Search

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 aim of this study is to evaluate feasibility and safety of robotic-assisted donor nephrectomy (RADN) as compared with the hand-assisted laparoscopic technique (HALDN). Patient and methods: This is a retrospective study of the first 83 consecutive RADN procedures which were compared with a group of 103 consecutive HALDN procedures. Results: The median operating time in the RADN group and the HALDN group were respectively 173 (SD = 37) and 137 (SD = 29) min (p = 0.000). The mean first warm ischemia time (min, SD) in the RADN and HALDN group were respectively 2.60 (0.78) and 2.15 (0.38) (p = 0.000). The median blood loss (ml, SD) in the RADN and HALDN group were respectively 33 (87) and 64 (146) ml (p = 0.000). There were no statistically significant differences in post-operative pain-score, post-operative length of stay and complications between the two groups. There were also no statistically significant differences in recipient serum creatinine at 1 week and 1 month after transplantation. The median recipients eGFR (CKD-EPI) at 1 week in the RADN and HALDN group were respectively 50 (SD = 20) and 38 (SD = 19) (p = 0.018) and at 1 month respectively 52 (SD = 16) and 47 (SD = 15) ml/min/1.73m2 (p = 0.090). Conclusion: Robotic-assisted donor nephrectomy is an evolving technique which is safe for the donor and for the graft.

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.

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.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.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.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.

Objectives: The aim of this study was to investigate the effects of antegrade balloon dilatation on ureteral strictures that developed after kidney transplant. Materials and Methods: The hospital databases of the Erasmus Medical Center (Rotterdam, The Netherlands) and the Academic Medical Center (Amsterdam, The Netherlands) were retrospectively screened for patients who underwent balloon dilatation after kidney transplant. Balloon dilatation was technically successful whenever it was able to pass the strictured segment with the guidewire followed by balloon inflation; the procedure was clinically successful if no further interventions (for example, surgical revision of the ureteroneocystostomy or prolonged double J placement) were necessary. Results: Fifty patients (2.4%) of 2075 kidney transplant recipients underwent antegrade balloon dilatation because of urinary outflow obstruction. Median time between transplant and balloon dilatation was 3 months (range, 0-139 mo). In 43 patients (86%), balloon dilatation was technically successful. In the remaining 7 patients (14%), it was impossible to pass the strictured segment with the guidewire. In 20 of 43 patients (47%) having a technically successful procedure, the procedure was also clinically successful, with median follow-up after balloon dilatation of 35.5 months (range, 0-102 mo). We did not identify any patient or stricture characteristic that influenced the outcome of treatment. Conclusions: Balloon dilatation is a good option for ureter stricture treatment after kidney transplant as it is minimal invasive and can prevent surgical exploration in almost 50% of cases.

Human cytomegalovirus (hCMV) infection is characterized by a vast expansion of resting effector-type virus-specific T cells in the circulation. In mice, interleukin-7 receptor α (IL-7Rα)-expressing cells contain the precursors for long-lived antigen-experienced CD8 + T cells, but it is unclear if similar mechanisms operate to maintain these pools in humans. Here, we studied whether IL-7Rα-expressing cells obtained from peripheral blood (PB) or lymph nodes (LNs) sustain the circulating effector-type hCMV-specific pool. Using flow cytometry and functional assays, we found that the IL-7Rα + hCMV-specific T cell population comprises cells that have a memory phenotype and lack effector features. We used next-generation sequencing of the T cell receptor to compare the clonal repertoires of IL-7Rα + and IL-7Rα − subsets. We observed limited overlap of clones between these subsets during acute infection and after 1 year. When we compared the hCMV-specific repertoire between PB and paired LNs, we found many identical clones but also clones that were exclusively found in either compartment. New clones that were found in PB during antigenic recall were only rarely identical to the unique LN clones. Thus, although PB IL-7Rα-expressing and LN hCMV-specific CD8 + T cells show typical traits of memory-type cells, these populations do not seem to contain the precursors for the novel hCMV-specific CD8 + T cell pool during latency or upon antigen recall. IL-7Rα + PB and LN hCMV-specific memory cells form separate virus-specific compartments, and precursors for these novel PB hCMV-specific CD8 + effector-type T cells are possibly located in other secondary lymphoid tissues or are being recruited from the naive CD8 + T cell pool. IMPORTANCE Insight into the self-renewal properties of long-lived memory CD8 + T cells and their location is crucial for the development of both passive and active vaccination strategies. Human CMV infection is characterized by a vast expansion of resting effector-type cells. It is, however, not known how this population is maintained. We here investigated two possible compartments for effector-type cell precursors: circulating acute-phase IL-7Rα-expressing hCMV-specific CD8 + T cells and lymph node (LN)-residing hCMV-specific (central) memory cells. We show that new clones that appear after primary hCMV infection or during hCMV reactivation seldom originate from either compartment. Thus, although identical clones may be maintained by either memory population, the precursors of the novel clones are probably located in other (secondary) lymphoid tissues or are recruited from the naive CD8 + T cell pool.

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.

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.

In addition to the classical TH1 and TH2 cytokines, members of the recently identified IL-17 cytokine family play an important role in regulating cellular and humoral immune responses. At present nothing is known about the role of these cytokines in atherosclerosis. Expression of IL-17A, -E and -F was investigated in atherosclerotic tissue by rtPCR and immunohistochemistry. IL-17E and its receptor were further studied in cultured smooth muscle cells and endothelial cells, using rtPCR and western blot. rtPCR showed that IL-17A, -E and -F were expressed in the majority of plaques under investigation. IL-17A/F was expressed by mast cells in all stages of plaque development. IL-17A/F(+) neutrophils were always observed in complicated plaques, but hardly in intact lesions. IL-17A/F(+) Tcells ('TH17') were never observed. IL-17E was expressed by smooth muscle cells and endothelial cells in both normal and atherosclerotic arteries, and in advanced plaques also extensively by mature B cells. Cultured smooth muscle cells and endothelial cells were found to express both IL-17E and its functional receptor (IL-17RB). The constitutive expression of IL-17E by resident plaque cells, and the additional presence of IL-17E(+) B cells and IL-17A/F(+) neutrophils in advanced and complicated plaques indicates a complex contribution of IL-17 family cytokines in human atherosclerosis, depending on the stage and activity of the disease.

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.

Background Infection with microorganisms is considered a pathogenic factor in atherogenesis. Several studies have shown the presence of a broad spectrum of bacterial species in atherosclerotic plaques, which could trigger local inflammation. Because T cells contribute to atherosclerotic plaque inflammation, we studied the responsiveness of human plaque derived T-cell cultures to bacteria of different species. Materials and methods Primary polyclonal T-cell cultures were generated from both carotid endarterectomy tissue and peripheral blood of nine patients, and the peripheral blood of eight matched controls. The in vitro proliferative responses of the T-cell cultures against H. pylori, N. meningitidis, N. lactamica, S. aureus, S. pneumoniae, S. epidermidis and E. coli were analysed. T-cell proliferation was measured by 3H-thymidine incorporation and expressed as a stimulation index. Selective outgrowth of intraplaque microbial specific T cells was studied by calculating the ratio of plaque T-cell SI and peripheral blood T-cell SI in each patient. Results All patients showed T-cell responsiveness to multiple bacteria in their plaque tissue. Stimulation indices were in the range of 0·3–30, and this degree of reactivity with the different species was heterogeneous among patients. Selective outgrowth (plaque/peripheral blood ratio) of T cells against multiple bacteria was observed in six out of nine patients. Conclusions T cells in atherosclerotic plaques have the capacity to selectively respond to antigens of a wide variety of microbial antigens. This supports the view that such mechanisms could contribute to the atherosclerotic inflammatory response.

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.

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

In renal transplantation, prolonged cold ischaemia time (CIT) increases the risk of delayed graft function, rejection and graft failure. To minimise CIT, renal transplantations are performed directly upon graft availability and often take place during the night. Night-time surgery is supposedly associated with an increased risk of surgical complications compared with daytime operations. The aim of this study was to assess the consequences of night-time renal transplantation on surgical complications and graft function.384 adult recipients of deceased-donor renal transplantations performed between January 2007 and June 2012 were retrospectively examined. Night-time renal transplantations were defined as surgery between 11 PM and 6 AM. The primary outcome was the occurrence of surgical complications. The secondary outcome was graft function.No differences in surgical complications or graft function were observed among daytime and night-time groups. CIT was significantly increased in night-time renal transplantation (p0.001).Night-time renal transplantation is not associated with an increased risk of surgical complications or graft failure, and can be considered a safe procedure. Given the need to minimise CIT, delaying the procedure until the morning is unjustified.

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

Although many relevant immune reactions are initiated in the lymph nodes, this compartment has not been systematically studied in humans. Analyses have been performed on immune cells derived from tonsils, but as this tissue is most often inflamed, generalization of these data is difficult. Here, we analyzed the phenotype and function of the human CD4+ T-cell subsets and lineages in paired resting lymph node and peripheral blood samples. Naive, central memory cells and effector memory cells as well as Th1, Th2, Th17 and Treg cells were equally represented in both compartments. On the other hand, cytotoxic CD4+ T cells were strikingly absent in the lymph nodes. CXCR5+CD4+ T cells, representing putative follicular Th (Tfh) cells were over-represented in lymph nodes and expressed higher levels of Tfh markers than their peripheral blood counterparts. Compared with the circulating pool, lymph-node-derived CXCR5+CD4+ T cells were superior in providing help to B cells. Thus, functionally competent Tfh cells accumulate in resting human lymph nodes, providing a swift induction of naive and memory antibody responses upon antigenic challenge.

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.

To determine short-term differences in renal function evolution between patients with renal cell carcinoma (RCC) submitted to radical nephrectomy (RN) and living kidney donors matched for age and gender. To assess the role of co-morbidity as a risk factor for developing an estimated glomerular filtration rate (eGFR) of60 mL/min/1.73 m(2) .In this retrospective study patients undergoing Radical Nefrectomy (RN) between January 2000 and February 2011 for suspicion of localised RCC were matched by age and gender to living kidney donors. Renal function was compared between the groups using the Modification in Diet and Renal Disease (MDRD) equation at 1 year after RN. Charlson co-morbidity score, incidence of hypertension, diabetes and cardiovascular disease were compared and assessed as predictors for developing an eGFR of60 mL/min/1.73 m(2) .In all, 196 patients were included, 98 in each group. The mean age was respectively 60.6 (RCC group) and 59.1 years (donors). The 1-year postoperative mean eGFR (available in 89 patients with RCC and 87 donors) was similar, at a mean (sd) of 56.7 (16.4) mL/min/1.73 m(2) in patients with RCC and 56.2 (9.8) mL/min/1.73 m(2) in donors (P = 0.83). In patients with RCC the incidence and severity of co-morbidities was significantly higher. A preoperative eGFR of 60-89 mL/min/1.73 m(2) was the only independent risk factor for developing a postoperative eGFR of60 mL/min/1.73 m(2) (odds ratio 4.4, confidence interval 2.1-9.5, P0.001, 95% confidence interval).In our cohorts with advanced age the 1-year follow-up eGFR was similar in both groups. Despite increased co-morbidity in the RCC group there was no increased decline in renal function. Only reduced preoperative eGFR could be identified as risk factor for developing a postoperative eGFR of60 mL/min/1.73 m(2) .

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.