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Timing of bilateral nephrectomy (BN) is controversial in patients with refractory symptoms of autosomal dominant polycystic kidney disease (APKD) in need of a renal transplant.Adults who underwent live donor renal transplant (LRT) + simultaneous BN (SBN) from August 2003 to 2013 at a single transplant center (n = 66) were retrospectively compared to a matched group of APKD patients who underwent LRT alone (n = 52). All patients received general health and polycystic kidney symptom surveys.Simultaneous BN increased operative duration, estimated blood loss, transfusions, intravenous fluid, and hospital length of stay. Most common indications for BN were pain, loss of abdominal domain, and early satiety. There were more intraoperative complications for LRT + SBN (6 vs 0, P = 0.03; 2 vascular, 2 splenic, and 1 liver injury; 1 reexploration to adjust graft positioning). There were no differences in Clavien-Dindo grade I or II (39% vs 25%, P = 0.12) or grade III or IV (7.5% vs 5.7%, P = 1.0) complications during the hospital course. There were no surgery-related mortalities. There were no differences in readmission rates (68% vs 48%, P = 0.19) or readmissions requiring procedures (25% vs. 20%, P = 0.51) over 12 months. One hundred percent of LRT + SBN allografts functioned at longer than 1 year for those available for follow-up. Survey response rate was 40% for LRT-alone and 56% for LRT + SBN. One hundred percent of LRT + SBN survey responders were satisfied with their choice of having BN done simultaneously.Excellent outcomes for graft survival, satisfaction, and morbidity suggest that the combined operative approach be preferred for patients with symptomatic APKD to avoid multiple procedures, dialysis, and costs of staged operations.

Controversy exists regarding the benefit of ureteral stents in kidney transplantation. We aimed to examine the association of stents with risk of ureteral complications, particularly in relationship with donor type.Kidney transplants from 2005 to 2009 were evaluated (n=1224). Patients with previous or simultaneous nonkidney transplants, death, or lost to follow-up within 90 days were excluded, unless already developed a ureteral complication. Only cases with a single extravesical ureteroneocystostomy were included. The cohort (n=961) was divided into stent (32.2%) and no-stent (67.7%) groups. Poisson regression was used to examine the association of stent with ureteral complications (leak or stricture) and urinary tract infections (UTI).Ureteral complication rate was 1.9% in stent versus 5.8% in no-stent group (P=0.007). UTI rate was 14.2% with stent versus 7.9% without stent (P=0.003). Stent use was independently associated with reduction in ureteral complications (incidence rate ratios [IRR], 0.40; P=0.04; 95% confidence interval [CI], 0.17-0.96) and an increase in UTI risk (IRR, 1.79; P=0.006; 95% CI, 1.18-2.74). Stent protective effect was primarily related to reduction in stricture risk (IRR, 0.23; P0.05; 95% CI, 0.05-0.99). Stents were associated with a decrease in ureteral complications in deceased donor recipients (IRR, 0.34; P=0.03; 95% CI, 0.13-0.88), but not living donors (IRR, 1.24; P=0.84; 95% CI, 0.15-10.2).Ureteral stents are associated with a significant reduction in ureteral complications but increases UTI risk. Routine stenting in deceased donor transplants is recommended as its protective effect was observed in this group. The value of stents in living donor transplants warrants further investigation.

Introduction La transplantation d'organe chez les patients âges est devenue plus courante ces dernieres annees. Un nombre croissant de patients presentent une insuffisance renale exigeant une transplantation, associee a une pathologie aortique occlusive ou anevrismale. La strategie optimale pour la programmation et la gestion de la maladie aortique et de la transplantation renale chez ces patients est inconnue. Avant la disponibilite des therapies endovasculaires, notre politique etait de realiser une cure chirurgicale a ciel ouvert de la maladie aortique avant la transplantation, ou une reconstruction aortique simultanee a la transplantation renale si un donneur vivant etait disponible. Depuis l'acceptation large des techniques endovasculaires, notre strategie a change pour tirer profit du traitement endovasculaire en pre-transplantation. Cette etude examine les resultats des deux approches. Methodes Nous avons realise un examen retrospectif de 12 patients entre 1996 et 2009 qui avaient subi une transplantation renale et une procedure aortique abdominal importante simultanement (n = 6), avec des procedures se produisant dans le meme mois (n = 2), ou a distance, avec des procedures aortiques se produisant entre 5 et 24 mois avant ou apres la transplantation (n = 4). Tous les patients presentant une maladie occlusive ont subi un pontage aorto-bifemoral, un avant la greffe, un apres la transplantation, et quatre simultanement a la greffe renale. Pour evaluer le statut du greffon renal, les taux de creatininemie des patients etaient suivis tous les 3 mois. Parmi les 12 patients, huit ont subi des procedures aortiques a ciel ouvert, tandis que quatre ont subi un traitement endovasculaire d'un anevrysme aortique. Les patients qui ont subi une cure endovasculaire d'anevrysme aortique ont ete suivis par echodoppler a intervalles de six mois, et par angioscanner tous les deux ans. Resultats La reconstruction aortique a ete realisee avec succes chez les 12 patients independamment de la strategie de programmation. Tous les patients qui ont subi une reparation endovasculaire avaient des greffons renaux fonctionnels au cours du suivi. Deux patients ont eu un pontage aorto-bifemoral simultane a une transplantation rein-pancreas sans complication. Parmi les patients presentant des cures aortiques a ciel ouvert, il y a eu un deces a cinq ans et un patient a presente un rejet de deux greffes renales. Aucun des patients n'a ete ampute, et les pontages aortiques sont demeures permeables (un membre a exige une procedure secondaire). La survie des malades a cinq ans etait de 90% et la survie du greffon renal de 75%, comparable aux resultats de la population generale greffee sans maladie aortique. On a observe deux complications significatives liees aux procedures a ciel ouvert : deux greffes renales ont developpe des hematomes postoperatoires exigeant une evacuation et un pontage aorto-bifemoral (PABIF) a developpe une infection de la cicatrice femorale exigeant une evacuation et une myoplastie de couverture par le Sartorius. Le taux de mortalite a 30 jours chez tous les patients etait nul. La longueur du sejour pour des patients ayant des procedures simultanees s'etendait de 5 a 14 jours (mediane 10,5) et etait sensiblement inferieure (mediane 18) a la duree combinee de 10 a 52 jours des sejours des groupes a procedures sequentielles (p = 0,016). Conclusion La coexistence d'une maladie aortique et d'une transplantation renale est un scenario clinique de plus en plus courant. La contre-indication a la transplantation des patients presentant une atteinte severe aorto-iliaque est frequente dans beaucoup de centres de greffe car les premieres donnees publiees suggeraient des resultats mediocres. La planification appropriee avec une equipe chirurgicale vasculaire peut mener a des resultats comparables a la population generale des greffes sans maladie aortique significative.

Background. Renal transplantation (RTx) in the geriatric population (age >65 years) accounts for 14% of all RTx performed nationally in 2007. Methods. We reviewed 3297 RTx recipients from our database over a 15-year period to evaluate recipient and donor age, date of transplant and graft loss, cause of graft loss, and cold ischemic time in the geriatric population. Results. Since 1991, we have performed 468 living donor RTx (LDRTx) and deceased donor RTx (DDRTx) in patients more than 65 years: 280 (65―69 years), 128 (70―74 years), and 60 (>75 years). Geriatric recipients of DDRTx demonstrated 83.0%, 74.1%, and 64.1% uncensored graft survival at 1, 3, and 5 years, respectively. Interestingly, these rates were similar compared with DDRTx in adults (18―64 years, P=0.49). Geriatric recipients of LDRTx demonstrated 1-year, 3-year, and 5-year graft survival rates of 94.3%, 88.8%, and 72.3%, respectively. Although better than geriatric DDRTx recipients, these results were not equal to the success of adult LDRTx recipients, potentially because of poorer graft survival in LDRTx recipients more than 75 years (P=0.004). Death-censored graft survivals were similar between adult and geriatric recipients of LDRTx (P=0.28). Graft loss secondary to death was twice as great in geriatric versus adult recipients (P

BACKGROUND: Historically, antibody induction has been used because of the higher immunologic risk of graft loss or rejection observed in simultaneous pancreas and kidney (SPK) transplantation compared with kidney transplantation alone. This trial was designed to assess the effect of antibody induction in SPK transplant recipients receiving tacrolimus, mycophenolate mofetil, and corticosteroids. Induction agents included T-cell-depleting and interleukin-2 receptor antibodies. METHODS: A total of 174 SPK transplant recipients were enrolled in a prospective, open-label, multi-center study. They were randomized to induction (n=87) or non-induction (n=87) groups and followed for 3 years. RESULTS: At 3 years, actual patient (94.3% and 89.7%) and pancreas (75.9% and 75.9%) survivals were similar between the induction and non-induction groups, respectively. Actual kidney survival was similar at 1 and 2 years, but at 3 years, it was significantly better in the induction group compared with the non-induction group (92% vs. 81.6%; P =0.04). At 3 years, median serum creatinine and hemoglobin A1C were similar between the induction and non-induction groups (1.35 mg/dL and 1.20 mg/dL, 5.4% and 5.5%, respectively). Three-year cumulative incidence of biopsy-confirmed, treated acute kidney rejection in the induction and non-induction groups was 19.5% and 27.5% (P =0.14), respectively, with odds 4.6 times greater in African Americans regardless of treatment (P =0.004). Significantly higher rates of cytomegalovirus (CMV) viremia and CMV syndrome occurred in those receiving T-cell-depleting antibody induction (36.1%) when compared with those receiving anti-interleukin-2 receptor antibodies (2%) and non-induction (8.1%) (P

BACKGROUND: Transplantation of solitary pediatric renal allografts from donors 2 years of age or younger into adult recipients is controversial. METHODS: Between 1998 and 2001, 15 solitary renal allografts from pediatric donors 2 years of age or younger were transplanted into adult recipients. Thirty-three en bloc renal allografts transplanted between 1994 and 2001 were used for comparison. En bloc kidneys were considered for separation if they measured greater than or equal to 6 cm in length. Renal function (creatinine clearance [CrCl]) was estimated using the Cockroft-Gault formula. RESULTS: Two-year graft survival for the solitary and en bloc groups were 93% and 77%, respectively (P =0.405). Five grafts were lost because of arterial thrombosis (four en bloc and one solitary). Ureteral complications occurred in three grafts in the en bloc group. One-year postoperative CrCl of the surviving solitary (n=14) and en bloc (n=26) grafts were 51.4+/-26.2 mL/min and 55.1+/-27.5 mL/min (P >0.05), respectively. Donor weight and kidney length were greater in the solitary group (14.3+/-3.5 kg and 6.3+/-0.4 cm, respectively) compared with the en bloc group (10.8+/-2.6 kg and 5.9+/-0.3 cm, respectively) (P =0.001 and P

Polyoma virus (PV) can cause interstitial nephritis and lead to graft failure in renal transplant recipients. The clinical course of patients with polyoma virus nephritis (PVN) is not well understood, partially due to its relatively low incidence. This study is a retrospective analysis of our experience over 4 yr. The specific purpose is to outline the clinical course and outcome of patients with PVN and to study the relationship between immunosuppression and the disease process. Between June 1997 and March 2001, 67 patients with graft dysfunction were found to have biopsy-proven PVN. The diagnosis was made at a mean of 12.8 +/- 9.9 mo posttransplantation. The majority of patients were men (79%) with a mean age of 54 +/- 14 yr (range, 28 to 75). All patients received immunosuppression with a calcineurin inhibitor (tacrolimus in 89% of patients). All patients except two received mycophenolate mofetil and prednisone. After the diagnosis of PVN, maintenance immunosuppression was reduced in 52 patients and remained unchanged in 15 patients. After reduction of immunosuppression, eight patients (15.3%) developed acute rejection and six (11.5%) became negative for PV in biopsy and urine. After a mean observation period of 12.6 mo (mean of 26 mo posttransplantation), 16.4% of patients had lost their grafts (8 of 52 in the reduction group and 3 of 15 in the no change group). In comparison to a case-matched polyoma virus-negative control group, the PVN patients were older (P =.0004) and there was a predominance of men (P = 0.02). Kaplan-Meier analysis demonstrated that patients with PVN had reduced graft survival compared with negative controls (P =.0004). It is concluded that PVN is a serious hazard for renal transplant recipients and contributes directly to graft loss. Antiviral drugs are needed, as the reduction of immunosuppression alone may not significantly improve graft function in patients with already established PVN. Although multiple factors probably play a role in the development of PVN, judicious use of immunosuppressive agents is indicated to minimize the occurrence of this infection.

Background. Graft losses due to leaks, bleeding, thrombosis, infections, and early pancreatitis are grouped together under the category of technical failure. Among these complications, massive vascular thrombosis continues to be the most important cause of early graft loss due to technical failure. Pathological evaluation of most allografts lost early in the posttransplantation period shows vascular thrombosis with associated proportional parenchymal necrosis. The morphological findings in allografts that are considered to be lost due to technical failure has not been systematically addressed. In particular, the role of acute rejection in early graft loss has not been well studied. Methods. Seventy-four consecutive pancreas graft pancreatectomies were studied histologically to evaluate for thrombosis (recent versus organized), type of vessel involved by thrombosis (arteries, veins, or both), acute rejection grade, chronic rejection grade, endotheliitis, transplant arteritis, coagulation necrosis, acute pancreatitis, presence of infectious organisms, transplant (obliterative) arteriopathy, neoplasia, relative proportions of alpha and beta islet cells, and immunoglobulin and complement deposition. The histological findings were correlated with donor and recipient data as well as clinical presentation. Results. In 23 out of 39 grafts lost in the first 4 weeks posttransplantation, the only pathological changes found were vascular thrombosis and bland ischemic parenchymal necrosis. In these cases, no underlying vascular pathology or any other specific histological change was identified. Most of these grafts (78%) were lost in less than 48 hr and all in the first 2 weeks posttransplantation. Massive vascular thrombosis occurring in an otherwise histologically normal pancreas was the most common cause of graft loss in the first 4 weeks posttransplantation (59%). In most of the remaining cases (33%), although the clinical presentation suggested technical failure, there was clear histological evidence that the massive thrombosis resulted from vascular injury due to immune damage (acute and hyperacute rejection). Increased incidence of early graft thrombosis was seen in grafts from older donors and longer cold ischemia times. After the first month posttransplantation, graft pancreatectomies revealed a wider variety of pathological processes that included severe acute rejection, combined acute and chronic rejection, chronic rejection, and infections. Acute and chronic vascular thrombosis in large and small vessels was commonly seen at all times posttransplantation; chronic, organized thrombosis was strongly associated with chronic rejection. Conclusions. (a) Early acute thrombosis occurring in a histologically normal pancreas defines a true technical failure. This study showed that acute rejection leading to massive thrombosis, which clinically simulates technical failure, results in a significant proportion of early graft losses. (b) Systematic histological evaluation of failed grafts is absolutely necessary for the accurate classification of the cause of graft loss. (c) There is morphological evidence that chronically ongoing thrombosis is an important, common, contributing factor for late graft loss.

Background Alloimmunization can present a virtually insurmountable barrier to kidney transplantation. Past protocols to desensitize patients using plasmapheresis and cyclophosphamide have not been broadly applied because of the fear of complications, including high rates of immunologic failure. Methods Fifteen patients with a positive donor-recipient cross-match were desensitized with plasmapheresis to permit live donor (LD) transplantation under newer maintenance immunosuppressants. Pretransplant the patients received plasmapheresis three times weekly for a planned maximum of six treatments, plus intravenous hyperimmune globulin, tacrolimus, mycophenolate mofetil, and prednisone. Patients who were successfully desensitized and received transplants were given 10 days of OKT3 postoperatively. Results Eleven of the 15 patients became anti-human globulin cross-match-negative after one to five plasmapheresis treatments and underwent LD transplantation. Relatively low initial titers of donor-specific antibody were predictive of successful attainment of a negative cross-match. Few side effects and rejection episodes were observed. All transplant patients remain dialysis-free after 3-26 months of follow-up. Conclusion A positive cross-match is not necessarily a contraindication to LD transplantation, especially for patients with low donor-specific alloantibody titers.

We determined whether laparoscopic living donor nephrectomy decreases the morbidity of renal donation for the donor, while providing a renal allograft of a quality comparable to that of open donor nephrectomy.In a 3-year period laparoscopic donor nephrectomy was performed via the transperitoneal approach. We evaluated donor and recipient medical records for preoperative donor characteristics, intraoperative parameters and complications, and postoperative recovery and complications.Of the 320 laparoscopic donor nephrectomies performed the left kidney was removed in 97.5%. Intraoperative complications, which developed in 10.4% of cases, tended to occur early in the experience and required conversion to open nephrectomy in 5. Average operative time was 31/2 hours and warm ischemia time was 21/2 minutes. As the series progressed, blood loss as well as laparoscopic port size and number decreased but extraction site size remained constant at 7 cm. Urinary retention, prolonged ileus, thigh numbness and incisional hernia were the most common postoperative complications. Postoperative analgesic requirements were low and average hospitalization was 66 hours.Laparoscopic donor nephrectomy appears to be safe and decreases morbidity in the renal donor. Allograft function is comparable to that in open nephrectomy series. The availability of laparoscopic harvesting may be increasing the living donor volunteer pool.

Simultaneous cadaver kidney pancreas transplantation (SPK) and sequential pancreas after kidney transplantation (PAK) are typically the only options for uremic or posturemic Type 1 diabetic patients who wish to undergo pancreas transplantation. Together they account for more than 99% of all pancreas transplants for uremic or posturemic diabetic patients. 1 SPK transplantation is more widely used than KTA followed by PAK, because SPK is a single operation and there is an “immunologic advantage” for the pancreas because the kidney can serve as a reliable marker for rejection of the pancreas. 2 However, some advocate PAK transplantation if there is a willing living kidney donor. 3 Use of a well-matched living-donor kidney can double the expected renal allograft survival half-life. 4 Living kidney donation also shortens the waiting time for transplantation and expands the organ donor pool. 5 The 1-year pancreas graft survival rate for SPK transplantation is now 83%. 1 During the past 3 to 4 years, the 1-year pancreas graft survival rate for PAK recipients has improved from 54% survival to 71%, shrinking the “immunologic advantage” of combining a cadaver pancreas with a kidney from the same donor. 1,3,6 The use of percutaneous pancreas biopsy coupled with tacrolimus-based immunosuppression results in equivalent success of solitary pancreas and SPK transplantation. 3 Largely because of these results, and because of the distinct advantages of living kidney donation, we have developed a new approach for uremic Type 1 diabetic patients: simultaneous cadaver-donor pancreas and living-donor kidney transplantation (SPLK). More than half of our uremic type I diabetic patients who desire pancreas transplantation now opt for SPLK. Selection of SPLK is generally limited only by the availability of a living donor. As a single procedure, SPLK has obvious advantages over the standard living-donor kidney transplant followed by PAK. Moreover, because the SPLK kidney is from a living donor, there may be both short-term and long-term benefits over SPK transplantation. Potential benefits of SPLK for Type 1 diabetic uremic patients include a shorter waiting time for transplantation and better early and long-term renal graft function. Generalized use of SPLK transplantation would expand the renal organ donor pool, thus benefiting all patients waiting for a kidney transplant. The main drawback to SPLK, coordination of a living donor nephrectomy with a cadaver pancreas transplant, is easily overcome. This paper describes the technique of SPLK and reviews the results of our first 30 consecutive cases. Comparison is made with contemporaneous consecutive series of primary SPK and PAK transplants.

Fibromuscular dysplasia (FMD) of the donor renal artery may be encountered by transplant surgeons during kidney transplantation. Renal artery reconstruction prior to transplantation is indicated to reduce the risk of renovascular hypertension and ischemic nephropathy. The authors report a patient who underwent living donor (LD) transplantation of a kidney with FMD, where the artery was reconstructed with an internal iliac artery interposition graft harvested from the recipient. They conclude that this is a safe procedure that results in a satisfactory outcome. Additionally, there may be a reduced risk of progressive renovascular hypertension in the donor by eliminating FMD.

Background. Allograft rejection continues to be the most common cause of graft failure in technically successful pancreas transplants. Early diagnosis and treatment of rejection is essential for long-term graft survival. Pancreas graft biopsies are now used routinely for the diagnosis of acute allograft rejection. The correlation between clinical evidence of graft dysfunction (increased serum enzymes and glucose), severity of acute rejection on biopsy (rejection grade), and response to treatment has not been previously studied. Methods. A total of 151 pancreas transplant needle biopsy specimens from 57 patients were evaluated. Statistical correlation was done between the histologic rejection grade (0 ‐V) and the peak level of enzymes in serum, glycemia, type of antirejection treatment instituted, and response to treatment. Differentiation between grades was also evaluated statistically. Results. Response to antirejection treatment was 25%, 40%, 88%, 78%, 50%, and 17% for grades 0 ‐V, respectively. The response for grades II and III was better than for grades 0 ‐I and IV‐V (P50.0003 and 0.0008, respectively). The response to corticosteroids alone was 36%, 86%, 68%, and 0% for grades I, II, III, and IV, respectively. The response to antilymphocyte regimen was 50%, 89%, 85%, 71%, and 17% for grades I, II, III, IV, and V, respectively. Overall correlation between the mean levels of enzymes and rejection grade was seen; the increase of lipase was statistically significant (r50.24, P50.012). Amylase and lipase correlated very well with each other (r50.84, P50.0001). No correlation was found in the mean values of blood glucose with the serum enzyme increase and with severity of rejection. Hyperglycemia was present in 12 patients; this abnormality in patients with grades II‐IV responded promptly to treatment, whereas in patients with grade V, hyperglycemia persisted despite antirejection treatment. Other causes of increased enzymes were found in patients with biopsy specimens showing no rejection (grades 0 and I, 43% and 31%, respectively). Conclusions. Increased serum enzymes, particularly lipase, correlate with the grade of acute rejection, but their lack of specificity precludes their use as sole markers of acute rejection. Glucose levels are not a sensitive marker for acute rejection. Rejection grades II and III are the most responsive to treatment, and a significant proportion of these cases respond to treatment with corticosteroids only. The higher rejection grades (IV and V) require treatment with antilymphocytic regimens, and their overall response to treatment is moderate to poor, respectively.

Background. This study examines the current cost of live donor (LD) transplantation at our institution, and compares it with that of dialysis. Methods. The study population consisted of 184 consecutive adult recipients of laparoscopically procured LD kidney transplants. Cost-containment measures instituted during this series included elimination of routine postoperative antilymphocyte induction and an accelerated discharge clinical pathway with planned discharge of the recipient on postoperative day (POD) 2. Costs of the transplants to Medicare were estimated from hospital charges, readmission rates, and immunosuppressant usage. These were compared with published costs of dialysis to Medicare in terms of a fiscal transplant-dialysis break-even point. Results. Kaplan-Meier patient and graft survival rates at 1 year were 97 and 93%, respectively. Among patients followed for at least 90 days and treated with no induction and either cyclosporine-mycophenolate mofetil or tacrolimus-mycophenolate mofetil, acute rejection rates were low (27.6 and 13.9%, respectively). In the last 124 patients, 32.3% were discharged by POD 3 and 71.8% by POD 6, with corresponding mean transplant hospital charges (excluding organ acquisition) of $11,873 and $17,350, respectively. The 30-day readmission rate for patients discharged on the accelerated pathway by POD 3 was only 16%. The least expensive subgroup in the present study (30% of patients) was that of patients discharged by POD 6 and not readmitted during the first year; the break-even point with dialysis costs was calculated as 1.7 years after the transplant. Conclusions. The cost of LD transplants can be safely reduced by elimination of routine postoperative antilymphocyte immune induction and by an early discharge clinical pathway. Uncomplicated LD kidney transplants, meaning those with a short length of stay in the hospital after transplantation and no need for readmission within the first year, accrue savings over dialysis within 2 years.

D espite renewed efforts l’ocused on education of the public on the great disparity between the number of organ donors relative to the number of patients awaiting organ transplantation in the United States, the gap continues to increase. Currently, there are over 50,000 patient registrations on the United Network for Organ Sharing (UNOS) waiting list. Thirty-four thousand seven hundred sixty-six patients are awaiting kidney transplantation. It is estimated that 10 patients die each day awaiting transplantation. In 1996, there were 5,411 cadaveric organ donors. Although the waiting list size has increased approximately 20% per year, the cadaveric organ donor pool has only increased 4% per year. Median waiting times have nearly doubled for all organs in the last 6 years. From 1988 to 1995, cadaveric donors in the 18-34 age group decreased from 41% to 29%. During the same time period, the percentage of older donors (50 years) doubled from 12% to 24% and likely will continue to increase in prevalence as the population ages. Innovative strategies to compensate for this major constraint to kidney transplantation provided the impetus to conduct a protocol for the use of kidneys from older donors with suboptimal nephron mass, kidneys that otherwise might not have been used for transplantation. The protocol was initiated in 1994 and entailed the simultaneous transplantation of both kidneys from a single donor into a recipient. The background for this novel approach was based on several elegant

Background Multicenter clinical trials have shown that mycophenolate mofetil (MMF) reduces the risk of acute rejection, but it is unknown whether African-Americans constitute a subgroup of recipients less likely to benefit from MMF. Methods. This study compared the acute rejection rates within 6 months of kidney transplantation in MMF-treated transplant patients with those on azathioprine (AZA) at a single center. The study population consisted of 353 consecutive recipients of cadaver or living donor kidney transplants. African-Americans constituted 43% of the patients on AZA and 49% of the patients on MMF. Variables used in a Cox regression analysis included MMF immunosuppression, recipient race, type of transplant, delayed graft function, postoperative immune induction, average cyclosporine trough level, and HLA mismatch. Results. Significantly fewer patients on MMF experienced a biopsy-proven rejection episode than those treated with AZA (24% vs. 42%, respectively; relative risk [RR]=0.57, P=0.001). This decrease in risk was greater in Caucasian transplant recipients (MMF vs. AZA: 16% vs. 46%, RR=0.35, P

Background The risk associated with transplantation of renal allografts from hepatitis B virus core antibody-positive (HBcAb(+)), hepatitis B virus surface antigen-negative (HBsAg(-)) donors is not well defined. Methods. Over 4 years, we performed 45 kidney transplants from IgG HBcAb(+), IgM HBcAb(-), HBsAg(-) donors into recipients with a history of prior hepatitis B virus (HBV) infection or reported vaccination. We examined HBV-related outcomes in these 45 patients, in comparison with 45 recipients of allografts from HBcAb(-) donors (matched for transplant type, date, and pretransplant HBV antibodies). We sought evidence for HBV transmission by testing posttransplant sera for the presence of HBcAb, hepatitis B virus surface antibody, and HBsAg. Additionally, we analyzed alanine aminotransferase profiles and allograft survival rates for all patients. Results. No patient receiving an allograft from an HBcAb(+) donor developed clinical HBV infection. No patient receiving an allograft from an HBcAb(+) donor had HBsAg detected through retrospective testing of stored sera or through prospective routine clinical evaluation and care. However, among the HBcAb(+) kidney recipients, 27% developed new HBcAb and/or hepatitis B virus surface antibody after transplant; in contrast, only 4% of control patients developed new antibody responses (relative risk=4.94; confidence interval 1.07-22.83). Among the recipients of HBcAb(+) organs, 18% developed elevated transaminases after transplant, in comparison with 36% of the controls. No association was found between seroconverter status and elevated alanine aminotransferase profiles in either group. Conclusions. Transplantation of renal allografts from HBcAb(+), HBsAg(-) donors was not associated with clinically detectable HBV disease or antigenemia. However, recipients had a significantly increased risk of HBV seroconversion, consistent with exposure to HBV antigen. These results suggest that HBcAb(+) kidneys can be safely used if transplanted into appropriate recipients, but highlight the need for effective HBV vaccination and vaccine-response monitoring in potential recipients.

Background Progressive deterioration of renal function in kidney transplant recipients is the leading cause of graft failure. Both nonimmunologic and immunologic mechanisms contribute to this deterioration. Methods. Twenty-eight cyclosporine (CsA)-treated renal transplant recipients (21 cadaveric, 5 living, 2 simultaneous kidney-pancreas) with progressive deterioration of renal function were prospectively enrolled in a clinical trial and had their immunosuppressive regimen changed 24.3±7.7 months after transplant. All patients had their CsA dose reduced by 50%, azathioprine was discontinued, and mycophenolate mofetil was added to the medical regimen. The mean creatinine of the patients at the initiation of the change in immunosuppression was 3.5±1.2 mg/dl (range 1.9 to 6.2 mg/dl). Results. Before the change in immunosuppression, the mean loss in renal function as indicated by the least-squares slope of the reciprocal of creatinine versus time was -0.006±0.002 (mg/dl) -1 per month. The change in immunosuppression significantly decreased the rate of loss in renal function for most patients when compared with their pretreatment values with a mean slope of 0.007±0.003 (mg/dl) -1 per month (P=0.003). Renal function improved in 21 of 28 patients. Only one patient had continued deterioration of renal function. In a multivariate analysis adjusting for CsA dose, mean arterial blood pressure, and baseline creatinine, the change in immunosuppression was significantly associated with improved renal function (P=0.02). There were no acute rejections after the immunosuppression change. Conclusions. We conclude that adding mycophenolate mofetil and reducing CsA in patients with chronic deterioration of graft function is well tolerated and results in a short-term improvement in renal function.

BACKGROUND Tissue samples for the diagnosis of pancreatic allograft rejection are now obtained routinely through the application of the percutaneous needle biopsy technique. The availability of biopsy material (89% adequate for diagnosis in our setting) presents a challenge for pathologists who are asked to provide a fast and accurate diagnosis of rejection and its severity, while at the same time being able to differentiate rejection from other causes of graft dysfunction. METHODS To differentiate rejection from other pathologic processes, 26 histologic features were assessed in 92 biopsies performed for confirmation of clinical diagnosis of rejection and the results were compared with 31 protocol biopsies, 12 allograft pancreatectomies with non-rejection pathology, and 30 native pancreas resections with various disease processes. RESULTS Based on these comparisons, a constellation of findings relating to the vascular, septal, and acinar inflammation was identified for the diagnosis of rejection. Application of these features led us to revise our scheme for grading rejection (ranging from 0-normal to V-severe rejection) to include the categories of "inflammation of undetermined significance" and "minimal rejection." The scheme was used by five pathologist to grade 20 biopsies independently of any clinical data and the interobserver level of agreement was highly significant (kappa=0.83, P

Background. This study was conducted to determine the risk of clinically significant posttransplant cardiac events (PCEs) in a cohort of diabetic patients referred for pancreas transplantation. Methods. Between April 1991 and December 1995, 316 insulin-dependent diabetics were evaluated for pancreas transplantation. Patients were assessed for risk factors for coronary artery disease (CAD), and underwent screening for significant CAD by a standardized algorithm that included selective coronary angiography. For the 3-year period following transplantation, PCEs were identified, and related to pretransplant cardiac risk factors. Results. Only four patients (1.3%) were turned down for cardiac contraindications. Coronary angiography was done in 74 patients (27% of the active transplant candidates) during the evaluation period because of the patient's history or a positive stress test. Significant coronary artery stenoses were found in 54% of the patients catheterized. Twenty-five of these 40 patients (63%) underwent revascularization with percutaneous transluminal coronary angioplasty and/or coronary artery bypass grafting. A total of 359 organs were subsequently transplanted into 194 of these patients. No deaths occurred within 30 days of any of the transplants ; four percent of transplant recipients died of cardiac causes within the follow-up period (median 23 months). Those with no pretransplant evidence of CAD had significantly lower rates of PCE (2% and 8% at 1 and 3 years, respectively) than those with pretransplant evidence of CAD (11% and 29% at 1 and 3 years, P

Simultaneous pancreas/kidney transplantation (SPK) has evolved to become a therapeutic option for patients with renal failure resulting from type 1 diabetes mellitus. However, the appropriate route for drainage of the exocrine secretions of the pancreas allograft remains unclear. While bladder drainage (BD) is the current state of the art, it is associated with a high frequency of urologic complications, including urinary tract infections, hematuria, metabolic acidosis, dehydration, and reflux pancreatitis. Although enteric drainage (ED) is the more physiologic route, it has been associated in the past with decreased graft survival and increased infectious complications. In addition, BD offered a technique for detection of rejection through measurement of urinary amylase. However, with the advent of improved immunosuppression and antibiotic therapy, percutaneous pancreas biopsy, improved radiologic imaging, and greater understanding of pancreas transplantation, we hypothesized that ED could be performed without increased morbidity or cost. A group of 23 consecutive SPK was performed with ED during the period from July 1995 to November 1995. Another 23 age- and sex-matched recipients of SPK with BD performed from November 1994 to June 1995 served as a historical control group. Because of the differing lengths of follow-up, data were analyzed with respect to the first six months posttransplant. ED and BD were associated with equivalent actuarial one-year patient and graft survival rates: 100% and 88% for ED, and 96% and 91% for BD, respectively. Hospital charges, length of stay, readmissions, rejection, sepsis-related procedures were also equivalent in ED and BD. However, ED was associated with significantly fewer urinary tract infections and urologic complications. In addition, no grafts were lost as the result of sepsis. In the setting of SPK, ED represents a viable alternative to BD for primary drainage of pancreas exocrine secretions. Further studies with extended lengths of follow-up are necessary to confirm our observations.

The results of clinical islet transplantation have remained poor when compared with the consistent success of pancreas transplantation. Autoimmunity has usually been discounted as a cause of islet transplant failure. Previously, we demonstrated that pancreas transplants from the diabetes resistant BB rat (BB-DR) function indefinitely in autoimmune diabetic hosts, but islets from the same donor are vulnerable to recurrent autoimmunity. Addition of 100 million pancreatic lymph node cells (PLNC) to BB-DR islets restores resistance to autoimmunity and leads to repletion of a T cell subset (RT6.1) in the recipients. Autoimmune (BB-Ac) and streptozocin (BB-Sz) diabetic BB rats were recipients of Wistar Furth (WF) intraportal islet or islets plus PLNC transplants with cyclosporine 5 mg/kg/day recipient treatment. One cohort of Brown Norway (BN) islet transplants to BB-Ac with CsA was performed. At the termination of the experiment, recipient peripheral blood lymphocytes (PBL) were characterized by flow cytometry (FACS) for class I, CD4, CD8, RT6.1, and RT6.2, a T cell maturation marker found in WF but not BB rats. All (14/14) WF and 75% (6/8) BN islet transplants to BB-Ac recipients failed after a mean of 42 and 36 days, respectively, despite CsA immunosuppression. WF islets were successful in 6/8 (75%) transplants to BB-Sz recipients (P

The persistent shortage of ideal donor organs has resulted in increased transplantation of kidneys from older donors (age60 years). The overall experience with this donor subgroup indicates decreased graft survival.The records of 413 renal transplants performed between July 1991 and July 1995 were reviewed in a retrospective fashion to determine those patients who had received a cadaveric (CT60; n = 17) or living donor (LT60; n = 7) renal transplant from an older donor. Control groups consisted of randomly selected patients who received cadaveric (CT50; n = 20) or living related (LT50; n = 20) renal transplants from donors less than 50 years of age.In the CT60 group, 1-year graft survival was 57.4%, significantly less than in those of the LT50 (100%), LT60 (100%), and CT50 (89%) groups. Mean recipient serum creatinine in the CT60 group was twofold greater than that of other groups at 1, 6, and 12 months following transplantation. Cold ischemia time and creatinine clearance correlated highly with graft survival. Stepwise regression analysis showed creatinine clearance to be the sole independent predictor of graft survival. A calculated donor creatinine clearance50 mL/minute was associated with ultimate graft loss.Age alone should not be an exclusion criterion to renal organ donation. When considering the older renal donor, creatinine clearance should be included within the decision algorithm.

In the Banff classification of kidney transplant pathology the "borderline changes" category falls short of a diagnosis of mild acute rejection, with the recommendation that no treatment is a possible clinical approach. We reviewed the clinical course of patients whose renal allograft biopsies showed "borderline changes" to determine how often these histologic findings actually represented acute rejection. Between January 1992 and June 1994, 351 biopsy specimens were obtained from 170 renal allografts and graded according to the Banff criteria. Eighty-one biopsy specimens were classified as "borderline changes" (23%). Of these, 59 had Banff scores of i1, t1, and vO; the remaining 22 had scores of i2, t1, and vO (i = interstitial infiltrate, t = tubulitis, and v = vasculitis). Medical record review showed that nearly all the "borderline" biopsies had been performed because of an elevated creatinine (Cr; 78 of 81 [96%]), with a mean increase of 1.1 +/- 0.1 mg/dL (+/- SE) over baseline. Most of the patients with "borderline changes" and elevated Cr were treated for acute rejection (61 of 78 [78%]); some with pulse steroids alone (29 of 61 [48%]), the rest with antilymphocyte antibody (32 of 61 [52%]). Among all 61 patients with "borderline" biopsies treated for rejection, 26 had a complete response (43%), 17 had a partial response (28%), and 18 had no response (30%). Interpretation of these changes in Cr, however, was confounded by intercurrent conditions in 28 of the patients. A group of 33 patients was therefore identified in whom a "borderline changes" biopsy was obtained, who were treated for rejection, and in whom all other identifiable causes of elevated Cr other than possible acute rejection had been systematically eliminated from consideration. In this group the mean Cr was 2.0 +/- 0.1 mg/dL at baseline, 3.3 +/- 0.2 mg/dL at the time of biopsy, and 2.2 +/- 0.1 mg/dL 1 month after treatment (P < 0.001 Cr at biopsy v Cr 1 month later). Among these 33 patients, 19 had a complete response (58%), 10 had a partial response (30%), and four had no response (12%). Therefore, the Cr in 88% of the patients in this group was lower 1 month after treatment for rejection than it was at the time of the biopsy. Follow-up biopsies were performed within 1 month of the "borderline" biopsy in 24 cases; these showed "borderline changes" (five of 24 [21%]), mild acute rejection (eight of 24 [33%]), or moderate to severe acute rejection (11 of 24 [46%]). We conclude that in the clinical setting of deteriorating renal graft function with mild elevation of serum Cr, the "borderline changes" biopsy frequently represents acute rejection. Antirejection treatment is therefore appropriate in the majority of cases. The reader should bear in mind that the current study is retrospective, with no control group. The risk of loosely interpreting these data is that some patients will be treated without due cause. Banff "borderline changes" should be used as part of an algorithm, but not the sole criterion, for therapeutic decision making.

A case series of 31 cadaveric pancreas transplant recipients who were insulin-independent at least for one year was analyzed for the factors predisposing to late acute rejection (>12 months posttransplant). Sixty-two pancreas transplants were performed in 61 patients, of whom 53 had functioning allografts 3 months posttransplant ; 31 of these had a follow-up >12 months. Twenty had no evidence of late rejection, whereas 11 had evidence of acute rejection after 12 months. All patients received quadruple induction immunosuppression. No demographic or clinical factors-including donor age, organ cold time, HLA mismatch, age, sex, or race - could distinguish the late acute rejection group. The presence of acute rejection in the first year posttransplant was similar in the late rejectors (21 episodes in 9 of 11 patients) compared with patients without late rejection (31 episodes in 16 of 20 patients). Antilymphocyte induction therapy type had no influence, but the amount of immunosuppression with prednisone and cyclosporine (CsA) at 3 months posttransplant was significantly lower in those patients who experienced late rejection. After the first year posttransplant, CsA 12-hr trough levels were significantly lower in late rejection months (121±7 ng/ml) compared with each patient's own stable months (183±8 ng/ml, P

Background : An expanded polytetrafluoroethylene (ePTFE) graft for hemodialysis designed for immediate cannulation was tested. The graft contains a cannulation segment consisting of a stretch ePTFE base tube surrounded by flat and round ePTFE fibers that are secured by a thin, perforated ePTFE cover. This study reports our early experience with this new vascular prosthesis. Patients and methods : Between June 1994 and March 1995, 48 arteriovenous grafts were implanted in 47 patients for whom autogenous fistula construction was impossible. Mean patient age was 57 years (range 37 to 85), 86% of the patients were black, and 60% were men. Twenty-two (46%) grafts were in the forearm, 19 (39%) in the upper arm, and 7 (15%) in the groin. Unassisted and assisted patency rates were calculated by the Kaplan-Meier method. The times of first hemodialysis relative to implantation and the times to hemostasis after first decannulation were recorded. Explanted grafts were histologically evaluated with hematoxylin and eosin and Gram's stains. Results : The unassisted and assisted 6-month patency rates were 42% and 73%, respectively. Five of the first 10 grafts were lost to management and technical errors, after which the respective patency rates were 56% and 82%. Eleven of 22 thrombosed grafts were salvaged, 9 with urokinase thrombolysis and 2 with surgical thrombectomy. Twenty-eight grafts were cannulated within 7 days. The time to hemostasis was usually 2 to 4 minutes and always less than 15 minutes. Histologic analysis of a graft explanted at 40 days showed good fibrous incorporation and capillary ingrowth between the cover and round fibers. Conclusions : This new ePTFE vascular prosthesis can be safely cannulated immediately after implantation, avoiding the morbidity of temporary central venous catheter hemodialysis. After an initial period of familiarization, patency similar to that of other ePTFE arteriovenous grafts was achieved. For patients requiring urgent hemodialysis, this graft is an ideal alternative that allows immediate, safe cannulation.

Background Solid organ transplantation in elderly patients has become more common in recent years. An increasing number of patients present with renal failure requiring transplantation and comorbid occlusive or aneurysmal aortic pathology. The optimal strategy for the timing and management of the aortic disease and renal transplantation in these patients is unknown. Before the availability of endovascular therapies, our policy was to provide open repair of aortic disease before cadaveric transplantation, or by simultaneous aortic reconstruction with renal allotransplantation if a living donor was available. Since the wide acceptance of endovascular modalities, our strategy has changed to take advantage of endovascular treatment pre-transplant. This study examines the outcome of both approaches. Methods We performed a retrospective review of 12 patients between 1996 and 2009 who underwent both renal transplantation and a major abdominal aortic procedure either simultaneously (n = 6), metachronous, with the procedures occurring within the same month (n = 2), or distant, with the aortic procedures occurring between 5 and 24 months before or after transplantation (n = 4). All patients with occlusive disease underwent an aortobifemoral bypass, one before transplant, one subsequent to transplantation, and four simultaneous with a renal allograft. To assess renal transplant status, patients’ serum creatinine levels were followed up every 3 months. Of the 12 patients, eight underwent open aortic procedures, whereas four underwent endovascular aortic aneurysm repair. Patients who underwent endovascular aortic aneurysm repair were followed up with ultrasound examinations at 6-month intervals, and with contrast computed tomography scans every other year. Results Aortic reconstruction was performed successfully in all the 12 patients irrespective of timing strategy. All the patients who underwent endovascular repair had functional renal allografts for the duration of follow-up. Two patients had simultaneous aortobifemoral bypass and pancreas–kidney transplantation without complication. Among the patients with open aortic repairs, there was one 5-year mortality and one patient had failure of two renal allografts. None of the patients had limb loss, and aortic grafts (one limb required a secondary procedure) remained patent. The 5-year patient survival of 90% and kidney survival of 75% appeared similar to results in the general transplant population without aortic disease. Two significant complications related to the open procedures were observed: two renal transplants developed postoperative hematomas requiring evacuation and one aortobifemoral bypass (ABF) developed a femoral wound infection requiring evacuation and sartorius flap closure. The 30-day mortality rate in all patients was zero. The length of stay for patients receiving simultaneous procedures ranged from 5 to 14 days (median, 10.5) and was significantly lower than the 10-52-day (median, 18) combined length of stay in the metachronous and/or distant groups (p = 0.016). Conclusion The coexistence of aortic disease and renal transplantation is an increasingly common clinical scenario. Exclusion from transplantation of patients with major aortoiliac disease is commonplace in many transplant centers as early registry data suggested a poor outcome. Appropriate planning with a vascular surgical team can lead to outcomes, which are comparable with the general transplant population without significant aortic disease.

Nucleic acid testing (NAT) for HIV, HBV and HCV shortens the time between infection and detection by available testing. A group of experts was selected to develop recommendations for the use of NAT in the HIV/HBV/HCV screening of potential organ donors. The rapid turnaround times needed for donor testing and the risk of death while awaiting transplantation make organ donor screening different from screening blood-or tissue donors. In donors with no identified risk factors, there is insufficient evidence to recommend routine NAT, as the benefits of NAT may not outweigh the disadvantages of NAT especially when false-positive results can lead to loss of donor organs. For donors with identified behavioral risk factors, NAT should be considered to reduce the risk of transmission and increase organ utilization. Informed consent balancing the risks of donor-derived infection against the risk of remaining on the waiting list should be obtained at the time of candidate listing and again at the time of organ offer. In conclusion, there is insufficient evidence to recommend universal prospective screening of organ donors for HIV, HCV and HBV using current NAT platforms. Further study of viral screening modalities may reduce disease transmission risk without excessive donor loss.

The long-term graft outcomes after positive cross-match (PXM) living donor kidney transplantation (LDKT) are unknown and the descriptive published data present short-medium term results. We conducted a retrospective cohort study of LDKT with PXM by flow cytometry performed at our center during February 1999 to October 2006, compared to a control group, matched 1:1 for age, sex, race, retransplantation and transplant year. The PXM group was treated with a course of plasmapheresis/low-dose intravenous immunoglobulin (IVIg) preoperatively, and OKT3 or thymoglobulin induction. Both groups (n = 41 each) were comparable except for duration of end-stage renal disease (ESRD), induction, HLA mismatch and panel-reactive antibody (PRA). During the period of up to 9 years, 14 PXM and 7 controls lost their grafts (p < 0.04). Graft survival rates at 1 and 5 years were 89.9% and 69.4% for PXM group and 97.6% and 80.6% for the controls, respectively. PXM was associated with higher risk of graft loss (HR 2.6, p = 0.04; 95%CI 1.03-6.4) (t(1/2)= 6.8 years), but not with patient survival (HR 1.96, p = 0.29; 95%CI 0.6-7.0) or 1-year serum creatinine (beta= 0.06, p = 0.59 for ln (SCr); 95% CI -0.16 to 0.28). These results suggest that despite the favorable short-term results of PXM LDKT after PP/IVIg conditioning, medium-long-term outcomes are notably worse than expected, perhaps comparable to non-ECD deceased donor kidney transplantation (KT).

A variety of refinements in the care of kidney transplant recipients have been instituted over the past decade. The authors studied the overall impact of these refinements on kidney allograft losses at a single institution. To do this they compared the causes and rates of graft loss for primary kidney transplants in the 1970s (January 1, 1970 to December 31, 1979; n = 1012; 657 nondiabetics, 355 diabetics; 617 living donors, 395 cadaver donors) versus the 1980s (January 1, 1980 to December 31, 1989; n = 1,384; 756 nondiabetics, 628 diabetics; 740 living donors, 644 cadaver donors). Overall patient survival improved significantly, with rates at 1, 5, and 10 years of 94%, 84%, and 68% for the 1980s, compared with 86%, 69%, and 57% for the 1970s (p less than 0.001). Actuarial graft survival also improved significantly, with rates at 1, 5, and 10 years of 86%, 71%, and 52% for the 1980s, compared with 73%, 58%, and 43% for the 1970s (p less than 0.001). This improvement occurred even though there were proportionately more cadaver donors and diabetic recipients in the 1980s. For both decades combined, 24% of the lost grafts were due to chronic rejection, 18% to cardiovascular causes of death with function, 13% to infectious causes of death with function, and 11% to acute rejection. The overall gain in graft survival rates in the 1980s was principally due to fewer cases of acute rejection and fewer infectious deaths. Improvement in graft survival due to the two leading causes--chronic rejection and cardiovascular causes of death--was relatively small, if any. These data indicate that future kidney transplantation research should emphasize prevention of chronic rejection and cardiovascular death.

A patient with end-stage renal disease treated with peritoneal dialysis had two old, thrombosed hemodialysis access grafts in her upper limb. She presented with the puzzling problem of a slowly recurring hematoma over the venous anastomo sis of the upper arm graft . When the hematoma was explored surgically, its source was not immediately apparent; however, when the arterial anastomosis of the upper arm graft was subsequently explored, a small anastomotic pseudoaneurysm was encountered. Blood from the pseudoaneurysm had been dissecting between the graft and its fibrous tunnel and slowly accumulating at the venous anastomosis. Pseudoaneurysms occur in less than 5% of dialysis access grafts. They almost invariably present as a pulsatile hematoma over the arterial anastomosis or over a needle hole in a patent graft. The case described herein is interesting because of its unique presentation.

Detergent properties of bile salts are thought to account for their capacity to damage the gastrointestinal mucosa. Bile salts are thought to disrupt the mucosal barrier by dissolving the lipid components of cell membranes. We tested this hypothesis by comparing deoxycholate to several classes of detergents (anionic, nonionic, zwitterionic, cationic) in an in vivo perfused rabbit model of esophagitis. Barrier disruption was indicated by elevated transmu-cosal fluxes of glucose, calcium and potassium. Detergent strength was measured by the in vitro release of [3H]cho-lesterol from a mixture of phosphatidylcholine and cholesterol after 1 h of agitation at 37 °C and pH 7.4. We found that all detergents significantly solubilized cholesterol in vitro. The nonionic agents were strong detergents, but did not disrupt the esophageal mucosal barrier. The ionic detergents were also strong detergents, but caused significant barrier disruption in vivo. We conclude that the barrier-disrupting capacity of bile salts is not related to their detergent properties per se, but rather to some other physiochemical property not yet determined.

Despite the common use of diagnostic pretransplant deceased donor kidney biopsy, there is no consensus on the prognostic significance of the pathologic findings. In order to assist clinicians with interpretation we analyzed 371 pretransplant biopsies and correlated the findings with graft failure. Glomerular pathology was assessed with percent glomerulosclerosis (GS), glomerular size and periglomerular fibrosis (PGF); vascular pathology with arterial wall-to-lumen ratio (WLR) and arteriolar hyalinosis and interstitial pathology with measurement of cumulative fibrosis and presence of scar. Using two-thirds of the study population as a model-development cohort, we found that biopsy features independently associated with an increased risk of graft failure were GS > or =15%, interlobular arterial WLR > or =0.5 and the presence of PGF, arteriolar hyalinosis or scar. The Maryland Aggregate Pathology Index (MAPI), was developed from these parameters and validated on the remaining one-third of the population. Five-year actuarial graft survival was 90% for kidneys with MAPI scores between 0 and 7, 63% for scores from 8 to 11 and 53% for scores from 12 to 15 (p < 0.001). We conclude MAPI may help transplant physicians estimate graft survival from the preimplantation biopsy findings, in clinical situations similar to this study population (cold ischemia over 24 h, GS < 25%).

Background and objectives: Kidney transplantation is the most desired and cost-effective modality of renal replacement therapy for patients with irreversible chronic kidney failure (end-stage renal disease, stage 5 chronic kidney disease). Despite emerging evidence that the best outcomes accrue to patients who receive a transplant early in the course of renal replacement therapy, only 2.5% of incident patients with end-stage renal disease undergo transplantation as their initial modality of treatment, a figure largely unchanged for at least a decade. Design, setting, participants, & measurements: The National Kidney Foundation convened a Kidney Disease Outcomes Quality Initiative (KDOQI) conference in Washington, DC, March 19 through 20, 2007, to examine the issue. Fifty-two participants representing transplant centers, dialysis providers, and payers were divided into three work groups to address the impact of early transplantation on the chronic kidney disease paradigm, educational needs of patients and professionals, and finances of renal replacement therapy. Results: Participants explored the benefits of early transplantation on costs and outcomes, identified current barriers (at multiple levels) that impede access to early transplantation, and recommended specific interventions to overcome those barriers. Conclusions: With implementation of early education, referral to a transplant center coincident with creation of vascular access, timely transplant evaluation, and identification of potential living donors, early transplantation can be an option for substantially more patients with chronic kidney disease.

We retrospectively studied the arteriograms of 135 men admitted for evaluation of lower extremity ischemia to examine whether race influences the severity of infragenicular occlusive disease. The scoring system prepared by the Ad Hoc Committee on Reporting Standards for the Society for Vascular Surgery and the International Society for Cardiovascular Surgery was used to grade the severity of stenosis in each of the upper, middle, and lower thirds of the anterior and posterior tibial and peroneal arteries (collectively called "infragenicular" arteries). The patients were divided into two groups: 83 blacks (140 arteriogram limbs) and 52 whites (87 arteriogram limbs). Disease severity scores between the groups were compared, and the existence of five known risk factors for atherosclerosis were considered for poststratification adjustment. Results showed that higher disease scores, indicating more severe disease, were found in the black population in every segment of the infragenicular arteries. The mean (±SE) score for all the infragenicular segments in blacks was significantly higher than that in the whites (2.08 ± 0.05 vs 1.57 ± 0.06, p p p ASC S URG 1990;11:536-43.)

Transplant nephrectomy for failed renal transplants can be challenging. Patients often have numerous comorbidities, and the procedure may be associated with considerable blood loss. This study was performed to determine if intraoperative coil embolization of the transplant renal artery reduces blood loss associated with transplant nephrectomy. Data were collected retrospectively on 13 consecutive transplant nephrectomies performed immediately following coil embolization and compared with the 13 most recently performed consecutive transplant nephrectomies without coil embolization. The groups were compared for operative time, estimated blood loss, and transfusion requirements. Mean age was 45 in both groups. There were no major complications in either group. Operative times were not significantly different, although open operative time was reduced in the embolization group (113 vs 96 minutes). Estimated blood loss was 465 mL versus 198 mL ( P = .035); packed red blood cell requirements during the operation and subsequent 48 hours were 1.85 units versus 0.31 units ( P = .008) and during the operation and subsequent hospital stay were 2.3 units versus 0.69 units ( P = .027) in the nonembolized group and embolized group, respectively. Intraoperative embolization of the transplant renal artery immediately prior to surgery facilitates transplant nephrectomy by significantly reducing intraoperative blood loss and transfusion requirements while slightly reducing open operative time.

Xanthogranulomatous pyelonephritis (XGP) is anuncommon form of chronic pyelonephritis that rarelyoccurs in renal allografts. XGP is characterized byfocal or diffuse replacement of renal parenchyma bygranulomatous tissue containing lipid filled macro-phages [1]. XGP has been found in 0.6–4% of thesurgically proven cases of chronic pyelonephritis in thegeneral population [2]. It usually occurs in associationwith urinary obstruction, calculus disease and chronicinfection. There are only nine cases of XGP in renalallografts previously reported in the literature. Herein,we report the first case of renal allograft XGPassociated with xanthogranulomatous diverticulitis.

Kidneys from organ donors who have behaviors that place them at increased risk for infection with human immunodeficiency virus (HIV) or hepatitis C virus (HCV) are often discarded, even if viral screening tests are negative. This study compared policies that would either 'Discard' or 'Transplant' kidneys from Centers for Disease Control classified increased-risk donors (CDC-IRDs) using a decision analytic Markov model of renal failure treatment modalities. Base-case CDC-IRDs were current injection drug users (IDUs) with negative antibody and nucleic acid testing (NAT) for HIV and HCV, comprising 5% of kidney donors. Compared to a CDC-IRD kidney 'Discard' policy, the 'Transplant' policy resulted in higher patient survival, a greater number of quality-adjusted life-years (QALYs) (5.6 vs. 5.1 years per patient), more kidney transplants (990 vs. 740 transplants per 1000 patients) and lower cost of care ($60 000 vs. $71 000 per QALY). The total number of viral infections was lower with the 'Transplant' policy (13.1 vs. 14.8 infections per 1000 patients over 20 years), because the 'Discard' policy led to more time on hemodialysis, with a higher HCV incidence. We recommend that kidneys from NAT-negative CDC-IRDs be considered for transplantation since the practice is estimated to be beneficial from both the societal and individual patient perspective.

A randomized, multicenter, prospective study was conducted at 18 pancreas transplant centers in the United States to determine the role of induction therapy in simultaneous pancreas-kidney (SPK) transplantation. One hundred and 74 recipients were enrolled: 87 recipients each in the induction and noninduction treatment arms. Maintenance immunosuppression consisted of tacrolimus, mycophenolate mofetil, and corticosteroids. There were no statistically significant differences between treatment groups for patient, kidney, and pancreas graft survival at 1-year. The 1-year cumulative incidence of any treated biopsy-confirmed or presumptive rejection episodes (kidney or pancreas) in the induction and noninduction treatment arms was 24.6% and 31.2% (p = 0.28), respectively. The 1-year cumulative incidence of biopsy-confirmed, treated, acute kidney allograft rejection in the induction and noninduction treatment arms was 13.1% and 23.0% (p = 0.08), respectively. Biopsy-confirmed kidney allograft rejection occurred later post-transplant and appeared to be less severe among recipients that received induction therapy. The highest rate of Cytomegalovirus (CMV) viremia/syndrome was observed in the subgroup of recipients who received T-cell depleting antibody induction and received organs from CMV serologically positive donors. Decisions regarding the routine use of induction therapy in SPK transplantation must take into consideration its differential effects on risk of rejection and infection.

OBJECTIVE To evaluate the strategies instituted by the authors' center to decrease the time to transplantation and increase the rate of transplantation for African-Americans, consisting of a formal education program concerning the benefits of living organ donation that is oriented to minorities; a laparoscopic living donation program; use of hepatitis C-positive donors in documented positive recipients; and encouraging vaccination for hepatitis B, allowing the use of hepatitis B core Ab-positive donors. SUMMARY BACKGROUND DATA The national shortage of suitable kidney donor organs has disproportional and adverse effects on African-Americans for several reasons. Type II diabetes mellitus and hypertension, major etiologic factors for end-stage renal disease, are more prevalent in African-Americans than in the general population. Once kidney failure has developed, African-Americans are disadvantaged for the following reasons: this patient cohort has longer median waiting times on the renal transplant list; African-Americans have higher rates of acute rejection, which affects long-term allograft survival; and once they are transplanted, the long-term graft survival rates are lower in this population than in other groups. METHODS From March 1990 to November 2001 the authors' center performed 2,167 renal transplants; 944 were in African-Americans (663 primary cadaver renal transplants and 253 primary Living donor renal transplants). The retransplants consisted of 83 cadaver transplants and 17 living donor transplants. Outcome measures of this retrospective analysis included median waiting time, graft and patient survival rates, and the rate of living donation in African-Americans and comparable non-African-Americans. Where applicable, data are compared to United Network for Organ Sharing national statistics. Statistical analysis employed appropriate SPSS applications. RESULTS One- and 5-year patient survival rates for living donor kidneys were 97.1% and 91.3% for non-African-Americans and 96.8% and 90.4% for African-Americans. One- and 5-year graft survival rates were 95.1% and 89.1% for non-African-Americans and 93.1% and 82.9% for African-Americans. One- and 4-year patient survival rates for cadaver donor kidneys were 91.4% and 78.7% for non-African-Americans and 92.4% and 80.2% for African-Americans. One- and 5-year graft survival rates for cadaver kidneys were 84.6% and 73.7% for non-African-Americans and 84.6% and 68.9% for African-Americans. One- and 5-year graft and patient survival rates were identical for recipients of hepatitis C virus-positive and anti-HBc positive donors, with the exception of a trend to late graft loss in the African-American hepatitis C virus group due to higher rates of noncompliance, an effect that disappears with censoring of graft loss from that cause. The cadaveric renal transplant median waiting time for non-African-Americans was 391 days compared to 734 days nationally; the waiting time for African-Americans was 647 days compared to 1,335 days nationally. When looking at all patients, living and cadaver donor, the median waiting times are 220 days for non-African-Americans and 462 days for African-Americans. CONCLUSIONS Programs specifically oriented to improve volunteerism in African-Americans have led to a marked improvement in overall waiting time and in rates of living donation in this patient group. The median waiting times to cadaveric renal transplantation were also significantly shorter in the authors' center, especially for African-American patients, by taking advantage of the higher rates of hepatitis C infection and encouraging hepatitis B vaccination. These policies can markedly improve end-stage renal disease care for African-Americans by halving the overall waiting time while still achieving comparable graft and patient survival rates.

The authors present the case of a patient who developed near total colonic necrosis shortly after renal transplantation. The onset of symptoms was temporally related to the administration of sodium polystyrene (Kayexalate ® ;Sanofi Winthrop Pharmaceuticals, New York, NY)-sorbitol enemas for treatment of hyperkalemia. Three similar cases have been reported in the literature. The presence of uremia and the use of sorbitol appear to be common denominators in the pathophysiology of this complication. It is suggested that Kayexalate ® -sorbitol enemas be avoided in renal transplant patients.

During the past few years, we have witnessed a significant improvement in pancreas graft survival rates, resulting in a dramatic increase in the number of pancreas transplants performed. In 1998, more than 1,200 pancreas transplants were performed in the United States, a 15% increase from the previous year. 1 The technique of draining the pancreatic duct into the donor jejunum that was originally described 2 has historically been associated with a high incidence of intraabdominal infections. As a result, the modified technique of bladder drainage 3 gained wide acceptance as the method of choice for pancreatic duct drainage. Recently, enteric duct drainage has been readopted by many pancreas transplant centers primarily to avoid the well-known metabolic and urologic complications of bladder drainage. According to the International Pancreas Transplant Registry, 1 the proportion of enteric-drained procedures has continuously increased, concomitant with the number of centers using this technique. In 1995, 29% of all transplant centers performed at least one enteric-drained pancreas transplant, but by 1998, 98% of the transplant centers in the United States had at some point used enteric drainage. The graft survival and technical failure rates are comparable to those of bladder-drained pancreatic grafts. With recognition that more than 20% of bladder-drained grafts have to be converted to enteric drainage by 2 years, enteric drainage with systemic venous drainage has emerged as the procedure of choice. Systemic venous drainage of pancreas transplants has been associated with hyperinsulinemia, 4–6 which itself has been associated with dyslipidemia. 7 This raised the concern that pancreas transplantation with systemic venous drainage might promote accelerated atherosclerosis independent from the dyslipidemic effects of immunosuppressive medication. 4,8 To circumvent this problem, in 1992 Rosenlof et al 9 described a more physiologic technique of draining the transplanted pancreas into the recipient’s portal circulation via the splenic vein. The technique was later modified by Gaber et al. to drain directly into the superior mesenteric vein. 10 This technique has resulted in significantly reduced plasma insulin and C-peptide levels 11 as well as improvements in lipoprotein composition. 12 However, the immunologic benefits, although alluded to in a small number of patients, 13 were not confirmed by appropriate comparisons of systemic- and portal-drained procedures in a larger series. Numerous experimental models have shown an immunomodulatory role of the liver after exposure of donor antigen into the portal vein. It is possible, therefore, that drainage of the transplanted pancreas into the portal vein mimics these experimental models and elicits a degree of immunomodulation. The purpose of this study was to assess whether an immunologic or survival advantage exists in portal venous versus systemic venous drainage in both solitary pancreas transplants and in combined kidney and pancreas transplants.

Objective To examine the impact of laparoscopic nephrectomy and recipient education on the proportion of kidney recipients who could identify a potential live donor, and on the live donor (LD) transplantation rate. Summary Background Data Laparoscopic donor nephrectomy (LDN) results in less postoperative surgical pain, a shorter hospital stay, and quicker recovery than the standard open donor nephrectomy (ODN). The authors hypothesized that the availability of this less invasive surgical technique would enhance the willingness of family and friends to donate. Methods The study population consisted of 3,298 end-stage renal disease patients referred for kidney transplant evaluation between November 1991 and February 2000, divided into three groups. The first group received no formal LD education and had only ODN available. The second group received formal education about the LD process and had only ODN available. The third group had both formal LD education and LDN available. Records were examined to determine what proportion of each group had any potential donors tissue-typed, and the rate at which they received an LD transplant. Results Before LDN availability and formal LD education, only 35.1% of referrals found a potential donor, and only 12.2% received an LD transplant within 3 years. Institution of a formal education program increased the volunteer rate to 39.0%, and 16.5% received an LD transplant. When LDN became available, 50% of patients were able to find at least one potential donor, and within 3 years 24.7% received an LD transplant. Regression analysis indicated that availability of LDN was independently associated with a 1.9 relative risk of receiving an LD transplant. Kaplan-Meier death-censored 1- and 3-year graft survival rates for ODN transplants were 95.8% and 90.6%, versus 97.5% and 94.8% for LDN. Conclusions The availability of LDN and an LD family education program has doubled the live donor transplantation rate, and outcomes remain excellent.

Background Laparoscopic live donor nephrectomy (LDN) is a recently developed procedure, the performance of which needs to be studied. Given the reported advantages in the donors, this study looks at graft outcome and ureteral complications in recipients of kidneys procured by open donor nephrectomy (ODN) versus LDN. Methods The LDN recipients consisted of 193 patients since 3/27/96. A total of 168 ODN recipients from 1991 to 1998 served as controls. Immunosuppression protocols were similar for both groups. Results Two-year graft survival for LDN and ODN was 98% and 96%, respectively. Two-year patient survival for LDN and ODN was 98% and 97%, respectively. The incidence of delayed graft function and mean serum creatinine at 3 and 12 months was similar in both groups. However, the number of ureteral complications that required operative repair was significantly higher for LDN recipients compared to ODN recipients, 7.7% (n=15) vs. 0.6% (n=1) respectively (P=0.03). Ureteral stenting was required in an additional 3.1% (n=6) of LDN and 2.4% (n=4) of ODN (P=NS). There was, however, a learning curve with time. For the first 130 LDN patients, a total of 20 ureteral complications were recorded, whereas only one occurred in the more recent 63 patients (P=0.03). Conclusions The higher ureteral complication rate in LDN recipients has improved over time as technical causes have been identified. We have noted significant improvement in ureteral viability by using the endogastrointestinal anastomosis instrument on the ureter and peri-ureteral tissue. LDN is therefore an excellent alternative to ODN. Identification of hazards unique to this technique is critical before its broader application.

Background. Laparoscopic donor nephrectomy (laparoNx) has the potential to increase living kidney donation rates by reducing the pain and suffering of the donor. However, renal function outcomes of a large series of recipients of laparoNx have not been studied. Methods. We retrospectively reviewed the records of 132 recipients of laparoNx done at our center between 3/96 and 11/97 and compared them to 99 recipients of kidneys procured by the open technique (openNx) done between 10/93 and 3/96. Results. Significantly more patients in the laparoNx group (25.2%) were taking tacrolimus within the first month than those in the openNx group (2.1%). Mean serum creatinine was higher in laparoNx compared with openNx at 1 week (2.860.3 and 1.860.2 mg/dl, respectively; P50.005) and at 1 month (2.060.1 and 1.660.1 mg/dl, P50.05) after transplant. However, by 3 and 6 months, the mean serum creatinine was similar in the two groups (1.760.1 versus 1.560.05 mg/dl, and 1.760.1 versus 1.760.1, respectively). By 1 year posttransplant, the mean serum creatinine for laparoNx was actually less than that for openNx (1.460.1 and 1.760.1 mg/dl, P50.03). Although patients in the laparoNx compared to the openNx group were more likely to have delayed graft function (7.6 versus 2.0%) and ureteral complications (4.5 versus 1.0%), the rate of other complications, as well as hospital length of stay, patient and graft survival rates were similar in the two groups. Conclusion. Although laparoNx allografts have slower initial function compared with openNx, there was no significant difference in longer term renal function. Kidney transplantation is considered to be the treatment of choice for end-stage renal failure. Insufficient supply of organs for donation has produced long waiting times for many patients who may benefit from transplantation (1). During this period patients accumulate the morbidity of renal failure, they must endure the lifestyle limitations of dialysis, and they often die while waiting for the organ sharing system to grant them this resource. Live donor renal transplantation represents a large potential supply of organs that may relieve much of this shortage. Additionally, recipients of live renal transplants may reap benefits of improved patient and allograft survival that have been clearly demonstrated in this population (2,3). Although unilateral nephrectomy has proven to be safe and the solitary kidney state has been found to be well tolerated in a carefully chosen candidate for donation (4,5), substantial disincentives to donation exist. These include a significant hospitalization, prolonged convalescence period with time away from jobs, intractable perioperative pain, and, for some, cosmetic concerns of the resulting