Broken Chains and Reneging: A Review of 1748 Kidney Paired Donation Transplants

Concerns regarding the potential for broken chains and "reneges" within kidney paired donation (KPD) and its effect on chain length have been raised previously. Although these concerns have been tested in simulation studies, real-world data have yet to be evaluated. The purpose of this study was to evaluate the actual rate and causes of broken chains within a large KPD program. All patients undergoing renal transplantation through the National Kidney Registry from 2008 through May 2016 were included for analysis. Broken chains and loops were identified. A total of 344 chains and 78 loops were completed during the study period, yielding a total of 1748 transplants. Twenty broken chains and one broken loop were identified. The mean chain length (number of transplants) within broken chains was 4.8 compared with 4.6 of completed chains (p = 0.78). The most common causes of a broken chain were donor medical issues incurred while acting as a bridge donor (n = 8), donors electing not to proceed (n = 6), and kidneys being declined by the recipient surgeon (n = 4). All recipients involved in a broken chain subsequently received a transplant. Based on the results, broken chains are infrequent, are rarely due to lack of donor motivation, and have no significant impact on chain length.

Increased Frequency of BK Virus-Specific Polyfunctional CD8+ T Cells Predict Successful Control of BK Viremia After Kidney Transplantation

BACKGROUND

BK virus infection remains an important cause of loss of allograft function after kidney transplantation. We sought to determine whether polyfunctional T cells secreting multiple cytokines simultaneously, which have been shown to be associated with viral control, could be detected early after start of BK viremia, which would provide insight into the mechanism of successful antiviral control.

METHODS

Peripheral blood mononuclear cells collected during episodes of BK viral replication were evaluated by multiparameter flow cytometry after stimulation by overlapping peptide pools of BK virus antigen to determine frequency of CD8+ and CD4+ T cells expressing 1 or more cytokines simultaneously, as well as markers of T-cell activation, exhaustion, and maturation.

RESULTS

BK virus controllers, defined as those with episodes of BK viremia of 3 months or less, had an 11-fold increase in frequency of CD8+ polyfunctional T cells expressing multiple cytokines, as compared with patients with prolonged episodes of BK viremia. Patients with only low level BK viremia expressed low frequencies of polyfunctional T cells. Polyfunctional T cells were predominantly of the effector memory maturation subtype and expressed the cytotoxicity marker CD107a.

CONCLUSIONS

Noninvasive techniques for immune assessment of peripheral blood can provide insight into the mechanism of control of BK virus replication and may allow for future patient risk stratification and customization of immune suppression at the onset of BK viremia.

Spread of community-acquired meticillin-resistant Staphylococcus aureus skin and soft-tissue infection within a family: implications for antibiotic therapy and prevention

Outbreaks or clusters of community-acquired meticillin-resistant Staphylococcus aureus (CA-MRSA) within families have been reported. We describe a family cluster of CA-MRSA skin and soft-tissue infection where CA-MRSA was suspected because of recurrent infections which failed to respond to flucloxacillin. While the prevalence of CA-MRSA is low worldwide, CA-MRSA should be considered in certain circumstances depending on clinical presentation and risk assessment. Surveillance cultures of family contacts of patients with MRSA should be considered to help establish the prevalence of CA-MRSA and to inform the optimal choice of empiric antibiotic treatment.

Complications of laparoscopic living donor nephrectomy and their management: the UCLA experience

OBJECTIVES

Because of the shortage of cadaveric kidneys, laparoscopic living donor nephrectomy (LLDN) has become a more common option for transplant recipients. The complication rate has been reported at 6.4% to 16.5%. We present the initial University of California, Los Angeles experience with the complications and their management during LLDN.

METHODS

From January 2000 to December 2005, a single surgeon performed 300 consecutive LLDNs at our institution. A committee of urologists, nephrologists, and support staff approved each donor before surgery. After LLDN was completed, the patients received 30 mg of ketorolac intravenously every 6 hours until discharge. We reviewed the intraoperative and postoperative complications and their management at our institution.

RESULTS

Three patients required open conversion, for an overall conversion rate of 1%. Two of the three conversions were a result of a major vascular complication (0.6%). The first major vascular complication resulted from an endovascular stapler malfunction during transection of an accessory left renal artery. The second vascular complication was a Veress needle injury to the left common iliac artery. Three postoperative major complications (1%) occurred, including 1 case of rhabdomyolysis and 2 cases of chylous ascites. Also, 7 minor postoperative complications (2.3%) occurred. Our overall complication rate was 4%. No patients died, and the mean hospital stay was 1.1 days.

CONCLUSIONS

Our results have shown that LLDN is a safe procedure associated with low morbidity and a quick recovery. Appropriate patient selection is essential to ensure the safety of this procedure.