Total parathyroidectomy in patients with chronic kidney disease: Avoiding repeat surgery

Renal hyperparathyroidism (RHPT) is a common complication of renal failure and it is associated with significant morbidity and mortality. The aim of this study was to determine the patient characteristics which might predict persistent or recurrent hyperparathyroidism after surgery and to assess the long-term effect of unsuccessful surgery. This is a retrospective study of all chronic kidney disease patients who required a total parathyroidectomy (TP) because of failed medical management from January 1999 to December 2014. Patient characteristics, preoperative imaging, operative findings, and patient outcome were all studied. Differences between groups (dialysis-dependent and nondialysis-dependent; preoperative imaging and no imaging) were tested by the Chi-square statistic test and P <0.05 was regarded statistically significant. Eighty-eight patients underwent TP during this period and were followed up for a median of 35.5 months (range 1-119 months). Seventy (80%) had removal of all parathyroid glands with associated fall in parathyroid hormone level. There were no statistically significant differences in surgical success rates in neither the dialysis-dependent versus nondialysis-dependent groups nor the preoperative imaging versus no imaging groups. Two patients underwent repeat parathyroid surgery for persistent hyperparathyroidism and 16 were followed up without surgery. Preoperative imaging did not direct surgical management nor reduce surgical failure rate in this series. The long-term effects of pharmaceutical developments in this area are unknown but are likely to change indications for initial parathyroidectomy and reoperation. An agreed protocol is essential for the management of patients with RHPT.

The effect of new clinical pathways on the outcome of vascular access surgery

PURPOSE

Prior to 2007, the waiting time for vascular access surgery at our center was approximately 107 days compared to a UK average of 45 days. Two new pathways were developed; the rapid and super-rapid pathways incorporating an access liaison nurse who organized vessel mapping and referred patients for surgery. This audit was to determine whether the pathways were effective in reducing the waiting times and improving vascular accesses outcomes.

METHODS

All 210 patients with established renal failure undergoing 232 vascular access procedures between January 2008 and March 2011 were studied. Detailed patient information including type of procedure and cause of access failure were stored in an Excel spreadsheet and analyzed using SPSS for Windows.

RESULTS

One hundred and twenty patients had a brachiocephalic fistula, 61 a radiocephalic fistula, 39 an access using the basilic vein ± transposition, and 11 a transposition of the long saphenous vein and one a brachio-axillary graft. Overall median waiting time from referral to access surgery was 23 days. Patients were followed up for a median of 248 days after surgery. The overall primary failure rate was 9.1% and 25 of 27 accesses failed because of thrombosis. The overall cumulative survival probability of accesses at one year was 61.4% with a mean survival of 621.2 days (SEM = 34.8).

CONCLUSION

The clinical pathways have improved VA service to patients with a drastic reduction in waiting times, elimination of synthetic access, and maintenance of satisfactory results.

Bilateral psoas haematomata complicating renal transplantation

Background. The challenge in managing patients undergoing renal transplantation is how to achieve optimum levels of anticoagulation to avoid both clotting and postoperative bleeding. We report a rare case of severe postoperative retroperitoneal bleeding including psoas haematomata complicating renal transplantation. Case Report. SM, a 55-year-old female, had a past history of aortic valve replacement, cerebrovascular event, and thoracic aortic aneurysm and was on long-term warfarin that was switched to enoxaparin 60 mg daily a week prior to her living donor transplantation. Postoperatively, she was started on a heparin infusion, but this was complicated by a large retroperitoneal bleed requiring surgical evacuation on the first postoperative day. Four weeks later, she developed features compatible with acute femoral neuropathy and a CT scan revealed bilateral psoas haematomata. Following conservative management, she made steady progress and was discharged home via a community hospital 94 days after transplantation. At her last visit 18 months after transplantation, she had returned to full fitness with excellent transplant function. Conclusion. Patients in established renal failure who require significant anticoagulation are at increased risk of bleeding that may involve prolonged hospitalisation and more protracted recovery and patients should be carefully counselled about this.

Autogenous arteriovenous fistulas for haemodialysis: a review

The last 40 years has witnessed revolutionary changes in vascular access provision for haemodialysis. Autogenous arteriovenous (AV) fistula is the best access modality and should be considered first when planning vascular access. Education is required to ensure preservation of the cephalic veins in patients at potential risk for the development of end stage renal disease (ESRD). The best access procedure should be performed first and the AV fistula allowed to mature before use. Autogenous AV fistula have a cumulative patency of 85-90% and 60-85% at 1 and 3 years respectively. Increased use of preoperative imaging and the use of autogenous vein are essential to improved long-term results.

Central venous catheters for haemodialysis: a review

Indications for using central venous catheters (CVC) for haemodialysis include patients with: exhausted vascular access sites, no suitable vessels, failed peritoneal dialysis or short life expectancy. Catheter design and technology have changed in recent years to address the perennial problems of poor flow and infection. Permanent CVC offer a real alternative to arteriovenous access as 11-22% of long-term haemodialysis patients use CVC as their permanent vascular access. Recent advances in catheter use including measures to avoid insertion complications are highlighted. CVC provide mean flow rates of 274-525 ml/min with a one year cumulative catheter survival of 47-93%. Tunnelled CVC provide a safe and effective long-term access for haemodialysis and are particularly suitable for use in developing countries. They are cheaper to maintain and remove the temptation to re-use disposable dialysis needles.

Unusual Complications Following Living Donor Nephrectomy

BACKGROUND

The aim of this study was to highlight unusual complications following living‐donor nephrectomy within a single center.

METHODS

Between January 2003 and February 2008, 58 donor nephrectomies (52 open and 6 laparoscopic hand‐assisted) were performed. All donors were followed up at 6 weeks and then discharged to regular yearly visits with their designated nephrologists. All complications were entered prospectively into a database used for this analysis.

RESULTS

Forty‐four (76%) had a left donor nephrectomy, whereas 14 (24%) had a right nephrectomy. There were 22 men and 34 women with a median age of 48 years (range 27–70 years). Average length of hospital stay of the donors was 5 days (median 4 days). Fifty donors (86%) had no complications; the complications seen in the remaining 8 (14%) were hemorrhage in 4 donors, testicular pain treated by orchidectomy in 1 donor, neuropathic pain in 1 donor, and lymphoma in 1 transplanted kidney.

CONCLUSIONS

In addition to rigorous and careful assessment of potential donors, every effort must be made to reduce the risk of postoperative complications by adopting a careful surgical technique, ensuring a high level of vigilance, and early detection of complications—bearing in mind some of the unusual complications detailed in this report.

Outcome of renal transplantation in patients with lower urinary tract abnormality

Patients with end stage renal failure (ESRF) and lower urinary tract abnormality (LUTA) are often considered high risk for renal transplantation. To examine the degree of risk, we have reviewed our experience of 44 patients who received a total of 58 renal allografts at the Western Infirmary, Glasgow, between 1978 and 1996. All patients had a detailed urological assessment and 19 of them underwent a urinary diversion procedure prior to transplantation. One-year patient and graft survival rates were 97% and 84%, respectively, while the five-year figures were 87% and 59%, respectively. The presence of an ileal conduit did not adversely affect graft survival (P = 0.52). The commonest complication was persistent urinary tract infection, which occurred in 15 (34%) patients. Of the 29 graft losses that occurred during the follow up period of 7-217 months, only one was due to infection of the transplant. We conclude that renal transplantation is a satisfactory option for patients with ESRF due to LUTA but that it is important to carry out detailed urological assessment prior to the transplant procedure.

Effectiveness of Implantable Doppler Probe Versus Standard Clinical Care in Preventing Thrombosis-Related Graft Loss in Kidney Transplantation: A Systematic Review and Meta-Analysis

OBJECTIVES

The implantable Doppler probe can monitor the patency of vascular anastomosis, thereby facilitating early detection of vascular thrombosis critical to reducing graft loss. In this study, we examined the effectiveness of this technology compared with standard clinical care in reducing thrombosis-related graft loss and the requirement for color duplex ultrasonography in the first 24 hours postoperatively by a medical literature search of the application of this technology in kidney transplantation.

MATERIALS AND METHODS

We conducted a systematic search (January 15, 2024) of a wide range of experimental and observational studies that comprised kidney transplant recipients monitored with blood flow sensing technology (intervention group) and standard clinical care (control group). Primary outcomes were differences between groups of thrombosis-related graft loss and surveillance requirement of color duplex ultrasonography scans in the first 24 hours postoperatively. Two independent researchers conducted critical appraisal and data extraction of the selected papers using the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument. We used a random effects model for the meta-analysis. Dichotomous outcomes were expressed as relative risk or odds ratio.

RESULTS

The search identified 43 articles. After exclusion criteria, 7 studies (1 experimental, 6 observational) were included, with a total participant sample of 874 adult kidney transplant recipients with and without blood flow sensing technology. The certainty of evidence level was rated as moderate. Blood flow sensing technology resulted in a 66% reduction in the risk of thrombosis-related graft loss and a 61% lower probability of requiring color duplex ultrasonography in the first 24 hours postoperatively compared with standard clinical care.

CONCLUSIONS

Blood flow sensing technology can be used as a helpful adjunct in the postoperative monitoring of kidney transplant recipients. However, given the technical limitations, signals should be interpreted alongside the traditional clinical assessment techniques.

Renal transplantation in developing countries

Patients with established renal failure, living in developing countries, face many obstacles including lack of access to transplantation centers, quality and safety issues, and exploittation associated with transplant tourism. This review aims to determine the state and outcome of renal transplantation performed in developing countries and to recommend some solutions. The lack of suitable legislation and infrastructure has prevented growth of deceased donor programs; so, living donors have continued to be the major source of transplantable kidneys. Transplant tourism and commercial kidney transplants are associated with a high incidence of surgical complications, acute rejection and invasive infection, which cause major morbidity and mortality. Developing transplant services worldwide has many benefits - improving the results of transplantation as they would be performed legally, increasing the donor pool, making transplant tourism unnecessary and granting various governments the moral courage to fight unacceptable practices. A private-public partnership underpinned by transparency, public audit and accountability is a prerequisite for effective transplant services in the developing world. Finally, lack of dialysis facilities coupled with better outcomes in patients spending <6 months on dialysis prior to transplantation favor pre-emptive transplantation in developing countries.

Preserving function and long-term patency of dialysis access

Of the 283, 932 patients with end stage renal disease (ESRD) receiving replacement therapy in the US in 1996, 62% were being treated with haemodialysis. Improved survival of haemodialysis patients coupled with the inability to provide enough renal transplants for the growing ESRD population has resulted in an increase in the average length of time patients spend on dialysis. Vascular accesses are, therefore, required to function for longer periods of time. Maintenance of a reliable access to the circulation has been described as the Achilles' heel of modern haemodialysis. Preserving access function and long-term patency are essential for efficient dialysis delivery.

Caecal tumour masquerading as an appendicular mass

Appropriate management of appendix mass is based on an accurate diagnosis of the underlying pathology. This is a report of a complex patient presenting with an appendix mass, whose surgery was deferred due to severe co-morbidities and who later died from severe metastatic disease. A 65-year-old lady presented with right iliac fossa pain and a mass. She was treated for an appendix mass initially and when the mass failed to resolve after four weeks, she was thoroughly investigated for the possibility of a tumour. Severe co-morbities had a significant impact on her management as definitive surgery was delayed. She represented 10 months after the initial admission with small bowel obstruction and died of metastatic caecal cancer. Management of appendix mass must entail a careful approach to investigating and treatment with emphasis on early intervention if the mass does not resolve promptly. This will avoid delayed diagnosis, treatment and a detrimental impact on prognosis.

Urological complications of renal transplantation: Reducing the risk

Urological complications can have a significant effect on the outcome of renal transplantation including the loss of the graft. The aims of this study were to determine the incidence of urological complications occurring after kidney transplantation at our unit, and how the risk of complications can be reduced. All 398 renal transplantations performed at Derriford Hospital, Plymouth between August 1997 and December 2006 were reviewed. Twenty nine (7.3%) urological complications were noted with a median time to diagnosis of 8.5 days (range 1-950 days) following transplantation; 81% occurring within two weeks. Fourteen (48.3%) of these patients had identifiable risk factors; 10 patients required ureteric reimplantation, 6 had Boari flap reconstruction, and 3 underwent transurethral resection prostatectomy. One graft was lost to severe ureteric necrosis. Steps to reduce the risk of complications include avoiding damage to organs during retrieval, meticulous bench preparation including hydrodilating ureters to exclude ureteric injury and vigilance during the transplant procedure. Prompt and appropriate corrective surgery can diminish the effect of urological complications on graft survival.

Audit of major gastrointestinal surgery in patients aged 80 years or over

The value of preoperative assessment in relation to outcome and long-term survival was studied in 171 octogenarians undergoing major gastrointestinal surgery at Dumfries and Galloway Royal Infirmary between 1985 and 1990. The 30-day mortality rates for elective and emergency operations were 11% and 25% respectively. The American Society of Anesthesiologists (ASA) physical status scale was found to be a useful predictor of morbidity and mortality. ASA class 2 patients had a postoperative complication rate of 36% and a mortality rate of 13% while the figures for ASA class 4 patients were 85% and 54% respectively. Cox proportional hazards survival analysis using the variables age group, sex, ASA class, and type of surgery showed that the only statistically significant differences were between ASA classes. The relative 5-year survival of 63% indicates that these patients compare favourably with a population of the same age and sex not undergoing an operation. These data suggest that in the absence of severe concomitant medical disease, gastrointestinal surgery can be carried out reasonably safely in the elderly.

Use of permanent dual lumen catheters for long-term haemodialysis

Permanent dual lumen catheters (PDLC) provide alternative vascular access in patients considered unsuitable for arteriovenous fistula, arteriovenous graft or peritoneal dialysis. Experience with their use for long-term haemodialysis is presented. Between January 1990 and April 1994, 101 catheters were inserted into 63 patients (median age 62 years). A PDLC was the primary vascular access type in 5 patients. Of the first catheters, 70% were inserted percutaneously into the subclavian vein. The median duration of catheter use was 168 days (range 5-1582 days). The overall cumulative observed catheter survival rate was 94% at 6 months, 89% at 1 year and 75% at 4 years following insertion. The major complications were blockage and catheter related infection occurring in 28% and 15% of catheters, respectively. Death and blockage were the commonest reasons for catheter removal. PDLC play a vital role in the provision of access for long-term dialysis and should be considered the access type of choice in patients with limited life expectancy.

Exploring the Role of an Implantable Doppler Probe as a Blood Flow-Monitoring Device in Kidney Transplant: A Feasibility Randomized Controlled Trial

OBJECTIVES

Vascular thrombosis is a disastrous postoperative complication resulting in the loss of 3.5% to 5.7% of all kidney transplants. The use of blood flow-sensing technology in the early postoperative period may help in the early identification of vascular complications crucial to reducing graft loss. This study aimed to assess the feasibility of an implantable Doppler probe as a blood flow-monitoring device in kidney transplant recipients and to evaluate its usefulness in the prevention of early graft loss.

MATERIALS AND METHODS

This 2-arm feasibility randomized controlled trial compared the demographic characteristics and surgical outcomes of kidney transplant recipients who received implantable Doppler probe monitoring (intervention group; n = 30) with those who had standard clinical care (control group; n = 30). Surgical outcomes compared between the groups included the number of early vascular complications identified,the number of departmental ultrasonography scans requested in the first 72 hours postoperatively, and month 3 graft loss.

RESULTS

Both groups were similar in demographic characteristics. In the intervention group versus the control group, fewer ultrasonography scans were requested in the first 24 hours postoperatively (56% vs 91%) and lower graft loss (0% vs 6.6%) was recorded. The results addressed uncertainties around the feasibility study's research methods and required resources for a future pragmatic trial.

CONCLUSIONS

An implantable Doppler probe may be a beneficial adjunct for graft monitoring after kidney transplants. This feasibility study provided the necessary preliminary information and filled initial gaps in the evidence that can inform future research. The prespecified progression criteria ofthe study were fulfilled. The study template used can be transferable to other transplant centers across theUnited Kingdom. A pragmatic large-scale randomized controlled trial is warranted to evaluate the effectiveness of implantable Doppler probes in clinical practice.

Refashioning of an aneurysmatic arterio-venous fistula by using the multifire GIA 60 surgical stapler

We describe a technique for refashioning an aneurysmatic arterio-venous fistula by using the multifire GIA 60 surgical stapler. After obtaining proximal and distal control of the aneurysmatic vein each aneurysmal segment of the anterior wall of the vein is excised by applying the GIA 60 stapler. The layer of the staple-line is re-enforced with one layer of 6/0 prolene continuous suture. After completion of the procedure, the size of the vein is reduced by approximately 50%. The AVFs were successfully re-used for dialysis within four weeks postoperatively.

Management of patients with challenging vascular access needs

The proportion of patients on dialysis with multiple access procedures, failed transplant(s), or no suitable sites for conventional arteriovenous (AV) fistula is increasing. We report on 4 patients at our institution requiring unusual measures to achieve vascular access for dialysis. All 4 patients had temporary femoral vein catheters for dialysis, but 3 had tunneled femoral catheters, with 1 patient using this modality of access for 28 months. One patient who had 13 vascular access procedures developed collateral circulation that was amenable to a new autogenous AV fistula. Two patients died of causes unrelated to vascular access, whereas 1 died from infection of an access device. In patients with challenging vascular access requirements, the use of simple procedures such as the insertion of a tunneled femoral catheter should be considered. A thorough assessment must be made before each new access procedure as collateral circulation may present new options.

Congenital absence of the gallbladder: ways of avoiding laparotomy

Two cases of congenital absence (agenesis) of the gallbladder seen at one hospital over a 5-year period are presented. One patient presented with ascending cholangitis due to choledocholithiasis, while the other presented with right upper quadrant abdominal pain and equivocal findings on ultrasound and oral cholecystography. Although diagnosis was made at laparotomy in both cases, it is likely that the arrival of laparoscopic cholecystectomy will avoid laparotomy in the future. The place of laparoscopy in establishing the presence of this anomaly is discussed.

Living kidney donor assessment: Kidney length vs differential function

BACKGROUND

The key question in living kidney donor assessment is how best to determine the contribution of each kidney to overall renal function and guide selection of which kidney to donate, ensuring safety of procedure and good outcome for both recipient and donor. It is thought that a length difference > 2 cm may indicate significant difference in function and therefore need for measurement of differential function.

AIM

To determine the effect of using kidney length to decide which kidney to donate in a retrospective cohort of potential donors.

METHODS

All 333 potential living kidney donors between January 2009 and August 2018 who completed assessment were retrospectively evaluated. Donor assessment was performed as per United Kingdom guidelines. Data included age, sex, kidney length (cranio-caudal) obtained by computed tomography/ultrasono-graphy,51-chromium ethylenediamine tetraacetatic acid measured glomerular filtration rate, mercapto acetyl tri glycine split function and vascular anatomy. There were 48 exclusions due to inadequate data or incomplete investigations. Statistical analysis was performed using Excel pivot tables and GraphPad Prism. Correlation between kidney length and differential function was determined with Pearson's correlation coefficient.

RESULTS

Of 285 potential donors included in the study, there were 144 males (mean age 49.9 ± 14.75) and 141 females (mean age 51.2 ± 11.23). Overall, the Pearson's correlation between differences in length and divided function of kidney pairs was 0.1630, P = 0.0058. Of 73 with significant difference (> 10%) in divided function, 18 (24.7%) had no difference in kidney length; 54 (74%) had a difference of < 2 cm and only one of > 2 cm. Using a length difference of > 1 cm would only predict significant difference in divided function in 8/34 (23.5%) of cases. Using a difference of > 2 cm as cut off for performing split function would lead to false reassurance in 72 patients (6 had > 20% difference in divided function whereas 66 had 10%-20% difference).

CONCLUSION

Length difference between kidney pairs alone is not sufficient to replace measurement of divided function. This issue requires a randomised controlled trial to resolve it.