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Background. Activation of the renin angiotensin system may contribute to the development of delayed graft function after renal transplantation. We, therefore, examined the impact of pretransplant treatment with blockers of the renin angiotensin system on early graft function after renal transplantation. Method. The case records of all patients who received a live donor transplant between January 2001 and August 2008 were reviewed. Results. Serum creatinine measurements were recorded for the first nine posttransplant days, in 94 recipients of live donor kidneys, where there were neither surgical nor hemodynamic complications and no documented rejection or infection. Forty patients (43%) were treated with a blocker of the renin-angiotensin-aldosterone system before transplantation. Serum creatinine levels fell more slowly in these patients (P = 0.02). Two patients required hemodialysis after transplantation; both were on an angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker. Conclusion. Live donor renal transplant recipients who are taking a renin-angiotensin-aldosterone system blocker at the time of transplantation are more likely to have impaired graft function postoperatively in the absence of other explanations. This observation requires further exploration in live and deceased donor renal transplantation

Introduction The aim of this study was to evaluate donor acute kidney injury (AKI) using a novel biomarker (NGAL). Methodology A pilot study of 20 patients undergoing hand-assisted live donor nephrectomy was undertaken. eGFR and serum NGAL measurements were obtained pre-operatively, immediately post-operatively, day 1 and 6 weeks post-operatively. Results Mean age: 40.6 ± 11.1 years. Mean pre-operative eGFR: 105.6 ± 10.1 ml/min/1.73 m 2 . Mean day 1 post-op eGFR: 65.7 ± 10.4 ml/min/1.73 m 2 (37.7 ± 9.2% reduction from baseline). Mean eGFR 6 weeks post-operatively was 74.1 ± 8.6 ml/min/1.73 m 2 (29.4 ± 8.8% reduction from baseline). Serum NGAL increased by 34.1 ± 16.7% following an overnight fast pre-operatively (day 0) (ΔNGAL 45.1 ± 36.0 ng/ml), by a further 14.9 ± 7.2% following surgery (post-op) and a further 3.1 ± 1.2% by post-operative day 1. The largest ΔNGAL was observed during the pre-operative fasting period. ΔNGAL [day −1 to day 0] and [day −1 to post-op] were found to correlate inversely with eGFR at 6 weeks ( p r 2 = 0.47 and p r 2 = 0.52, respectively). Conclusion Significant AKI occurs with live donor nephrectomy. This is difficult to quantify using standard biochemistry due to the overwhelming effect of nephrectomy on eGFR. AKI is associated with poorer donor eGFR at 6 weeks. Pre-operative hypovolaemia plays a role in AKI. Optimisation of perioperative fluid management is likely to have a protective role.

Aims The study presents the early results of hand-assisted laparoscopic living donor nephrectomy (HALDN) carried out in West of Scotland from June 2009 to October 2010. Methods The first 20 HALDN procedures carried out in our unit are presented. The outcomes reported are warm ischaemia time, operative time, delayed graft function, recipient renal function and one-month morbidity and mortality of donor and recipient. SPSS 15.0 was used for statistical analysis. Results The mean age of the donors was 44 ± 10 years, predominantly females ( n = 13), median operative time 135 ± 33 min and warm ischaemia time 41 ± 16 s. The length of the incision used was 65 mm in all cases. Duration of hospital stay was 5 ± 1 days. Patient mortality was 0 and morbidity minimal with two donors developing minor wound infection and no other clinically significant postoperative morbidity. Among the recipients, 18/20 (90%) transplants worked primarily with two delayed graft functions, one due to early surgical complications in a small paediatric recipient and one due to recipient renal artery thrombosis. Conclusion HALDN is safe and associated with minimal morbidity; further analysis aims to confirm excellent cosmetic results and quick return to activity compared with the standard open nephrectomy technique.

Introduction The burden of pain from cannulation of arteriovenous fistulae (AVF) and the impact it has on quality of life is poorly described in the literature. Methodology A pain score questionnaire was employed for all patients in the West of Scotland dialyzing via AVF (n = 461). Pain was assessed using visual analogue score (VAS) and McGill pain score. Patients with severe pain (VAS > 5) were compared to those with minimal pain. Results The questionnaire as completed by 97.5% of the patients. Median VAS on cannulation was 3 (IQR 0.5 - 4.5). Of those who had completed the questionnaire, 24.4% had severe pain on cannulation and 3.2% experienced severe chronic pain. 53 patients (11.3%) cut a dialysis session short due to pain. Of the patients with severe chronic pain, 46.7% had a physical complication affecting their AVF (e.g., venous stenosis, pseudoaneurysm). Following treatment of the problem, pain improved in 71.4% and resolved completely in 14.3%. Brachiobasilic AVF was associated with a higher incidence of severe pain than either brachiocephalic or radiocephalic AVF (50%, 23.3% and 24.4% respectively; p = 0.03). There was a trend towards more severe pain with rope-ladder cannulation (27.7%) compared to button-hole cannulation (18.2%); however, this difference did not reach statistical significance (p = 0.09). Conclusions Pain from AVF is poorly recognized and an under-reported problem. While severe pain resulting in the avoidance of dialysis is rare, it can lead to significant difficulties and ultimate abandonment of AVF. Pain is often suggestive of an underlying anatomical problem.

In January 2007, our centre changed from a cyclosporin (CyA)/azathioprine (Aza)/ prednisolone (Pred) primary immunosuppression regimen (with basiliximab induction and mycophenolate mofetil [MMF] for those at immunologically high risk) to a tacrolimus (Tac) (low dose)/MMF/Pred regimen with basiliximab induction, following presentation of Symphony trial results. This analysis assesses the impact of this change on 5-year outcomes. Three hundred consecutive renal-only transplants were identified: 140 from the 2005-06 era and 160 from the 2007-08 era. The proportions of living donor (37.5 vs. 22.9%; p = 0.04) and donors after circulatory death (11.9 vs. 5.0%; p = 0.03) were higher in the 2007-08 cohort. Five-year actuarial patient survival was higher in the 2007-08 cohort (96.8 vs. 87.1%; p = 0.003), with a trend toward higher 5-year transplant survival (84.7 vs. 76.3%; p = 0.08). Estimated glomerular filtration rate (eGFR) was higher than in the 2005-06 era at 1 (53.5 vs. 44.5 ml/min/1.73m2; p = 0.0006) and 3 years (50.9 vs. 43.4 ml/min/1.73m2; p = 0.02), with a trend toward higher eGFR at 5 years (41.8 vs. 49.6 ml/min/1.73m2; p = 0.09). Differences were consistent when living donor and deceased donor transplants were analysed separately. In a "real world" population, a change from a CyA-based to a Tac (low-dose)/MMF/Pred primary immunosuppression regimen has been associated with better 5-year outcomes.

CDKN2A is a proven and validated biomarker of ageing which acts as an off switch for cell proliferation. We have demonstrated previously that CDKN2A is the most robust and the strongest pre-transplant predictor of post- transplant serum creatinine when compared to “Gold Standard” clinical factors, such as cold ischaemic time and donor chronological age. This report shows that CDKN2A is better than telomere length, the most celebrated biomarker of ageing, as a predictor of post-transplant renal function. It also shows that CDKN2A is as strong a determinant of post-transplant organ function when compared to extended criteria (ECD) kidneys. A multivariate analysis model was able to predict up to 27.1% of eGFR at one year post-transplant (p = 0.008). Significantly, CDKN2A was also able to strongly predict delayed graft function. A pre-transplant donor risk classification system based on CDKN2A and ECD criteria is shown to be feasible and commendable for implementation in the near future.

Objectives: This study explored the pattern of Internet use by renal transplant patients in the West of Scotland. Materials and Methods: A 31-item questionnaire was used to obtain information about patient’s Internet use and the relations between Internet use and sex, age, education, and health requirements. Results: The study consists of 84 postrenal transplant patient surveys. Validation of the questionnaire showed an intraclass correlation coefficient 0.77 to 0.96 with 95% confidence interval (CI 0.75-0.99). The overall response rate was 65% (n=84/130). In all, 87% of the patients (n=73/84) had access to a computer and the Internet. And 94% of the patients (n=60/64) in age groups 21 to 60 years had access to the Internet with no difference in the access in various age subgroups, whereas 67% of the patients (n=12/18) in age group 61 to 70 years (P = .004) had Internet access. The Internet was a preferred source of health information for 70% of the patients (n=59/84) as compared to books 17% (n=14/84; P = .003) and magazines 12% (n=10/84; P = .001). Of the Internet group, 90% (n=53/59) looked up information on transplantation mostly about transplant operations (69%) and rejection (66%). Of all the patients, 85% (n=71/84) of them would like the transplant team to develop a Web site for information on transplantation and 52 (62%) would like to receive health advice by e-mail. Conclusions: The majority of renal transplant patients use the Internet for information on transplantation. Almost all patients under 60 years old had access to the Internet for this purpose; suggesting a trend toward the Internet as the favored way to get information. Transplant units should develop flexible, Web-based sources of transplant-related information. This would allow rapid adaptation to changes in prevalent practice, reflecting the preferences of the patient population.

The authors present a rare case of ventriculitis secondary to cerebro spinal fluid (CSF) colonization with Escherichia coli species in a 65-year-old woman. Passage of bacterial organisms from the lumen of the gastrointestinal tract to the bloodstream or lymphatic tissue is known as translocation. Once in the bloodstream, particular bacteria are able to cross the blood–brain barrier and migrate to CSF. Elective abdominal surgery, intestinal obstruction, colorectal cancer, ischaemic reperfusion injury and pancreatitis have all increased the risk of this phenomenon. This account highlights particular events in presentation and management of such a case, followed by a brief literature review.

Aims This paper presents an e-survey of current clinical practice of use of intra-operative diuretics during renal transplantation in the United Kingdom and a study to compare outcome of renal transplants carried out with or without intra-operative diuretics in our centre. Methods An e-mail questionnaire to renal transplant surgeons exploring their practice of renal transplantation with or without intra-operative diuretics, the type of a diuretic/s if used and the relevant doses. An observational study comparing the outcome of renal transplant recipients, group no-diuretics (GND, n = 80) carried out from 2004 to 2008 versus group diuretics (GD n = 69) renal transplant recipients who received intra-operative diuretics over a one year period is presented. Outcome measures were incidence of delayed graft function and a comparison of graft survival in both groups. Results Forty surgeons answered from 18 transplant centres with a response rate of 67%. 13 surgeons do not use diuretics. Mannitol is used by 10/40, Furosemide 6/40 and 11 surgeons use a combination of both. In comparative study there was no significant overall difference in one year graft survival of GD versus GND ( N = 65/69, 94% and 75/80, 94% respectively, p = 0.08) and the incidence of delayed graft function was also comparable (16/69, 23% and 21/80, 26% respectively, p = 0.07). The donor characteristics in both groups were comparable. Conclusion The study showed variation in clinical practice on the use of intra-operative diuretics in renal transplantation and it did not demonstrate that the use of diuretics can improve renal graft survival.

BACKGROUND: Transplantation of embryonic kidneys (metanephroi) offers a potential solution to the problem of kidney donor shortage. The aim of this study was to characterise the haemodynamic capacity of transplanted rat metanephroi and to determine the number and maturity of the tubules. METHODS: Metanephroi from E15 Lewis rat embryos were transplanted adjacent to the abdominal aorta of uninephrectomised adult female syngeneic Lewis rats. Twenty-one days later, a single metanephros ureter was anastomosed to the host's urinary system. Three months later animals were prepared for standard clearance measurements. RESULTS: Effective renal blood flow (149 +/- 33 microl min(-1) per g kidney weight) and glomerular filtration rate (17 +/- 9 microl min(-1) per g kidney weight), standardised to kidney weight, were significantly lower in transplanted metanephroi compared with control adult kidneys (P < 0.001); renal vascular resistance (934 +/- 209 mmHg ml min(-1) per g kidney weight) was significantly higher (P < 0.001). Nephron number in transplanted metanephroi was significantly greater than that of E21 kidneys (P < 0.01) but lower than that of postnatal day (PND) 1 kidneys (P < 0.001). Angiotensin II type 2 receptor mRNA expression, a marker of nephrogenesis, was markedly reduced in metanephroi. Aquaporins 1 and 2, epithelial Na channel and Na-K-2Cl cotransporter type 2 mRNA and protein were expressed in transplanted metanephroi; the urea transporters-A1, 2 and 3 were absent. Vascular markers (alpha-smooth muscle actin and CD31) were identified in metanephroi but their expression did not differ from that of E21 and PND 1 kidneys. CONCLUSIONS: This study shows that metanephroi continue to develop post-transplantation but only reach a stage of development equivalent to that of a normal rat kidney at birth.

Renal failure and end-stage renal disease are prevalent diseases associated with high levels of morbidity and mortality, the preferred treatment for which is kidney transplantation. However, the gulf between supply and demand for kidneys remains high and is growing every year. A potential alternative to the transplantation of mature adult kidneys is the transplantation of the developing renal primordium, the metanephros. It has been shown previously, in rodent models, that transplantation of a metanephros can provide renal function capable of prolonging survival in anephric animals. The aim of the present study was to determine whether increasing the mass of transplanted tissue can prolong survival further. Embryonic day 15 rat metanephroi were transplanted into the peritoneum of anaesthetized adult rat recipients. Twenty-one days later, the transplanted metanephroi were anastomosed to the recipient's urinary system, and 35 days following anastomosis the animal's native renal mass was removed. Survival times and composition of the excreted fluid were determined. Rats with single metanephros transplants survived 29 h longer than anephric controls (P0.001); animals with two metanephroi survived 44 h longer (P0.001). A dilute urine was formed, with low concentrations of sodium, potassium and urea; potassium and urea concentrations were elevated in terminal serum samples, but sodium concentration and osmolality were comparable to control values. These data show that survival time is proportional to the mass of functional renal tissue. While transplanted metanephroi cannot currently provide life-sustaining renal function, this approach may have therapeutic benefit in the future.

A novel approach to circumventing the shortage in transplantable donor organs is the use of embryonic primordia that develop inside the host. Previously published work has shown that transplantation of rat fetal kidney primordia (metanephroi) onto the omentum of adult rat hosts results in growth and development of the metanephroi into functioning kidney units capable of providing a measurable renal function. However, for anatomical and physiological reasons the omentum may not provide the ideal site for transplantation and may limit the maximum renal function that the transplants can achieve. We postulate that it may be possible to increase the renal function of the transplants by transplantation to sites with increased blood flow. To test this we transplanted rat embryonic day 15 metanephroi into the retroperitoneal fat adjacent to major blood vessels in the peritoneum of unilaterally nephrectomized rats; 21 days later the transplants were examined and suitable transplants connected to the host urinary system. Approximately 130 days later the glomerular filtration rate of the connected transplants was analyzed. Our results show that transplantation of metanephroi to the regions highlighted in this study results in an increased presence of urinary cysts, suggesting increased early renal function in the transplants compared to metanephroi transplanted onto the omentum, but most importantly we show that we can increase the renal function of the transplants to a level comparable with other renal therapies such as dialysis. This work suggests life-sustaining renal function could be achieved through transplantation of renal primordia.

Background: An arteriovenous fistula is the optimal form of vascular access in patients with end-stage renal failure requiring haemodialysis. Unfortunately, approximately one-third of fistulae fail at an early stage. Different anaesthetic techniques can influence factors associated with fistula success, such as intraoperative blood flow and venous diameter. A regional anaesthetic brachial plexus block results in vasodilatation and improved short- and long-term fistula flow compared to the infiltration of local anaesthetic alone. This, however, has not yet been shown in a large trial to influence long-term fistula patency, the ultimate clinical measure of success. The aim of this study is to compare whether a regional anaesthetic block, compared to local anaesthetic infiltration, can improve long-term fistula patency. Methods: This study is an observer-blinded, randomised controlled trial. Patients scheduled to undergo creation of either brachial or radial arteriovenous fistulae will receive a study information sheet, and consent will be obtained in keeping with the Declaration of Helsinki. Patients will be randomised to receive either: (i) an ultrasound guided brachial plexus block using lignocaine with adrenaline and levobupivicaine, or (ii) local anaesthetic infiltration with lignocaine and levobupivicaine. A total of 126 patients will be recruited. The primary outcome is fistula primary patency at three months. Secondary outcomes include primary patency at 1 and 12 months, secondary patency and fistula flow at 1, 3 and 12 months, flow on first haemodialysis, procedural pain, patient satisfaction, change in cephalic vein diameter pre- and postanaesthetic, change in radial or brachial artery flow pre- and post-anaesthetic, alteration of the surgical plan after anaesthesia as guided by vascular mapping with ultrasound, and fistula infection requiring antibiotics. Conclusions: No large randomised controlled trial has examined the influence of brachial plexus block compared with local anaesthetic infiltration on the long-term patency of arteriovenous fistulae. If the performance of brachial plexus block increases fistulae patency, this will have significant clinical and financial benefits as the number of patients able to commence haemodialysis when planned should increase, and the number of “redo” or revision procedures should be reduced. Trial registration: This study has been approved by the West of Scotland Research Ethics Committee 5 (reference no. 12/WS/0199) and is registered with the ClinicalTrials.gov database (reference no. NCT01706354).

Testicular duplication is an extremely rare condition. It is usually asymptomatic or found incidentally at examination. In this case a relatively common clinical scenario proves to represent a duplex, cryptorchid testis. The aetiology of this condition, its management and implications for malignancy and fertility are reviewed.

Optimal treatment for established renal failure is living donor kidney transplantation. However this pathway exposes healthy individuals to significant reduction in nephron mass via major surgical procedure. Laparoscopic donor nephrectomy is now the most common method for live donor transplantation, reducing both donor post-operative pain and recovery time. However this procedure exposes kidneys to additional haemodynamic stresses. It has been suggested that donor hydration—particularly the use of preoperative intravenous fluids—may counteract these stresses, reducing subclinical acute kidney injury and ultimately improving long-term renal function. This may be important in both preservation of donor renal function and recipient graft longevity. A prospective single-centre single-blinded randomized controlled trial will be carried out to determine the effects of donor preoperative intravenous fluids. The primary outcome is donor subclinical acute kidney injury (defined as plasma NGAL, >153 ng/ml) on day 1 postoperatively. Secondary outcomes include intraoperative haemodynamics, recipient subclinical acute kidney injury, perioperative complications and donor sleep quality. Donors will be randomised into two groups: the intervention group will receive active pre-hydration consisting of three litres of intravenous Hartmann’s solution between midnight and 8 am before morning kidney donation, while the control group will not receive this. Both groups will receive unlimited oral fluids until midnight, as is routine. Plasma NGAL will be measured at pre-specified perioperative time points, intraoperative haemodynamic data will be collected using non-invasive cardiac output monitoring and clinical notes will be used to obtain demographic and clinical data. The researcher will be blinded to the donor fluid hydration status. Blinded statistical analysis will be performed on an intention-to-treat basis. A prospective power calculation estimates a required sample size of 86 patients. This study will provide important data, as there is currently little evidence about the use of donor preoperative fluids in laparoscopic nephrectomy. It is hoped that the results obtained will guide future clinical practice. This study has been approved by the West of Scotland Research Ethics Committee 3 (reference no. 14/WS/1160, 27 January 2015) and is registered with the International Standard Randomised Controlled Trial Number Register (reference no. ISRCTN10199225 , 20 April 2015).