Surgical complications of 269 living kidney donor transplants

Stented Lich–Gregoir ureteroneocystostomy: Case series report and cost-effectiveness analysis

Extravesical ureteroneocystostomy to reestablish urinary tract continuity in renal transplantation has been examined through a meta-analysis of more than 14,000 kidney transplants leading to the finding that stented anastomosis was associated with a lower urologic complication rate compared with nonstented anastomoses. Fourteen stents must be used to prevent one urologic complication. We now report the urologic complication rate in our case series in which a stented Lich-Gregoir anastomosis was routinely utilized. We present a cost-effectiveness analysis regarding the usage of ureteral stents.

METHODS

The records of 395 consecutive renal transplants were reviewed. Minimum follow-up time was 6 months. The standard anastomosis was a Lich-Gregoir with a 6- or 8-F 12- or 14-cm J-J stent. Monitored urologic complications included postoperative vesicoureteral leak or ureteral necrosis, obstruction or stricture, or clinically significant hematuria. Charges in 2004 US dollars were reported by the hospital accounting office.

RESULTS

Four urologic complications were noted-three leaks and one stricture (complication rate of 1.0%). There were no stent-related complications requiring reoperation. There were no cases in which the urologic complication led to graft loss or patient death. Total charges associated with stent use were $1,087 per patient, or $15,218 per urologic complication prevented.

CONCLUSIONS

The urologic complication rate in this case series is similar to the five previously published randomized trials, as well as our previously published meta-analysis. These results support the routine use of a ureteral stent. Our analysis suggests that stent use is cost effective.

Stented versus nonstented extravesical ureteroneocystostomy in renal transplantation: a metaanalysis

Stenting of the extravesical ureteroneocystostomy in renal transplantation is controversial. This study is a metaanalysis of 49 published studies over 30 years time in which the extravesical technique was used. Stented and nonstented anastomoses were compared. One-hundred six articles published between 1973 and 2002 were reviewed and 49 met criteria for inclusion. Articles were required to list original, numeric, previously unpublished data and to report or to describe the use of an extravesical ureteroneocystostomy, with or without stent. Data were analyzed within separate groups, (1) randomized, controlled trials and (2) case series. Data were included from five randomized, controlled trials and 44 case series. In the controlled trials group, there were urologic complications in 6 of 407 stented (1.5%), and 35 of 389 nonstented subjects (9.0%) (p < 0.0001, OR 0.24, 95% CI 0.10-0.57). In the case-series group, there were urologic complications in 137 of 4245 stented (3.2%) and 433 of 9077 nonstented subjects (4.8%) (p = 0.007, OR 0.58, 95% CI 0.39-0.86). Renal transplants with stented extravesical ureteroneocystostomy have a significantly lower urologic complication rate than those with nonstented anastomoses. All five randomized, controlled trials individually found stented anastomoses to have a lower complication rate and this was confirmed by metaanalysis of these trials and of case-series data.

[Surgical aspects of kidney transplantation in children (study of 148 cases)]

OBJECTIVE

Kidney transplantation is the best treatment for end-stage renal disease. This procedure is by now routinely used and permits children survival and rehabilitation. We describe the surgical complications of kidney graft in our paediatric experience.

MATERIALS AND METHODS

From April 1987 to August 2000, 175 kidney transplantation were proceeded in the department of urology and transplantation in Edouard Herriot Hospital (Lyon). Twenty-nine kidneys (17%) were from living related donors and 146 (83%) were from cadaveric donors. We evaluated 148 kidney transplantation (132 patients) in 79 male and 53 female children. Mean age was ten years (range: seven months to 18 years). Twelve allografts were from living related donors and 136 cadaveric donors.

RESULTS

Twelve patients died of various medical complications. One patient was lost of sight. Surgical complications were postoperative bleeding, lymphocele, urologic and digestive troubles. The rest of our patients had uneventful evolution.

CONCLUSION

A general commitment is the only way to promote organ donation and enable patients with terminal renal failure to have access to renal transplantation.

Issues in Islamic biomedical ethics: a primer for the pediatrician

The United States is becoming increasingly pluralistic. Pediatricians must become familiar with the factors that affect the emotional, physical, and spiritual health of their patients that are outside the kin of the traditionally dominant value system. Although many articles have addressed the cultural and ethnic factors, very few have considered the impact of religion. Islam, as the largest and fastest-growing religion in the world, has adherent throughout the world, including the United States, with 50% of US Muslims being indigenous converts. Islam presents a complete moral, ethical, and medical framework that, while it sometimes concurs, at times diverges or even conflicts with the US secular ethical framework. This article introduces the pediatrician to the Islamic principles of ethics within the field of pediatric care and child-rearing. It demonstrates how these principles may impact outpatient and inpatient care. Special attention is also given to adolescent and end-of-life issues.

Pancreas after kidney transplants

BACKGROUND

For certain uremic diabetic patients, a sequential transplant of a kidney (usually from a living donor) followed by a cadaver pancreas has become an attractive alternative to a simultaneous transplant of both organs. The purpose of this study was to compare outcomes with simultaneous pancreas-kidney (SPK) versus pancreas after kidney (PAK) transplants to determine advantages and disadvantages of the two procedures.

METHODS

Between January 1, 1994, and June 30, 2000, we performed 398 cadaver pancreas transplants at our center. Of these, 193 were SPK transplants and 205 were PAK transplants. We compared these two groups with regard to several endpoints, including patient and graft survival rates, surgical complications, acute rejection rates, waiting times, length of hospital stay, and quality of life.

RESULTS

Overall, surgical complications were more common for SPK recipients. The total relaparotomy rate was 25.9% for SPK recipients versus 15.1% for PAK recipients (P = 0.006). Leaks, intraabdominal infections, and wound infections were all significantly more common in SPK recipients (P = 0.009, P = 0.05, and P = 0.01, respectively, versus PAK recipients). Short-term pancreas graft survival rates were similar between the two groups: at 1 year posttransplant, 78.0% for SPK recipients and 77.9% for PAK recipients (P = not significant). By 3 years, however, pancreas graft survival differed between the two groups (74.1% for SPK and 61.7% for PAK recipients), although this did not quite reach statistical significance (P = 0.15). This difference in graft survival seemed to be due to increased immunologic losses for PAK recipients: at 3 years posttransplant, the incidence of immunologic graft loss was 16.2% for PAK versus 5.2% for SPK recipients (P = 0.01). Kidney graft survival rates were, however, better for PAK recipients. At 3 years after their kidney transplant, kidney graft survival rates were 83.6% for SPK and 94.6% for PAK recipients (P = 0.001). The mean waiting time to receive the pancreas transplant was 244 days for SPK and 167 days for PAK recipients (P = 0.001).

CONCLUSIONS

PAK transplants are a viable option for uremic diabetics. While long-term pancreas graft results are slightly inferior to SPK transplants, the advantages of PAK transplants include the possibility of a preemptive living donor kidney transplant, better long-term kidney graft survival, significantly decreased waiting times, and decreased surgical complication rates. Use of a living donor for the kidney transplant expands the donor pool. Improvements in immunosuppressive regimens will hopefully eliminate some of the difference in long-term pancreas graft survival between SPK and PAK transplants.