Single versus en bloc kidney transplantation from pediatric donors less than or equal to 15 kg

BACKGROUND

Kidney transplantation from small pediatric donors is being performed with increased frequency as single (SK) or en bloc (EBK) kidneys.

METHODS

Between 2002 and 2006, 19 EBK and 14 SK transplants from pediatric donors less than or equal to 15 kg were performed. SK arterial anastomoses were performed to the aortic patch (n=8), aortic conduit (n=1), or renal artery orifice (n=5).

RESULTS

En bloc kidney donors were on average younger (12+/-10 vs. 24+/-8 months, respectively; P=0.0102) and weighed less (10+/-3 vs. 13+/-3, respectively; P=0.0184). There were no differences between the two groups in recipient age, race, body mass index, degree of sensitization, retransplantation, and cold ischemia time; however, EBK recipients were somewhat better matched at the human leukocyte antigen DR locus (P=0.0515). Delayed graft function was more frequent in the SK group (25% vs. 0%; P=0.0542). Acute rejection occurred in 21% of recipients in both groups. Glomerular filtration rates were significantly higher with EBK than SK at 12-months posttransplantation. At 1 year, graft survival for SK and EBK was 86% and 79%, respectively (P=1.000). Graft thrombosis occurred in 0% (0/9) of SK recipients in which an aortic cuff or conduit was used, 40% (2/5) of SK recipients without an aortic cuff, and 5% (1/19) of EBK recipients (P=0.03).

CONCLUSION

Short-term outcomes of kidneys from small pediatric donors are satisfactory when transplanted as SKs or en bloc; however, the absence of an aortic patch in SK transplantation is a risk factor for early thrombosis.

Acute liver failure secondary to yellow phosphorus rodenticide poisoning: Outcomes at a center with dedicated liver intensive care and transplant unit

Accidental or suicidal poisoning with yellow phosphorus or metal phosphides (YPMP) such as aluminum (AlP) zinc phosphide (Zn3P2) commonly cause acute liver failure (ALF) and cardiotoxicity. These are used as household, agricultural and industrial rodenticides and in production of ammunitions, firecrackers and fertilizers. In absence of a clinically available laboratory test for diagnosis or toxin measurement or an antidote, managing their poisoning is challenging even at a tertiary care center with a dedicated liver intensive care unit (LICU) and liver transplant facility.

PATIENTS AND METHODS

Patients with YPMP related ALF were monitored using standardized clinical, hemodynamic, biochemical, metabolic, neurological, electrocardiography (ECG) and SOFA score and managed using uniform intensive care, treatment and transplant protocols in LICU. Socio-demographic characteristics, clinical and biochemical parameters and scores were summarized and compared between 3 groups i.e. spontaneous survivors, transplanted patients and non-survivors. Predictors of spontaneous survival and the need for liver transplant are also evaluated.

RESULTS

Nineteen patients with YPMP related ALF were about 32 years old (63.2% females) and presented to us at a median of 3 (0 - 10) days after poisoning. YPMP related cardiotoxicity was rapidly progressive and fatal whereas liver transplant was therapeutic for ALF. Spontaneous survivors had lower dose ingestion (<17.5 grams), absence of cardiotoxicity, < grade 3 HE, lactate < 5.8, SOFA score < 14.5, and increase in SOFA score by < 5.5. Patients with renal failure need for CVVHDF and KCC positivity on account of PT-INR > 6.5 had higher mortality risk. Patients undergoing liver transplant and with spontaneous recovery required longer ICU and hospital stay. At median follow-up of 3.4 (2.6 - 5.5) years, all spontaneous survivors and transplanted patients are well with normal liver function.

CONCLUSIONS

Early transfer to a specialized center, pre-emptive close monitoring, and intensive care and organ support with ventilation, CVVHDF, plasmapheresis and others may maximize their chances of spontaneous recovery, allow accurate prognostication and a timely liver transplant.

Archimedes Absorbable Internal Biliary Stent in Liver Transplants to Prevent Bile Leak

BACKGROUND

Biliary complications, especially bile leaks, are an important cause of early postoperative morbidity and, rarely, mortality after liver transplant. The risk is higher in living donor liver transplant (LDLT) compared to deceased donor liver transplant (DDLT). Attempts to reduce bile leaks have included refinements in the biliary anastomosis technique and use of various external and internal stents, with inconsistent benefits. Recent availability and successful use of the absorbable Archimedes stent has prompted its intrabiliary placement across the anastomosis.

METHODS

In this retrospective study, we analyzed the data of 20 adult patients who underwent a liver transplant with duct-to-duct biliary anastomosis using the Archimedes stent. Both DDLT and LDLT were performed using cava-preserving hepatectomy followed by standard implantation methods. Duct-to-duct biliary anastomosis was performed in all cases using interrupted sutures with extracorporeal knots over an absorbable intrabiliary stent. In addition to standard postoperative care, patients were monitored for bile leak.

RESULTS

Nine DDLTs had a single anastomosis over a 10-Fr stent. Out of 11 LDLT patients, 7 had a single anastomosis and 4 patients had 2 anastomoses, all over a 6-Fr stent. Two patients died, 1 as a result of graft primary nonfunction and another because of multidrug-resistant pneumonia. One patient had ascending cholangitis owing to stent migration in the duodenum. This episode was treated with endoscopic stent removal and appropriate antibiotics, with good recovery. None of the other patients had bile leaks, biloma, or stent-related complications.

CONCLUSIONS

Archimedes internal absorbable biliary stents can be safely used in both living and deceased donor liver transplants to prevent bile leaks.