CURRENT STATUS OF RENAL TRANSPLANTATION

Urodynamics prior to renal transplantation--its impact on treatment decision and final results

OBJECTIVE

To evaluate the role of urodynamics prior to renal transplantation in a selected group of patients.

MATERIAL AND METHODS

This retrospective study included 44 consecutive patients (20 males, 24 females; age range 7-57 years; mean age 27.14 +/- 15.17 years) referred for urodynamic evaluation due to known or suspected lower urinary tract dysfunction. End-stage renal disease was due to obstructive uropathy in nine patients, reflux nephropathy in 13, neuropathic bladder in nine and various parenchymal diseases in four; in nine patients the origin of renal failure remained obscure despite detailed investigations. All the patients were subjected to detailed video-urodynamics.

RESULTS

In 30 patients (68.2%) a urodynamic abnormality was found which precluded kidney transplantation into their native bladders without major reconstruction, a minor corrective procedure and/or pharmacotherapy prior to transplantation. More specifically, seven patients were found to have infravesical obstruction, one had a small fibrotic bladder, seven had small capacity bladders due to long-term non-use, four were found on cystometry to have an idiopathic overactive detrusor and 11 exhibited evidence of neurogenic lower urinary tract dysfunction. Fourteen affected patients (32%) were subjected to treatment prior to kidney transplantation: three underwent bladder neck incision, seven recycling of their small bladders, one substitution and three augmentation cystoplasty. Kidney transplantation followed reconstruction 3-18 months later (mean 5 +/- 6.2 months). The follow-up ranged from 12 to 107 months (mean 25 +/- 21 months).

CONCLUSION

Urodynamics prior to kidney transplantation in this selected group of patients established a definitive diagnosis of the type of lower urinary tract dysfunction, offered the opportunity for reconstructive surgery and enabled kidney transplantation.

Effect of family environment and donor source on patient quality of life following renal transplantation

The authors examined the degree to which the supportiveness of a patient's family environment predicts change in quality of life following renal transplantation. The sample consisted of 95 patients receiving renal grafts from either a living donor or a cadaveric donor. Patients were initially assessed prior to transplantation with follow-up assessment occurring an average of 5.5 months after transplantation. Among patients receiving a living-donor kidney, those reporting a more supportive family environment exhibited reduced depression, improved mobility, and improved social functioning. However, those living-donor recipients reporting less family support exhibited increased depression and diminished mobility and social functioning after transplantation. Patients receiving a kidney from a cadaveric donor showed modest improvements in quality of life regardless of the degree of family support.

Predicting change in depression following renal transplantation: effect of patient coping preferences

Improvement in patient quality of life is a central goal of renal transplantation. This study examined the hypothesis that change in depression following transplantation would vary as a function of patient coping preferences. Sixty patients were assessed with the Krantz Health Opinion Survey and the Beck Depression Inventory while on the waiting list for a cadaveric renal transplant. Patients were reassessed approximately 12 months later. Among the 33 patients receiving a transplant during the follow-up period, those with a high preference for health-related information exhibited a substantial reduction in depression. In contrast, patients low in preference for information showed a slight increase in depression. Among the 27 patients who were not transplanted during the follow-up period, preference for information had no effect on depression. Patient differences in preference for behavioral involvement did not exert a significant effect on depression.

Anesthesia for kidney transplant surgery

Organ viability associated with renal transplantation is a product of the managing of the donor patient, the allograft, and the recipient patient. Short- and long-term outcome is influenced by perioperative fluid and drug treatment, and the function and viability of the transplanted kidney seem to be optimized if graft perfusion is maximized through mild hypervolemia. At the same time, careful balancing of intraoperative fluids is necessary against cardiovascular problems frequently encountered in patients with uremia. Close intraoperative monitoring, optimization of intravascular fluid volume status to maximize kidney perfusion, and prompt correction of electrolyte disturbances (especially potassium) are key to short- and long-term success of renal transplants.

Management of renal cell carcinoma in von Hippel-Lindau disease

BACKGROUND

An evaluation of nephron-sparing surgery (NSS) or radical nephrectomy (RN) for treating renal cell carcinoma (RCC) in patients with von Hippel-Lindau disease (VHL) was carried out.

METHODS

Between 1976 and 1997, 10 patients with RCC from four VHL families, of whom seven were from one family, were studied by clinical and histopathological examination. Before 1991, three patients were treated using RN, and thereafter five patients were treated using NSS. Two patients were not operated on.

RESULTS

RCCs in our patients showed a slow growth rate (on average 0.3 cm year-1), and asymptomatic patients presented with tumours of low-grade malignancy. In all patients, tumours were surrounded by a fibrous pseudocapsule. In 5 out of 17 tumours, pseudocapsular invasion was observed, and three of these five tumours broke through the pseudocapsule. To date, these patients have not shown a less favourable outcome than those without pseudocapsular involvement by tumour growth. Multicentricity of RCC was relatively low (4.6 lesions per kidney). In two of the three RN patients, only a single satellite lesion, in the direct vicinity of a RCC, was found in one kidney. Six tumours (1.8-5.5 cm) were enucleated by NSS. During a mean follow-up of 30 months, renal function in these patients was well preserved.

CONCLUSIONS

In our patients, RCCs grew slowly, were of low grade, had a dense fibrous pseudocapsule and were thus good candidates for NSS.

Anesthesia for Renal Transplantation

Renal transplantation is the preferred mode of replace ment therapy for most patients with end-stage renal disease (ESRD) and accounts for nearly 60% of all organ transplants in the United States. While as many as 35,000 people remain on the list waiting to receive a cadaveric kidney, living-related renal transplantation offers a shorter waiting period and greater survival. Maximization of the health of the kidney recipient before transplantation can improve ultimate outcome. Proper anesthetic management is facilitated by under standing the physiology and pharmacology of ESRD. Maintaining intraoperative blood volume is a key to good graft function, especially the living-related pediat ric kidney recipient. Recent improvements in combined immnosuppression therapy have improved the overall outcome in transplant recipients. The average 3-year survival is nearly 75%.

Maintenance therapy with triple versus double immunosuppressive regimen in renal transplantation: a meta-analysis

BACKGROUND

The purpose of this study was to compare the effect of triple immunosuppressive maintenance therapy (cyclosporine, azathioprine, and prednisolone) with that of double therapy (cyclosporine and prednisolone) in renal transplant patients using graft failure, mortality, and acute rejection episodes as outcome measures.

METHODS

A systematic overview of articles published between 1984 and 1995 was done. MEDLINE, Science Citation Index, reference lists, and expert files were searched. Of 449 originally identified studies, five controlled trials were finally selected. Information was retrieved on the topics of methodological quality, baseline characteristics, interventions, and outcomes. The Mantel-Haenszel fixed effect method was used to combine results from different studies.

RESULTS

Pooled analysis did not show a statistically significant difference between triple-drug therapy and double-drug therapy in the main outcome of graft failure (odds ratio [OR], 0.82; 95% confidence interval [CI], 0.61-1.16), survival (OR, 0.83; 95% CI, 0.57-1.21), or the occurrence of acute graft rejection (OR, 1.02; 95% CI, 0.76-1.36). There was a nonsignificant trend for better graft survival under triple therapy. A lower withdrawal rate suggests a more stable immunosuppressive effect on triple therapy.

CONCLUSIONS

There is no statistically significant difference in the long-term management of renal transplant recipients between the two treatment regimens.

Evaluation of voiding cystourethrography prior to renal transplantation

In many centers, voiding cystourethrography is a routine part of pretransplantation assessment of the lower urinary tract. To assess the value of this investigation, a retrospective review of transplant candidates evaluated in our center over 2 years was undertaken. A total of 517 patients were fully evaluable. Only 13 voiding cystourethrograms (VCUGs) (2.5%) of 517 were found to be abnormal. Three patients with reflux alone did not require intervention before transplantation. Four patients with decreased bladder capacity underwent hydrodistention. Two patients increased their capacity to over 150 ml and two patients failed distention, one requiring an ileal conduit and the other requiring an augmentation cystoplasty. Three patients had increased postvoid residual (PVR). Two patients started clean intermittent catheterization. One required prostate resection for benign prostatic hypertrophy. One patient with reflux and decreased bladder capacity refused treatment. One patient with reflux combined with increased PVR started clean intermittent catheterization and was cleared for transplant surgery. One patient with decreased bladder capacity and increased PVR had a stroke and was excluded from transplantation. All 13 patients with abnormal VCUGs had a prior urologic history. In total, only 56 of 517 patients evaluated had a prior urological history. Each VCUG costs approximately $500. Limiting VCUG studies to those patients with a prior urological history would have resulted in a significant cost savings. Hence, we recommend that only patients with a prior urological history should undergo this costly and often distressing examination.