunction than Caucasian counterparts. Disparities such as these have been identified as a problem in the delivery of health care in the United States, and resources have been allocated to help allay the disparity. Through organizations such as the Cleveland Clinic Minority Men's Health Center, policy initiatives, and increased cultural awareness by physicians, steps can be made to reduce and eliminate health care disparities.

Background: Wound healing problems and lymphoceles have been reported with greater frequency in kidney recipients given de novo sirolimus. This problem has led to increased patient morbidity and cost; and has been an impediment to the completion of randomized controlled trials in which wound problems have necessitated premature discontinuation of mammalian target of rapamycin inhibitors., Methods: We developed a systematic program to reduce these problems based on patient selection (body mass index [BMI] <32 kg/m2), the use of closed suction drains, modifications of surgical technique, and avoidance of a loading dose of sirolimus. Consecutive series of adult kidney-only recipients given antibody induction followed by de novo sirolimus, mycophenolate mofetil, and steroids were compared; group 1: 204 patients transplanted with few restrictions and group 2: 103 patients transplanted using the above program., Results: This approach resulted in a significant reduction (group 2 vs. group 1) in cumulative wound complications (7.8% vs. 19.6%, P=0.007), and nonoperative wound complications (2.9% vs. 14.2%, P=0.001). In addition, the incidence of lymphoceles detected (22.3% vs. 47.1%, P<0.0001), treated (4.8% vs. 24.5%, P<0.0001), or needing surgical intervention (1.9% vs. 14.2%, P=0.001) was significantly reduced. Multivariate analysis demonstrated that a BMI more than 30 to 32 kg/m2 was the most significant variable related to delayed wound healing (odds ratio [OR] 3.01, 0.02) or surgical repair (OR 8.05, P=0.0001), whereas BMI (OR 1.54, P=0.038) and acute rejections (OR 1.34, P=0.03) were most associated with lymphocele treatment., Conclusions: A systematic program of wound care using de novo sirolimus can produce wound healing complications comparable with that reported with other agents.

Objective: To investigate the effect of placing a prophylactic drain during renal transplantation on the incidence of lymphocele, wound complication and deep venous thrombosis (DVT) in renal transplant recipients induced with sirolimus vs calcineurin inhibitors (CNI), as sirolimus-based immunosuppression is a risk factor for the formation of fluid collections after transplantation., Patients and Methods: We analysed 165 consecutive adult renal transplant patients at our institution between January 2004 and February 2005. Group 1 (84) did not receive an intraoperative drain and group 2 (81) did. Recipients were analysed within each group based on immunosuppression (sirolimus or CNI) and whether they had wound complication, fluid collection, lymphocele treatment, or DVT., Results: In group 1 and 2, respectively, the wound complication rate was 22.6% vs 13.6% (P = 0.134), the fluid collection rate 45.2% vs 16.% (P < 0.001), the lymphocele treatment rate 19.0% vs 2.5% (P = 0.001) the DVT rate 14.3% vs 4.9% (P = 0.043) the fluid collection rate (for CNI) 26.5% vs 16.0% (P = 0.246), the lymphocele treatment rate (for CNI) 5.9% vs 0% (P = 0.084), the fluid collection rate (sirolimus) 58.0% vs 16.1% (P < 0.001) and lymphocele treatment rate (sirolimus) 28% vs 6.5% (P = 0.018). Multivariate analysis of risk factors for fluid collection showed significance for no drain (odds ratio 3.30, P = 0.002), associated wound complication (2.41, P = 0.041) and sirolimus (2.48, P = 0.015)., Conclusions: Placing a drain during transplantation decreased the incidence of fluid collection, lymphocele treatment and DVT. The reduction of fluid collection and lymphocele were significant for patients treated with sirolimus. We recommend placing a drain in patients undergoing induction with sirolimus-based immunosuppression.

Purpose: We evaluated biochemical relapse-free survival after surgery for localized prostate cancer, comparing rates between black and white men in the early and late prostate specific antigen eras. Our hypothesis was that the gap in biochemical relapse-free survival between these groups would lessen in the later prostate specific antigen era due to catch-up awareness/availability of screening and treatment in the black population., Materials and Methods: Data on 2,910 men treated with prostatectomy from 1987 to 2004 were evaluated. The primary end points were 1) rates of organ confined disease and 2) biochemical relapse-free survival after prostatectomy in the early (1987 to 1997) and late (1998 to 2004) prostate specific antigen eras. Rates of organ confined disease were compared using the chi-square test. Biochemical failure was analyzed using Kaplan-Meier estimates and Cox proportional hazards regression., Results: Median followup for the early and late prostate specific antigen periods was 9.8 (range 1.2 to 18.2) and 3.3 years (range 1.0 to 7.7), respectively. Based on rates of organ confined disease in the early vs late periods black and white men had significant gains in the number presenting with favorable disease at diagnosis in the late prostate specific antigen period (54% vs 76% and 49% vs 71%, respectively, each p <0.01). Despite gains of similar magnitude in favorable features at presentation biochemical relapse-free survival for black men lagged behind white men by 11% at 5 years in the early era and by 12% in the late era. Race was a significant predictor of biochemical relapse-free survival on multivariate analysis in each era., Conclusions: Despite similar increases in the rate of organ confined disease between black and white men in the late vs early prostate specific antigen eras black men continue to show higher rates of biochemical failure after surgery.

Background: We report the 5-year outcomes from a randomized prospective trial in primary adult renal allograft recipients, designed to evaluate calcineurin inhibitor (CNI)-free immunosuppression on kidney transplant function., Methods: Sixty-one patients were randomized to either sirolimus (n=31) or cyclosporine (n=30) after basiliximab induction and mycophenolate mofetil (MMF) with steroids. Sirolimus was concentration controlled at 10-12 ng/mL for at least 6 months., Results: After 5 years, sirolimus-MMF-steroids compared to cyclosporine-MMF-steroids provides similar patient survival (87.1 vs. 90%, P=0.681), acute rejection rates (12.9 vs. 23.3%, P=0.22), total cholesterol (209.1 vs. 204.3 mg/dL, P=0.973), urine protein/creatinine ratios (0.398 vs. 0.478 mg/dL, P=0.72), and overall medical and surgical morbidity (P=NS). Although unadjusted patient survival was similar, sirolimus based CNI-free patients had longer death censored graft survival (96.4 vs. 76.7%, P=0.0265), higher glomerular filtration rate (GFR) by the abbreviated Modified Diet in Renal Disease (66.7 vs. 50.7 cc/min, P=0.0075), and fewer graft losses from chronic allograft nephropathy. The Banff chronic scores at two years were strong predictors of 5-year GFR. At 5 years, there were six de novo (three solid organ, three skin) cancers in the CNI group and only two de novo (one skin, one leukemia, no solid organ) cancers in the sirolimus group (P=NS)., Conclusions: This study of low to moderate risk patients demonstrates that excellent 5-year kidney transplant outcomes can be achieved without CNI drugs, when therapeutic drug monitoring of sirolimus is employed. The application of CNI drug avoidance protocols to high-risk recipients (retransplants, highly sensitized, etc.), extrarenal allograft recipients, or alternative drug regimens such as steroid or MMF elimination should be subjected to controlled trials.

Background: Ischemia/reperfusion injury is an inherent consequence of solid organ transplantation that increases tissue inflammation and negatively impacts organ transplant function and survival. This study investigated the expression levels of chemokine and chemokine receptor genes in living versus cadaver donor renal allografts before and after reperfusion., Methods: This study involved 39 renal transplant patients (19 cadaveric and 20 living donor). The ischemia biopsy was taken just before graft declamping and the reperfusion biopsy 30 min after declamping. Whole-cell RNA was isolated and chemokine (IL-8, CCL2/MCP-1, CXCL10/IP-10 and CCL5/RANTES) and chemokine receptor (CCR2 and CCR5) expression was tested by quantitative PCR., Results: Just prior to declamping, ischemic cadaveric donor grafts had higher expression of CXCL10/IP-10 but not IL-8 or CCL2/MCP-1 than living donor grafts. IL-8 expression increased 50% from ischemia to reperfusion in living donor grafts but increased more than 13-fold during reperfusion of cadaver donor grafts. Increased total ischemia time induced greater IL-8 expression during reperfusion. MCP-1 expression also increased during reperfusion of living and cadaver donor grafts but differences were not observed between the two groups of grafts. RANTES, CCR2, and CCR5 expression did not change in ischemic vs. reperfusion biopsies., Conclusions: The expression of chemokines directing neutrophil and macrophage recruitment increases during reperfusion of living and cadaveric donor renal allografts. Expression levels of IL-8 correlate with the ischemic time imposed on the renal graft. Early tissue injury may be attenuated by strategies antagonizing chemokines directing the recruitment of neutrophils and macrophages into kidney grafts.

Background: The aim of this study was to evaluate the incidence and risk factors for posttransplant diabetes mellitus (PTDM; defined as new insulin use and/or new hyperglycemia) in 528 kidney recipients using different immunosuppressive agents., Methods: Maintenance therapy included mycophenolate mofetil or azathioprine plus glucocorticoids in combination with Group I cyclosporine (263); Group II tacrolimus (60); or Group III sirolimus (205)., Results: The mean follow-up was 39.2 (range 9.0-103.8) months. Overall, the number of patients needing insulin was 7.4% (39/528). The incidences for Groups I, II, and III of 7.6%, 11.7%, and 5.9%, respectively, were not statistically different. Characteristics of patients with PTDM included older age (P=0.007); greater body weight (kg) at transplant, 6 months, and 12 months, respectively (P<0.001); greater BMI (kg/m2) at transplant, 6 months, and 12 months, respectively (P<0.001); more acute rejection episodes 28.2% vs. 13.5% (P=0.012); and increased incidence in African Americans (P=0.03). Multivariable analysis demonstrated increased risk for PTDM (defined as new insulin use) for tacrolimus, (hazard ratio [HR] 3.794, P=0.007); treated rejections (HR 2.491, P=0.0115); age (HR 1.407, P=0.0116); and BMI (HR 1.153, P<0.0001). New insulin use occurred sooner and with less total glucocorticoid dose for tacrolimus patients. If PTDM is defined as all cases of new hyperglycemia, then no immunosuppressive drug group demonstrated an increased risk. CONCLUSION.: The risk for developing PTDM is greatest among older recipients, and those obese at the time of transplant; those given steroid pulse therapy were at exceptionally high-risk. PTDM risk reduction should focus on weight loss in the obese end-stage renal disease population prior to transplant.

We compared gene expression profiles from six donor kidneys prior to surgical manipulation to six kidneys removed after laparoscopic donor nephrectomy (LDN) and several hours of CO2 pneumoperitoneum. Biopsies were obtained from renal cortex and hybridized to Affymetrix HG-U133A GeneChips. For control kidneys, we identified 1380 genes present on all six samples that had a signal intensity >1,000. Functional classification of these revealed genes for cellular signaling (201; 15%), regulation of transcription (156; 11%), cellular transport (144; 10%) and cellular metabolism (111; 8%). A class comparison between the controls and LDN kidneys yielded 865 differentially expressed genes. Functional classification of the 502 genes differentially upregulated in LDN kidneys identified associations with apoptosis, cell adhesion, cell signaling, regulation of cell growth/proliferation, immune/inflammation, ischemia/stress response and proteolysis/peptidolysis. These data demonstrate an altered renal transcriptome induced by several hours of CO2 pneumoperitoneum and laparoscopic surgery characterized by upregulation of ischemia and injury associated genes.

We reviewed our experience with simultaneous single incision bilateral native nephrectomy and renal transplantation in 11 patients (Group 1), compared to seven recipients who underwent staged laparoscopic bilateral nephrectomy followed by kidney transplantation (Group 2). Mean age, donor source, sex, cause of ESRD, and specimen size were similar in both groups (P=0.1). All Group 2 patients and 9 of 11 Group 1 patients had autosomal-dominant polycystic kidney disease. Perioperative Group 1 complications included: bowel injury, transplant urine leak, necrotic pancreatitis, delayed bowel movement, and severe shoulder pain secondary to diaphragmatic irritation. Seven (63.6%) Group 1 patients required an additional surgical procedure: midline incisional hernia, repair ureteral fistula, and repair enterocutaneous fistula. One Group 1 patient lost his graft secondary to bowel injury and intra-abdominal sepsis. No major complications, reoperations, or graft loss occurred in Group 2. For simultaneous bilateral native nephrectomy and kidney transplantation, over 60% of patients required an additional surgical procedure. Laparoscopic bilateral nephrectomy followed by kidney transplantation is a safe and feasible alternative.

Objectives: To perform a retrospective study to determine the clinical utility of Doppler ultrasonography (DUS) and to determine its role in the management of transplant renal artery stenosis (TRAS)., Methods: Patients undergoing DUS between January 1998 and January 2001 for clinical suspicion of TRAS were included in the study. A total of 51 patients were divided into two groups according to the peak systolic velocity. Additional management was based on the clinical and DUS findings and their congruence. Patients were followed up and their outcome was analyzed., Results: Of the 51 patients who entered the study, 26 were in the low probability group (LPG) and 25 in the high probability group (HPG). Nine patients in the LPG underwent additional investigations; eight underwent magnetic resonance angiography and one angiography. Of these 9 patients, 6 had stenosis, 4 of whom required angiography. In total, 5 patients from the LPG underwent angioplasty, and 4 of them had stenosis (1 with TRAS, 2 with common iliac artery stenosis, and 1 with renal artery ostial stenosis). Three patients underwent angioplasty and 2 of them improved. In the HPG, 20 of 25 patients underwent additional investigations, including magnetic resonance angiography in 12 and angiography in 8, with stenosis in 15 patients. Of the HPG, 13 of 25 patients underwent angiography, with 10 requiring angioplasty--8 for TRAS and 2 for adjacent renal artery stenosis, with improvement in 8 patients. Congruent clinical and DUS findings were highly predictive of significant stenosis more amenable to improvement., Conclusions: The results of our study have shown that high-probability DUS and congruent clinical findings are likely to identify a significant stenosis that is amenable to treatment. Low-probability DUS findings do not eliminate the possibility of stenosis, but intervention in this group is less likely to result in improvement.

Objectives: To assess the patterns of early functional recovery and long-term function in laparoscopic and open procured live donor nephrectomy (LDN) kidneys, highlighting the radionuclide scan as an additional tool for assessment, because of concerns regarding renal functional recovery after laparoscopic LDN., Methods: We reviewed the donor and recipient records of 101 laparoscopic and 35 open LDNs performed between August 1997 and September 2001. Data were collected on demographic, immunologic, and intraoperative variables and ureteral/vascular complications. Delayed renal function recovery in recipients was evaluated by serum creatinine greater than 2.5 mg/dL on postoperative day 5, dialysis in first postoperative week, and two renographic criteria--the time to peak activity and the time to one-half peak activity on postoperative day 5. Long-term outcomes were evaluated by serum creatinine at 1, 3, 6, and 12 months and 2 and 3 years, creatinine clearance at 1 year, and patient and allograft survival., Results: Donor and recipient age, sex, body mass index, and number of HLA mismatches did not differ between the two groups. The mean operating room time and blood loss were comparable. No differences were found in the early functional parameters (renography, creatinine at postoperative day 1 and 5, or dialysis in week 1) or long-term outcome (patient and graft survival, creatinine, and rejection at 1 year and patient and graft survival at 1, 2, and 3 years)., Conclusions: Early recovery of graft function, longer term renal function, and 3-year patient and allograft survival are similar for live donor kidneys obtained by either a laparoscopic or an open surgical technique.

Background: We performed a sequential study to determine the efficacy and side effects of low-dose (1 g) mycophenolate mofetil (MMF) in a CNI drug avoidance regimen including sirolimus/steroids., Methods: A total of 260 kidney-only recipients were given basiliximab (232) or thymoglobulin (28) induction, and sirolimus/steroids. In addition, 160 recipients were begun on standard MMF 1 g twice daily (2-g group), while 100 recipients were begun on low-dose MMF 500 mg twice daily (1-g group). The 1-g recipients were concentration controlled to keep mycophenolic acid (MPA) C0 levels at 1.8-4 microg/ml., Results: There were no statistically significant differences in demographics between the groups. At 6 months there were no significant differences between the 2-g and 1-g MMF groups in patient survival (96.8% vs. 96%), graft survival (92.5% vs. 95%), biopsy-confirmed and treated acute rejection (8.8% vs. 13%), or mean creatinine mg/dL (1.41+/-0.52 vs. 1.47+/-0.67), respectively. Mean MPA C0 levels microg/ml were (4.7 vs. 2.3) at 1 month, (4.1 vs. 3.1) at 3 months, and (3.9 vs. 2.4) at 6 months. There were no significant differences at 1, 3, or 6 months in mean WBC, HgB, or platelets, or wound complications. There were significant reductions in the number of patients reporting nausea-vomiting-dyspepsia (20.6% vs. 8%, P=0.007), diarrhea (34.3% vs. 20%, P=0.01), and abdominal pains (10.6% vs. 4%, P=0.05), between the 2-g and 1-g MMF groups, respectively., Conclusions: The use of concentration-controlled 1-g MMF results in comparable transplant outcomes with less GI toxicity during the first 6 months posttransplant in a CNI drug-free sirolimus based immunosuppressive regimen.

Purpose: Laparoscopic donor nephrectomy (LDN) is an increasingly accepted modality for procuring donor kidneys for transplantation. We analyzed and compared the short and long-term outcomes of living transplant allografts from kidneys procured by laparoscopic or open donor (ODN) technique and managed with a single immunosuppression regimen in each group., Materials and Methods: Records of recipients who underwent living (laparoscopic or open) donor nephrectomy were reviewed from August 1999 to July 2001 for LDN and from January 1994 to December 1999 for ODN. Patients included were on a single immunosuppression regimen particular to each group. Sirolimus, mycophenolate mofetil and prednisone were given to the LDN group, and calcineurin inhibitor (FK-506 or cyclosporine), mycophenolate mofetil and prednisone were given to the ODN group. Excluded from study were patients with prior kidney transplant or patients not receiving immunosuppression as previously described. Also excluded from study were patients lost to followup before 1 year. Data were retrieved retrospectively from case notes or from the transplant database and analyzed using SAS software (SAS Institute, Cary, North Carolina)., Results: A total of 71 patients from the LDN group and 60 patients from the ODN group qualified for the study. Demographic data are comparable in both groups except for the significantly longer followup in the ODN group. Serum creatinine was 2.2 and 1.8 mg/dl at postoperative day 4, 1.3 and 1.3 mg/dl at day 10, and 1.3 and 1.4 mg/dl at 1 month in the LDN and ODN groups, respectively. Time to achieve nadir serum creatinine was 8.7 versus 6.6 days for LDN and ODN groups, respectively (p = not significant). Delayed graft function was noted in 5 of 71 (7%) in the LDN group and 3 of 60 (5%) in the ODN group (p = 0.5). In the LDN group 13 (18%) patients had a serum creatinine of greater than 1.5 mg/dl at postoperative day 30 compared to 6 (10%) in the ODN group (p = 0.06). Mean serum creatinine at 1 year was lower for LDN recipients (p = not significant). But at last followup this difference became statistically significant in favor of LDN. Mean followup was 939 versus 2,046 days for LDN versus ODN, respectively (p <0.0001). Recipient mean hospital stay was 5.2 versus 6.7 days for LDN versus ODN, respectively (p = 0.08). There were 8 of 78 (10.2%) episodes of acute rejection in the LDN group compared to 22% in the ODN group (p = 0.08). The complication rate (ureteral vascular, lymphocele, acute rejection and wound) was 11% in LDN compared to 15% in the ODN group. Long-term graft function, graft survival and patient survival in the LDN group were comparable to the ODN group., Conclusions: Early graft recovery is slower in LDN allografts, although not statistically significant, but long-term function in the LDN group is significantly better compared to the ODN group. Laparoscopic donor kidneys take longer to achieve nadir serum creatinine, but this does not influence long-term outcome and results.

Purpose: We compared the incidence of lymphocele formation and treatment in kidney transplant recipients given 3 immunosuppressive drug regimens., Materials and Methods: Consecutive series of adult kidney only recipients, including group 1-152 who received sirolimus/mycophenolate mofetil (MMF)/prednisone (P), group 2-168 who received cyclosporine/MMF/P and group 3-193 who received cyclosporine/azathioprine/P, were analyzed for post-transplantation lymphocele formation. All available records and imaging studies were reviewed, such as ultrasound, computerized tomography, magnetic resonance imaging etc, for peritransplant fluid collections greater than 2.5 cm. Demographic characteristics and the risk factors for lymphocele were compared in these 513 recipients using univariate and multivariate analysis., Results: The overall incidence of lymphocele formation was 174 of 513 cases (33.9%) and the incidence of treated lymphoceles was 81 of 513 (15.7%). In groups 1 to 3 the incidence was 45.5%, 33.9% and 24.7%, respectively. These differences were significantly higher in group 1 vs groups 2 or 3 (p = 0.014) but they were not significantly different between groups 2 and 3. Similarly the incidence of treated lymphoceles was 23%, 12.5% and 12.9%, respectively. Findings were again statistically higher in group 1 vs groups 2 and 3 (p = 0.003) but not statistically significant between groups 2 and 3. A greater number of group 1 patients required surgical interventions compared with those in groups 2 and 3 (13.8% vs 4.7% and 4.8%, respectively, p = 0.019). In addition, acute rejection (p = 0.001) and body mass index greater than 32 (p = 0.02) were significant risk factors on multivariate analysis., Conclusions: The combination of sirolimus/MMF/P, obesity with a body mass index of greater than 30 kg/m and acute rejection are independent risk factors for lymphocele formation and treatment after kidney transplantation. Patients should be counseled and consideration should be given to prophylactic measures in this higher risk renal transplant population.

Purpose: Delayed graft function after live donor transplantation affects 5% to 10% of recipients regardless of procurement technique. This delay in function is associated with an increased risk of rejection and decreased graft survival. In the present study we critically assess allograft recovery to identify the risk factors related to delayed graft function., Materials and Methods: We retrospectively reviewed donor and recipient medical records from 100 consecutive laparoscopic live donor nephrectomies from August 1997 to October 2001. Four criteria were used to classify delayed graft function: I) requirement of dialysis in postoperative week 1, II) creatinine 2.5 mg/dl or greater at postoperative day 5, III) time to half peak activity (mercaptoacetyltriglycine renal scan) at postoperative day 5 greater than 12.2 minutes (normal range 1 to 12.2) and IV) time to peak activity (mercaptoacetyltriglycine renal scan) at day 5 greater than 6.5 minutes (normal range 2.1 to 6.5). Patients could qualify for multiple outcome categories. Patients who did not match any of these criteria were classified as having normal renal function (outcome 0)., Results: The number of patients in the delayed graft function categories were 5 with outcome I, 14 with outcome II, 39 with outcome III and 24 with outcome IV. There were 23 patients represented in more than 1 category and 59 patients were classified as having normal function. Recipient age, donor/recipient gender relationship, unrelated highly mismatched donors and cold/total preservation time were identified as risk factors related to impaired early renal function recovery. None of the variables related to the laparoscopic technique itself represented risk factors for delayed graft function., Conclusions: Female donor kidneys into male recipients and highly HLA mismatched donors represent factors that may be controlled by donor selection when feasible. All attempts should be made to decrease cold ischemia time and, therefore, total preservation time. Prolonged carbon dioxide pneumoperitoneum, warm ischemia time, renal artery length or use of right kidney did not adversely affect the functional outcome of the allografts procured laparoscopically.

Introduction: The introduction of the microemulsion formulation of cyclosporine (CsA) (Neoral-NEO) has been shown to provide improved absorption and less intrapatient variability than the previous formulation (Sandimmune-SIM) in kidney transplant recipients. It has been suggested that the use of the microemulsion formulation results in less acute rejection, and therefore permits better long-term transplant outcomes. Our aim was to determine whether the microemulsion formulation of cyclosporine has reduced the long-term (5 yr or more) rates of chronic rejection (allograft nephropathy) in a renal transplant population., Methods: The study population included 792 (508 cadaveric and 284 living donor) transplants performed in 786 patients at the Cleveland Clinic Foundation and its affiliate hospitals between July 1, 1987 and July 1, 1998. Patients who were less than 18-yr-old or had less than 12 months of graft function were excluded from the analysis. Over 90% of the cadaveric and 11% of the live donor recipients were given an induction antibody. A total of 591 patients were given the SIM formulation and 201 the NEO formulation of cyclosporine. Additional maintenance therapy included either azathioprine or mycophenolate mofetil, and steroids. All patients were followed to graft loss, death, or return to dialysis. The NEO group was followed until December 2001. The diagnosis of acute rejection was biopsy confirmed in >92% of cases. Chronic rejection was identified by clinical and biopsy criteria. Demographic and clinical data was collected from medical records, interviews, and phone contact with patients and treating physicians., Results: The mean follow-up was 84 +/- 31 months for the SIM group, and 54 +/- 14 months for the NEO group. At 70 months there was no significant difference (p = 0.17) - actuarial patient survival between the SIM (90.7%) vs. the NEO (93%) treated patients. In addition, at 70 months there was no significant difference (p = 0.55) in death censored actuarial graft survival between the SIM (84.3%) and the NEO treated (85.7%) patients. The acute rejection-free rate was 10% higher for the NEO vs. the SIM patients (79 vs. 69%, p = 0.0004). Chronic rejection was diagnosed in 141 of 591 (24%) of the SIM patients and in 56 of 201 (28%) of the NEO patients (p = ns). At 5 yr the mean serum creatinine (mg/dL) was 2.07 +/- 1.69 for the SIM and 2.15 +/- 1.61 for the NEO patients (p = ns)., Conclusions: The use of the microemulsion formulation of CsA has led to the improved delivery of the parent drug, and a decrease in the number of acute rejection episodes post-transplant. However, patient and graft survival, renal function, and progression to chronic allograft nephropathy at 5 yr were no different. The advantages of greater drug exposure from the microemulsion formulation may be counterbalanced by increased drug induced nephrotoxicity over time.