Long-term quality of life after living kidney donation

BACKGROUND

The supply of deceased donor kidneys available for transplantation is not sufficient to meet the demand. Despite a low rate of complications for donors and superior outcomes for recipients, living kidney donation (LKD) is on the decline for reasons that remain unclear.

METHODS

We performed a retrospective review and analysis of living kidney donors (LDs) who underwent donor nephrectomy between January 1, 2000 and December 31, 2010. Candidates who were excluded from LKD were identified as control subjects (CSs). LDs and CSs were invited to voluntarily undergo a quality of life assessment using Short Form 12 v1.0 Questionnaire (SF-12) and an addendum questionnaire (AQ). The SF-12 and AQ were administered by telephone. Statistical analysis of the results was performed to obtain the SF-12 physical component score (PCS), SF-12 mental component score (MCS), and the AQ score. PCS and MCS for the general population were obtained from the 1998 National Survey of Functional Health Status.

RESULTS

During the study period, 83 LDs and 116 CSs were interviewed. LDs were noted to have higher PCS (54.1 vs 49.6) and MCS (55.7 vs 49.4) compared with the general population. Ninety-nine percent of LDs believed that their quality of life did not decrease after LKD; 21.7% reported experiencing complications. Half of the LDs (48%) reported missing 1 day of work for evaluation; 71% of LDs reported missing at least 4 weeks of work after LKD. Nearly all LDs (99%) would undergo donation again. Fifty-two percent of LDs reported adhering to the recommended 2-year follow-up schedule with the transplantation team; 87% of LDs reported seeing their primary care physician.

CONCLUSION

LDs are physically and mentally healthier after LKD compared to the general population. Most donors miss at least 1 month of work for LKD and undergo some form of post-donation monitoring. Despite this commitment, LKD is a very satisfying experience.

Antithymocyte antibody-induced coagulopathy in renal transplant recipients

BACKGROUND

Antithymocyte antibody (ATA) remains the most commonly used induction immunosuppressive agent in renal transplantation (RT). To date, few case reports of ATA-induced coagulopathy exist.

METHODS

We performed a single-center, retrospective analysis of renal transplant recipients (RTRs) who underwent RT followed by ATA therapy between 2007 and 2011. The protocol used for deceased donor and unrelated living donor recipient immunosuppression was Thymoglobulin (TMG), methylprednisolone, Cellcept, Prograf, and Rapamune. In related living donor recipients, Simulect (SIM) was substituted for TMG. The international normalized ratio (INR) was routinely checked on days 0 and 2, and thereafter at the discretion of the surgeon. RTRs were transfused packed red blood cells (PRBCs) or fresh frozen plasma (FFP) at the discretion of the surgeon.

RESULTS

During the study period, 257 RTs were performed at our institution. The following 18 RTR were excluded: simultaneous kidney and pancreas transplant recipients (4), RTRs on warfarin at the time of admission (2), RTRs who received OKT3 (2), and RTRs with INR ≥ 1.2 at the time of admission (10). Of the remaining 239 RTR, 208 (87%) underwent TMG induction therapy; 31 RTR (13%) underwent SIM induction therapy. The mean INR peaked in both groups on day 4 but was higher in TMG recipients (TMG 1.35, SIM 1.20). FFP was transfused in 65 TMG (31%) and 3 SIM (10%) recipients (P = .01); PRBCs were transfused in 88 TMG (44%) and 6 SIM (19%) recipients (P = .02). No patients returned to the operating room for bleeding complications within 7 days of RT. Patient age, gender, ethnicity, and diabetes status were not statistically significant factors in the development of coagulopathy.

CONCLUSION

TMG administration is associated with coagulopathy. Using an INR screening protocol and an aggressive transfusion protocol, bleeding complications associated with coagulopathy can be avoided in this higher-risk group.

Effect of preoperative sonographic mapping on vascular access outcomes in hemodialysis patients

BACKGROUND

Current DOQI guidelines encourage placing arteriovenous (AV) fistulas in more hemodialysis patients. However, many new fistulas fail to mature sufficiently to be usable for hemodialysis. Preoperative vascular mapping to identify suitable vessels may improve vascular access outcomes. The present study prospectively evaluated the effect of routine preoperative vascular mapping on the type of vascular accesses placed and their outcomes.

METHODS

During a 17-month period, preoperative sonographic evaluation of the upper extremity arteries and veins was obtained routinely. The surgeons used the information obtained to plan the vascular access procedure. The types of access placed, their initial adequacy for dialysis, and their long-term outcomes were compared to institutional historical controls placed on the basis of physical examination alone.

RESULTS

The proportion of fistulas placed increased from 34% during the historical control period to 64% with preoperative vascular mapping (P < 0.001). When all fistulas were assessed, the initial adequacy rate for dialysis increased mildly from 46 to 54% (P = 0.34). For the subset of forearm fistulas, the initial adequacy increased substantially from 34 to 54% (P = 0.06); the greatest improvement occurred among women (from 7 to 36%, P = 0.06) and diabetic patients (from 21 to 50%, P = 0.055). In contrast, the initial adequacy rate of upper arm fistulas was not improved by preoperative vascular mapping (59 vs. 56%, P = 0.75). Primary access failure was higher for fistulas than grafts (46.4 vs. 20.6%, P = 0.001), but the subsequent long-term failure rate was higher for grafts than fistulas (P < 0.05). Moreover, grafts required a threefold higher intervention rate (1.67 vs. 0.57 per year, P < 0.001) to maintain their patency. The overall effect of this strategy was to double the proportion of patients dialyzing with a fistula in our population from 16 to 34% (P < 0.001).

CONCLUSIONS

Routine preoperative vascular mapping results in a marked increase in placement of AV fistulas, as well as an improvement in the adequacy of forearm fistulas for dialysis. This approach resulted in a substantial increase in the proportion of patients dialyzing with a fistula in our patient population. Fistulas have a higher primary failure rate than grafts, but have a lower subsequent failure rate and require fewer procedures to maintain their long-term patency.

Risk and benefit of coronary revascularization in renal transplant candidates

The field of transplantation along with all of medicine has made tremendous progress in the past 30 years. Patients with end-stage renal disease are managed more effectively despite increasing chronic multisystemic comorbidities, particularly involving their cardiovascular system. These same patients are also undergoing renal transplant surgery with better short- and long-term results than any era previous. We will present some of the changing demographics encountered in today's renal transplant candidates along with the processes our institution is undertaking to optimize the patient's success with the renal allograft, particularly with respect to the diagnosis and therapeutics used to manage coronary artery disease.

Improved outcomes in cadaveric renal allografts with pulsatile preservation

BACKGROUND

Early immunologic and non-immunologic injury of renal allografts adversely affects long-term graft survival. Some degree of preservation injury is inevitable in cadaveric renal transplantation, and, with the reduction in early acute rejection, this non-immunologic injury has assumed a greater relative importance. Optimal graft preservation will maximize the chances of early graft function and long-term graft survival, but the best method of preservation pulsatile perfusion (PP) versus cold storage (CS) is debated.

METHODS

Primary cadaveric kidney recipients from January 1990 through December 1995 were evaluated. The effects of implantation warm ischemic time (WIT) ( < or = 20 min, 21-40 min, or > 40 min) and total ischemic time (TIT) ( < or > or = 20 h) on death-censored graft survival were compared between kidneys preserved by PP versus those preserved by CS. The effect of preservation method on delayed graft function (DGF) was also examined.

RESULTS

There were 568 PP kidneys and 268 CS kidneys. Overall death-censored graft survival was not significantly different between groups, despite worse donor and recipient characteristics in the PP group. CS kidneys with an implantation WIT > 40 min had worse graft survival than those with < 40 min (p = 0.0004). Survival of PP kidneys and those transplanted into 2 DR-matched recipients was not affected by longer implantation WIT. Longer TIT did not impact survival. DGF was more likely after CS preservation (20.2% versus 8.8%, p = 0.001).

CONCLUSIONS

Preservation with PP improves early graft function and lessens the adverse effect of increased warm ischemia in cadaveric renal transplantation. This method is likely associated with less preservation injury and/or increases the threshold for injury from other sources and is superior to CS.

US vascular mapping before hemodialysis access placement

PURPOSE

To prospectively assess the effect of preoperative ultrasonographic (US) mapping on surgical selection, placement of arteriovenous fistulas (AVFs) and grafts, and negative surgical exploration rates.

MATERIALS AND METHODS

US assessment of the upper extremity arterial and venous anatomy was performed in 70 patients with chronic renal failure before surgical evaluation. The surgeon documented the planned access procedure, which was based on physical examination results, and then reviewed the US preoperative mapping report. The surgical procedure and outcome were recorded.

RESULTS

Fifty-two of the 70 patients who underwent mapping had vascular access placement. Preoperative US mapping resulted in a change in the planned surgical procedure in 16 (31%) of the 52 patients. An AVF rather than the planned graft was placed in eight (15%) patients. The AVF placement rate increased from 32% (126 of 395 patients) to 58% (30 of 52 patients). Unsuccessful surgical explorations decreased from 11% (28 of 256) to 0%.

CONCLUSION

Preoperative US mapping before hemodialysis access placement can result in a change in surgical management, with an increased number of AVFs placed and an improved likelihood of selecting the most functional vessels preoperatively. Further study is needed to determine longer term outcomes.

Renal retransplantation at the University of Alabama at Birmingham: incidence and outcome

Only half the patients who lost a renal allograft either returned to the waiting list (32%) or were retransplanted (17%). One fifth died soon after allograft loss. Patients did not return to the waiting list for multiple reasons including patient choice, worsened medical condition and most commonly, interest but non-referral. Diabetics had a significantly diminished chance for survival on dialysis after graft loss. African-Americans had a better chance of survival after graft loss but a much worse opportunity to be retransplanted. The use of CellCept in triple immunosuppressive therapy, along with a flow cytometry crossmatch, has improved retransplant allograft survival commensurate with primary graft outcome. The incidence of retransplantation is decreasing at our institution even though the number of potential candidates for retransplantation remains stable.

Placement of a double lumen silastic catheter for hemodialysis access through the cephalic vein

The cephalic vein within the deltopectoral groove provides adequate access to the central venous system for the PermCath hemodialysis catheter. Unlike EJV techniques, which are successful in few instances, the cephalic vein approach was successful in approximately 75 percent of instances. In addition, the rate of complications secondary to bleeding or catheter kinking are decreased with the cephalic vein technique as compared with insertion through the EJV or IJV. We conclude that the cephalic vein is a dependable and functional approach to the central venous system for the PermCath hemodialysis catheter.