Comparison of Renal Growth, Proteinuria and Graft Survival between Recipients of Pediatric and Adult Cadaveric Kidney Transplants

BACKGROUND

The shortage of cadaveric kidney donors has prompted transplant teams to expanding the donor selection criteria. The usage of pediatric cadaveric kidneys is one of those expanded criteria. But the main concern is the probability of hyperfiltration syndrome due to small renal mass of pediatric donors.

OBJECTIVE

To compare the graft and patient survivals, post-transplantation complications, rate and severity of proteinuria secondary to hyperfiltration injury and the kidney growth of recipients who underwent transplantation from adult (group 1) and pediatric deceased donors (group 2).

METHODS

In this historical cohort study, each group contains 36 patients. Outcome measures included patient and graft survivals, quality of graft function as assessed by serum creatinine (SCr) and estimated GFR (eGFR), surgical complications, proteinuria that was detected by routine urinalysis and then confirmed by a 24-h urine protein >150 mg, blood pressure, and kidney length and volume measured by early and follow-up ultrasonography.

RESULTS

The mean donor age in groups 1 and 2 was 36 and 6.5 years, respectively. 9 (25%) kidneys taken from pediatric donors (group 2) were offered en-bloc. The mean follow-up was 28 month. The two groups were not significantly different in terms of the incidence of DGF, rate of acute rejection, 1-year graft survival, SCr and eGFR levels, rates of surgical complications requiring surgical interventions, development of proteinuria, and rate of post-transplantation rise in blood pressure. The mean±SD kidney length within 24 hours of transplantation was significantly higher in group 1 compared to group 2 recipients (112±14 vs. 75±12 mm; p=0.001), but the rate of increase in kidney length in group 2 was significantly higher than that in group 1 recipients (43±4 vs. 10±2 mm; p=0.002) during the follow-up period. 80% of the increase in the kidney size was observed during the first 12 months of surgery; another 20% happened between 12 and 18 months.

CONCLUSION

We found that obligatory and compensatory growth of pediatric kidney donors can overcome the concern of hyperfiltration syndrome and that the outcome is the same as adult donors.

Association of polymorphisms in PRKCI gene and risk of prostate cancer in a sample of Iranian Population

The atypical protein kinase C iota (aPKCι) is an oncoprotein encoded by the PRKCI gene. It has been reported to play multifunctional roles in cellular maintenance, cell proliferation, survival, differentiation and apoptosis. In the present study we aimed to assess the impact of PRKCI rs546950 C>T and rs4955720 C>A polymorphisms on prostate cancer (PCa) risk in a sample of Iranian population. This case-control study was done on 169 patients with pathologically confirmed PCa and 182 benign prostatic hyperplasia (BPH). The PCR-RFLP method was used for detection rs546950 C>T and rs4955720 C>A polymorphisms. Our findings showed that rs546950 polymorphism of PRKCI decreased the risk of PCa in codominant (OR=0.35, 95%CI=0.19-0.64, P<0.001, CT vs CC) and dominant (OR=0.39, 95%CI=0.22-0.69, P=0.001, CT+TT vs CC) inheritance model tested. No significant association was found between rs4955720 C>A polymorphism and PCa. In the combined analysis of these two variants subjects carrying CT/CC, CT/CA, TT/AA and CT/AA significantly decreased the risk of PCa in comparison with rs546950 CC/rs4955720 CC genotype. Haplotype analysis indicated that rs546950T/rs4955720A decreased the risk of PCa compared to CC. In conclusion, the results revealed that PRKCI rs546950 variant decreased the risk of PCa in an Iranian population. Further studies with larger sample sizes and different ethnicities are required to confirm our findings.

Comparison of surgical outcomes and cosmetic results between standard and mini laparoscopic pyeloplasty in children younger than 1 year of age

OBJECTIVE

To evaluate safety, efficacy, and cosmetic results after mini laparoscopic (mL) pyeloplasty and standard (sL) pyeloplasty in children younger than 1 year of age with ureteropelvic junction obstruction (UPJO).

MATERIALS AND METHODS

From August 2009 to March 2011, 20 sL pyeloplasties were performed in pediatric patients younger than 1 year of age; afterwards, 20 patients younger than 1 year of age underwent mini laparoscopic (mL) pyeloplasty from June 2011 to August 2012. The patients were followed by urine culture and ultrasonography at 3 and 6 months after surgery. Cosmetic appearance was assessed in all patients in both groups group 3 months after surgery using the Patient Scar Assessment Questionnaire.

RESULTS

Peri and postoperative results revealed that operative time (total and anastomosis of ureteropelvic junction), hospital stay, and overall complication rate were significantly lower in mL than in sL. Persistent hydronephrosis in follow-up imaging and recurrence of obstruction was not observed in any cases. Mean appearance score and consciousness score showed significantly better results in the mL group.

CONCLUSION

We believe that mL pyeloplasty in infant cases with UPJO is more cosmetically pleasing and less invasive than sL pyeloplasty and has similar functional outcomes.

Cadaver transplantation in Recent Era: Is Cadaveric Graft Survival Similar to Living Kidney Transplantation?

BACKGROUND

Renal transplantation is the procedure of choice for most of patients with end-stage renal disease. The graft, however can be procured from either cadaver or living donors.

OBJECTIVE

To compare graft and patient survival among patients who underwent kidney transplantation from cadaver donor vs. living donor.

METHODS

From April 2002 to February 2010, we performed 138 cadaver kidney transplantations. We reviewed and compared one-year graft and patient survival with 138 living kidney transplantations.

RESULTS

One-year graft and patient survivals in cadaveric groups were 93% and 96%, respectively, and in living groups were 92% and 97%, respectively.

CONCLUSION

There was no significant difference in one-year graft and patient survival between living and cadaver donor kidney transplantation.

The impact of hepatitis B infection on outcome of kidney transplantation: a long-term study

BACKGROUND

With the success of kidney transplantation, liver disease has emerged as an important cause of morbidity and mortality in kidney recipients.

OBJECTIVE

To determine the impact of hepatitis B virus (HBV) infection on patients and graft survival in both short- and long-terms.

METHODS

99 renal transplant patients infected with HBV on follow-up in two major transplant centers were included in a retrospective study. These patients were grafted between 1986 and 2005 and divided into two groups: (1) those only positive for hepatitis B surface antigen (HBsAg) and (2) those who were also positive for hepatitis C virus antibodies (HCV Ab).

RESULTS

There were 88 patients with HBsAg(+) and 11 with both HBsAg(+) and HCV Ab(+). The mean±SD age of patients was 38.8±13.2 years, and the median follow-up after transplantation was 19 months. Although not significant, the allograft survival rate in the first group (HBV(+)) was better compared to that in the second group (HBV(+) and HCV(+)); 1, 5 and 10 years graft survival rates were 91, 77 and 62 in the first group and 70, 56 and 28 in the second group, respectively (P=0.07). The overall mortality was 5% (4 of 88) in the first and 27% (3 of 11) in the second group (P=0.02).

CONCLUSION

Renal allograft recipients with HBV and HCV infections has a poor survival rate compared to patients with only HBV infection. However, there is no significant difference in terms of renal graft survival between the two groups.

Ureteroscopic management of urological complications after renal transplantation

OBJECTIVE

To determine the feasibility, safety and efficacy of diagnostic and therapeutic ureteroscopy in renal allograft ureters.

MATERIAL AND METHODS

We reviewed 1560 consecutive renal allografts performed between June 1989 and February 2002. A total of 28 patients (1.8%) had indications for an endoscopic procedure on the allograft ureter, as follows: obstructive ureteral calculi with a history of failed extracorporeal shock-wave lithotripsy, n=6; suspected ureteral stricture, n=3; upwardly migrated ureteral stents, n=9; and ureteral stricture at the ureteroneocystostomy site, n=10. Ureters were anastomosed to the bladder using the Leadbetter-Politano and Lich-Gregoire methods in six and 22 cases, respectively. Ureteroscopies were performed with a semi-rigid 9.8 F Wolf ureteroscope.

RESULTS

Identification of the ureteral orifice and insertion of a guide-wire into it was successful in 19 cases (68%). If we exclude the 10 patients with ureteral stricture, ureteroscopy was successful in 13/18 cases (72%). Four ureteral calculi (67%) were removed with the ureteroscope. Seven out of nine migrated stents (78%) were retrieved. Four patients with ureteral stricture at the ureteroneocystostomy site (40%) underwent successful ureteral dilatation and double-J ureteral catheters were also inserted. Diagnostic ureteroscopy was successful in all cases. Two complications (one urinary leakage and one symptomatic urinary tract infection) occurred and were managed conservatively.

CONCLUSIONS

Ureteral endoscopy is a safe and effective method for the management of urological complications after renal transplantation. This procedure can be considered the first choice, in preference to percutaneous and antegrade modalities.

The risk factors and laboratory diagnostics for post renal transplant tuberculosis: a case-control, country-wide study on definitive cases

BACKGROUND

Tuberculosis (TB) is an important cause of morbidity and mortality in renal transplant recipients and, because of its infrequency and the lack of medical awareness, it is usually misdiagnosed. This study was carried out to determine frequency and weight of multiple risk factors for post kidney transplantation TB.

METHODS

A total of 44 cases (0.3%), out of 12,820 patients from 12 major kidney transplantation centers in Iran from 1984 to 2003, were compared with 184 healthy transplant subjects who were transplanted by the same surgical team.

RESULTS

The mean age of cases and controls was 37.7 (13-63) and 35.6 (8-67) years (P=0.3), respectively. The mean duration of pre-transplantation hemodialysis was 30.3 (3-168) months in cases and 18.2 (1-180) months in controls (P=0.03). A positive past history of TB was detected in 2 cases and 1 control (P=0.3). The mean doses of initial and maintenance immunosuppressive drugs in cases and controls were not significantly different. A total of 25 cases (56.8%) and 60 controls (32.6%) had rejection before diagnosis of TB (P=0.004; OR=2.7, CI(95%): 1.3-5.6).

CONCLUSIONS

To our knowledge, this is the first study that demonstrated an increase in the risk of post-transplant TB by increasing the duration of pre-transplant hemodialysis and the number of post-transplant rejection episodes as 2 immunocompromised states. Further study is needed to clarify our new findings, specifically in relation to different immunosuppressive regimens.

Transplantation research in Iran: a bibliometric study

BACKGROUND

Scientific articles are indicators of research interest and efforts in every country. The aim of the current study is to describe the characteristics of the transplantation-related research efforts with respect to the domestic published works in Iran between 1993 and 2003.

MATERIALS AND METHODS

In a descriptive design, we searched IranMedex (Iranian database for indexing medical articles; available at: http//www.iranmedex.com) for all the biomedical articles published between 1993 and 2003 in 91 Iranian journals. The search was conducted using "transplantation" and "transplant" as key words. A printed copy of the references was reviewed individually so as to identify the transplanted organ, study design, number of authors, and type of article.

RESULTS

Among 11371 articles, 545 (4.8%) were related to transplantation. An increasing trend was observed in the number of publications from 1993 to 2003. Most articles were published in Farsi (90%). The most frequently published articles were original articles (84.4%). The main subjects of were kidney (61.7%), followed by liver (12%) and bone marrow transplantation (10.8%). Cornea was the topic of research in only 3% of the papers. Of all manuscripts, 9.5% consisted of clinical trials. The mean number of authors was 3.6 +/- 2.2 (1 to 14).

CONCLUSIONS

Iranian researchers seem to be interested in the topic of transplantation; however, some fields of transplantation are neglected. This pooling of valuable information can be used by other countries, especially by researchers from the Middle East Society for Organ Transplantation region. Such databases could form an invaluable network for an exchange of experience in the region to solve common problems.

Iranian Model of Renal Allograft Transplantation In 3028 Recipients: Survival and Risk Factors

BACKGROUND

Considering the organ shortage crisis for renal transplantation worldwide, assessing the risk factors to establish better allocation strategies to improve graft survival seems to be crucial.

OBJECTIVES

We aimed to evaluate the risk factors influencing graft and patient survival after renal transplantation to construct a model of prognostic factors for living renal transplantation (LRT), namely living unrelated renal transplantation (LURT).

METHODS

We designed a retrospective multicenter survey including medical record review of 3028 patients who received renal transplants at 2 hospitals between July 1984 and December 2005. We assessed the impact on graft survival of recipient/donor relationship, recipient age and gender, donor age and gender, and viral hepatitis B and C infections.

RESULTS

Among 3028 recipients, including 94.8% primary grafts, 63.4% were men, mean +/- SE of age 36.4 +/- 0.3 years, with mostly end-stage renal disease due to diabetes mellitus, hypertension, or glomerulonephritis. One-, 5-, 10- and 15-year graft survival rates were 85.4%, 68.3%, 46.4%, and 23.8%, respectively. Patient survival rates were 93.4%, 87.5%, 79.4%, and 66.4% at the above intervals, respectively. Donor age (relative hazard [RH], 1.024; P<.001), unrelated donors (RH, 1.7; P<.001), and hepatitis C virus (HCV) infection (RH, 2.65; P<.001) were the only significant factors affecting graft survival.

CONCLUSION

Increased donor age, unrelated donor, and HCV infection were significant factors negatively impacting graft survival; thus, proper management of these factors may lead to better graft and patient survival.

Cyclosporine Trough (C0) and 2-Hour Postdose (C2) Levels: Which One Is a Predictor of Graft Loss?

BACKGROUND

Compared with conventionally measured trough level (C0), cyclosporine 2-hour postdose (C2) concentrations show a better correlation with the area under the curve and acute graft rejection.

OBJECTIVES

We evaluated the relationships of C0 and C2 with long-term graft survival among kidney transplant recipients.

METHODS

In a case-control design, we selected 215 adult kidney recipients. Inclusion criteria were more than 18 years of age at transplantation and at least 6 months of follow-up. The case group consisted of patients with graft loss (n=17) and a control group, patients with functioning grafts (n=198). The C0 and C2 levels for the first 6 months posttransplantation, along with demographic and clinical data, were compared between the two groups using univariate analysis. P<.05 was considered to be significant.

RESULTS

The mean age at transplantation was 40.5 +/- 16.5 years. The mean follow-up duration was 18 +/- 14 months. The mean C0 values for the case and control groups were 257.8 +/- 126.5 and 248.5 +/- 104.4 mumol/L, respectively (P>.05). The values for C2 were 712.7 +/- 273.2 and 886.2 +/- 266.9 mumol/L, respectively (P=.01).

CONCLUSIONS

We observed that C2, but not C0, in the first 6 months posttransplantation were a predictor of long-term graft survival. The findings here in supported the results of other studies that have proposed cyclosporine concentration monitoring by C2 rather than C0 measurements.

The Outcome of Diverticulosis in Kidney Recipients With Polycystic Kidney Disease

INTRODUCTION

Diverticulosis is a common finding in autosomal-dominant polycystic kidney disease (ADPKD). To avoid the serious complications of diverticulosis after kidney transplantation, some policies have recommended aggressive actions, such as elective colectomy. These policies are not widely agreed upon. This controversy led us to investigate the serious complications and the outcome of diverticulosis in ADPKD kidney recipients to see whether such therapies are justified.

MATERIALS AND METHODS

From 2002 to 2006, we followed 18 ADPKD kidney recipient patients with barium enema-documented diverticulosis. All subjects were asymptomatic for diverticulosis at the time of transplantation. The mean value +/- SD of follow-up duration was 25.4 +/- 28.5 months. We documented demographic data, familial history of ADPKD, barium enema findings, and complications as well as graft and patient survivals.

RESULTS

Hepatic flexure was the most prevalent site for diverticula. The mean (SD) of diverticular count was 6 +/- 5.1. Patients with a familial history of ADPKD showed a higher number of diverticular (P=.01). Diverticulitis occurred in three patients, all of whom died.

CONCLUSION

Diverticulitis is a fatal and not rare complication in ADPKD patients. The rate of complications in our study was similar to previous findings, but we observed serious complications even among patients asymptomatic at the time of transplantation. The decision to take aggressive action such as elective colectomy is still a matter of debate that needs further evaluation.

The Cost of Kidney Transplantation in Iran

BACKGROUND

Kidney transplantation has gained widespread popularity by improving the outcome of end-stage renal disease (ESRD) patients. However, this is a highly complicated and expensive procedure that puts much pressure on the health system in developing countries. We report the costs in Iran model of kidney transplantation.

MATERIALS AND METHODS

We reviewed the regulations for kidney transplantation using Dialysis and Transplant Patients Association (DATPA) information, 2005. All data regarding the cost of transplantation procedure, immunosuppression, and the money given to donors were included. The cost of transplantation procedure was categorized into personnel, drugs, paraclinics, hospital bed, and other expenses. To achieve more comprehensive results, all costs were converted into US dollars (1 USD = 9000 Rials).

RESULTS

The total cost of kidney transplantation procedure was $9224. Of this, 65.8% ($6076) was related to the immunosuppression therapy in the first year, 22.2% ($2048) to the transplantation procedure, and 12% ($1100) to organ procurement. The details of donor nephrectomy were as follows: personnel, $183; accommodations, $107; drugs, $39; paraclinics, $23; and other, $22. These values for kidney recipient were personnel, $331; drugs, $367; paraclinics, $278; accommodations, $475; and other, $222.

CONCLUSION

Compared with other countries, the kidney transplantation cost is low in Iran. The health system also pays for all the expenses. These, along with full medical insurance coverage of kidney recipients, make kidney transplantation available for every patient, regardless of the socioeconomic status due to its low cost. It is expected that a higher number of transplantation candidates with a low socioeconomic status will select transplantation.

Effect of Warm Ischemia on Graft Outcome in Laparoscopic Donor Nephrectomy

PURPOSE

To assess the impact of warm ischemia time (WIT) on delayed graft function (DGF), graft loss, and graft function in laparoscopic donor nephrectomy (LDN).

PATIENTS AND METHODS

We prospectively studied 100 kidney recipients from LDN donors from 2001 to 2003. For comparison of graft outcome with different extents of WIT, recipients were divided into three groups: group A received kidneys having 4 to 6 minutes, group B kidneys having >6 to 10 minutes, and group C kidneys having >10 minutes of WIT. The median follow-up was 415 days (range 11-791) days.

RESULTS

The mean kidney WIT was 8.7 minutes (range 4-17 minutes). Graft outcome (DGF, graft loss, and median serum creatinine) was not significantly different in the three groups.

CONCLUSIONS

Different extents of WIT in LDN, within the range of our study, were not associated with an adverse outcome in kidney transplantation.

Living unrelated versus living related kidney transplantation: 20 years' experience with 2155 cases

PURPOSE

To compare the long-term results of kidney transplantation from living unrelated donors (LURDs) with that from living related donors (LRDs).

MATERIALS AND METHODS

From 1984 to 2004, we performed 2155 kidney transplantations of which 374 were from LRDs and 1760 from LURDs. We reviewed and compared the long-term data from these cases.

RESULTS

The LURD group included 64.2% men with an overall mean age of 33.46 +/- 14.61 (range 3 to 76) years. Laparoscopic donor nephrectomy was performed in 329 cases (18.7%) with mean follow-up of 45.68 +/- 46.80 months. The LRD group included 66.5% of male recipients with overall mean age of 28.97 +/- 9.58 (range 9 to 65) years. Laparoscopic donor nephrectomy was performed in 12 cases (3.2%) of LRDs with mean follow-up of 81.15 +/- 67.03 months. One-, 3-, 5-, 10-, and 15-year graft survivals among LRDs were 91.6%, 81.7%, 76.4%, 64.4%, and 48.4%; and for LURDs, 91.5%, 86.7%, 81.4%, 68.2%, and 53.2%, respectively (P = .07). Patient survivals for 1, 3, 5, 10, and 15 years in LRDs were 94.6%, 91.9%, 83%, 79.5%, and 73.9%, and in LURDs were 93.6%, 91.7%, 89.3%, 84%, and 76.4%, respectively (P = .14).

CONCLUSION

The results of living unrelated kidney transplantation upon long-term follow-up with a large number of cases were as good as living related kidney transplantation. The organ shortage can be alleviated by using living unrelated kidney transplantation. To our knowledge this is the largest experience with long-term follow-up reported from one center to date.

Laparoscopic Pyelopyelostomy for Retrocaval Ureter Without Excision of the Retrocaval Segment: First Report of 6 Cases

PURPOSE

We report our series of 6 cases of retrocaval ureter that were successfully treated with a laparoscopic approach.

MATERIALS AND METHODS

Three men and 3 women with a mean age of 31 years (range 16 to 50) were referred to our department with a diagnosis of retrocaval ureter. One patient had a 12 mm renal pelvic calculus. A transperitoneal laparoscopic approach was used in all cases. The retrocaval segment along with some of the more proximal and distal segments of the ureter was readily mobilized. The distal part of the dilated renal pelvis was transected and the divided distal segment was repositioned to lie anterior to the inferior vena cava. The renal pelvic stone in 1 patient was readily removed at this point. Re-anastomosis was then performed over a Double-J stent placed intraoperatively using 2 rows of running 4-zero polyglactin sutures with intracorporeal knot tying. The stent was removed 4 weeks later. Excretory urography was performed 3 months after the laparoscopic procedure.

RESULTS

Mean operative duration was 180 minutes (range 150 to 210). Patients were discharged home at a mean of 4 days (range 3 to 5). Followup excretory urogram 3 months after laparoscopic repair revealed a widely patent anastomosis with considerable improvement in hydronephrosis in all patients.

CONCLUSIONS

To our knowledge this is the largest series of laparoscopic repair of retrocaval ureter reported to date. Laparoscopic pyelopyelostomy for retrocaval ureter without excision of the retrocaval segment is associated with an excellent outcome, minimal postoperative morbidity, short hospital stay and highly satisfactory cosmetic results.

Does Pre-Transplantation Antireflux Surgery Eliminate Post-Renal Transplantation Pyelonephritis in Children?

PURPOSE

Antireflux surgery for VUR before renal transplantation decreases the risk of post-kidney transplant UTI in pediatric patients with primary vesicoureteral reflux. We studied the risk of post-kidney transplant UTI in patients with or without surgical correction of VUR before transplantation compared to patients without VUR.

MATERIALS AND METHODS

We compared 12 patients who had VUR corrected before transplantation (group 1) to 17 patients with VUR who did not undergo antireflux surgery before transplantation (group 2) and 36 patients undergoing renal transplantation without VUR (group 3). A total of 10 patients in group 1 (83.3%) and 10 in group 2 (58.8%) had high grade VUR.

RESULTS

Eight patients in group 1 (66.7%), 6 in group 2 (35.3%) and 33 in group 3 (91.7%) remained free of febrile UTI during followup (p = 0.00). Among patients with high grade VUR 6 in group 1 and 1 in group 2 remained UTI-free (p = 0.02). A total of 33 patients in the control group (91.7%) remained free of febrile UTI, an incidence that was significantly lower compared to group 1 (p = 0.03) and group 2 (p = 0.00). Of the patients with high grade VUR 3 in group 1 (30%) and 4 in group 2 (40%) experienced recurrent febrile UTIs (p = 0.64).

CONCLUSIONS

Even after surgical correction of VUR before transplantation the frequency of febrile UTI remained higher than that in kidney transplant recipients without VUR. In cases of high grade VUR reimplantation before renal transplantation decreased the rate of febrile UTI but it was still higher than the level of risk in the control group.

Pedicular Vascular Control in Laparoscopic Living Donor Nephrectomy: The Use of Clips Instead of Stapler in 341 Donors

PURPOSE

To demonstrate a less expensive approach for laparoscopic donor nephrectomy.

MATERIALS AND METHODS

Left donor nephrectomy was done transperitoneally in flank position. Renal vein and artery were exposed and prepared for nephrectomy. Nondisposable trocars and instruments were used. The adrenal vein was clipped and its arteries were bipolar coagulated. Both renal artery and vein were clip-ligated using three medium large nonautomatic metallic clips and divided, instead of using rather expensive vascular endostapler. Kidney was hand-extracted from suprapubic incision (no Endobag was used).

RESULTS

Donor nephrectomy was performed in 341 donors. Mean warm ischemia time was 8.17 minutes. Mean operative time was 260.3 minutes. Conversion and reoperation was required in 2.1% and 3.8% of donors, respectively. Ureteral complications were observed in 2.1% of recipients. No vascular accident occurred from pedicular vessels. One-year graft survival in recipients was 92.6%. By this approach, at least $600 was saved in each nephrectomy.

CONCLUSION

Laparoscopic donor nephrectomy can be performed with a less expensive setup without adverse effects on graft outcome. Vascular control using nonautomatic clips instead of more costly vascular endostapler and also hand extraction of the kidney is safe, practical, and economical.

Kidney retransplantation in comparison with first kidney transplantation

INTRODUCTION

The aim of this study was to depict the outcome of second and third kidney allografts in comparison with first kidney allografts.

METHODS

Among 2150 kidney transplantations are 103 second and 5 third transplantations. Demographic characteristics and survivals of retransplanted patients were compared with a randomly selected group of first kidney recipients, consisting of two cases matched with each retransplanted patient for age, gender, and date of transplantation.

RESULTS

Retransplanted patients consisted of 78 men and 30 women of mean age 32.63 +/- 11.92 years. They had received kidneys from 91 living-unrelated and 17 living-related donors. Median followup was 27 months. One-, 2-, 3-, and 5-year graft survivals were 81.4%, 78.9%, 78.9%, and 73.7% among retransplants, versus 92.9%, 91.5%, 89.8%, and 85.3% in the control group, respectively (P = .0037). Patient survival was 96%, 94.6%, 92.4%, and 87.8% in the retransplant group versus 93.1%, 92.4%, 90.9%, 87.4% in the control group, respectively (P = .63). Also, graft survivals were slightly lower in female compared to male retransplant patients (P = .09). No significant difference in survival rates was seen in different age groups.

CONCLUSION

It seems that kidney retransplantation can yield desirable outcomes, albeit relatively lower graft survivals.

Concomitant nephrectomy of massively enlarged kidneys and renal transplantation in autosomal dominant polycystic kidney disease

OBJECTIVES

We compared perioperative and intraoperative data of patients with end-stage renal disease (ESRD) due to autosomal dominant polycystic kidney disease (ADPKD) who received a renal allograft without native nephrectomy with ADPKD patients who underwent concomitant native nephrectomy of massively enlarged kidneys and renal transplantation to determine whether the latter approach is reasonable and safe.

PATIENTS AND METHODS

From January 1987 to December 2003, 13 patients with ESRD due to ADPKD were stratified as 6 patients who underwent bilateral and 7 patients who underwent unilateral native nephrectomy in conjunction with renal transplantation (group A), versus 20 patients with ESRD due to ADPKD underwent renal transplantation without native nephrectomy (group B). Operative time, need for intraoperative transfusion, time to oral intake, duration of hospital stay, serum creatinine level on the day of discharge, readmission rate, and postoperative complications were compared for both groups.

RESULTS

Mean intraoperative duration was significantly longer for patients in group A, but there was no statistically significant difference in the findings between both groups.

CONCLUSIONS

Concomitant native nephrectomy of massively enlarged kidneys at the time of renal transplantation is reasonable and safe for patients with ESRD due to ADPKD.

Laparoscopic Management of Ureteropelvic Junction Obstruction by Division of Anterior Crossing Vein and Cephalad Relocation of Anterior Crossing Artery

PURPOSE

We report our experience with laparoscopic management of ureteropelvic junction (UPJ) obstruction by division of the anterior crossing vein and cephalad relocation of the anterior crossing artery.

PATIENTS AND METHODS

We used this laparoscopic approach in four male and six female patients with UPJ obstruction associated with anterior crossing vessels. The mean age of the patients was 31.9 years (range 14-59 years). The obstruction was present on the right side in four and on the left side in six patients. Using a transperitoneal approach, the crossing vein was divided, while the crossing artery was preserved, relocated cephalad, and fixed to the peripelvic tissues with metal clips or sutures. Because a grossly normal appearance of the UPJ and upper ureter together with proper pyeloureteral peristalsis and complete renal pelvic emptying were observed intraoperatively, dismembered pyeloplasty was not performed in any of these patients. Diuretic renography and intravenous urography were performed 3, 6, and 12 months postoperatively.

RESULTS

The mean operative duration was 140 minutes (range 100-170 minutes). The mean hospital stay was 2.9 days (range 2-5 days), and the mean follow-up was 9.1 months (range 3-22 months). Diuretic renography revealed absence of obstruction in all patients, and intravenous urography showed considerable improvement of the hydronephrosis.

CONCLUSION

Select cases of UPJ obstruction associated with anterior crossing vessels seem to be amenable to laparoscopic management by division of the crossing vein and cephalad relocation of the crossing artery. Laparoscopy as a minimally invasive approach may offer a better opportunity to evaluate the role of anterior crossing vessels in UPJ obstruction.

Renal Allograft Accumulation of Technetium-99m Sulfur Colloid as a Predictor of Graft Rejection

Differentiation between rejection (the most common cause) and many other possibilities for detrimental effects on graft function represents a difficult issue to diagnose the cause of renal allograft dysfunction. This study was designed to determine whether technetium-99m sulfur colloid (TSC) accumulation predicted graft rejection. We prospectively studied 54 episodes of allograft dysfunction in 53 kidney transplant recipients who underwent TSC scintiscanning and graft biopsy. Visual analysis of TSC uptake compared uptake, in the allograft with that in the marrow of the fifth lumbar vertebra (L5). A 3+ result meant that allograft uptake was greater than L5 marrow uptake; 2+, the same; 1+, less and finally 0, no allograft uptake. Transplant accumulation of 2+ or more was considered consistent with rejection (P = .01). Allograft biopsies interpreted based on the Banff Working Classification showed rejection in 45 of 54 renal biopsies with 42 the biopsy-proven rejection episodes showing at least 2+ graft uptake. Furthermore, this nuclear medicine technique had a sensitivity of 93.3%, a specificity of 44.4%, a positive predictive value of 89.3%, a negative value of 57.1% and an efficiency of 83.3% for the diagnosis of renal allograft rejection.

Impact of Ramadan Fasting on Renal Allograft Function

Fasting during the holy month of Ramadan is a religious duty for all healthy adult Muslims. They are only allowed to eat and drink between sunset and dawn. This study was designed to find the effect of Ramadan fasting on allograft function. We prospectively studied 19 kidney transplant recipients who voluntarily chose to fast during Ramadan versus 20 matched recipients, who had not fasted for 3 consecutive years. Data were recorded before, during, and after the fasting month. The mean posttransplant periods in the fasting and control groups were 52.6 +/- 30.3 and 56.6 +/- 30.0 months, respectively. A statistical analysis showed no significant changes in serum creatinine concentrations before and after Ramadan 1.07 +/- 0.24 versus 1.08 +/- 0.22 mg/dL (P > .05) and 1.00 +/- 0.24 versus 1.03 +/- 0.28 mg/dL (P > .05) in fasting and control groups, respectively. The results did not show any adverse effects of fasting in recipients with stable renal function. In conclusion, our study suggests that fasting during the month of Ramadan is safe and has no significant harmful effects on kidney transplant recipients with normal renal function.

Preliminary Report of a Nationwide Case-Control Study for Identifying Risk Factors of Tuberculosis Following Renal Transplantation

BACKGROUND

Tuberculosis (TB) is an important infection encountered posttransplantation, especially among patients in developing countries, where there are high incidences of morbidity and mortality.

MATERIALS AND METHODS

One hundred and twenty subjects (1%) from 15 major kidney transplantation centers in Iran from 1984 to 2003 were compared with 440 controls who were matched for operative time, treatment center, and surgical team.

RESULTS

Mean ages of research subjects and controls were 38.6 and 36.6 years (P = .04), respectively. The mean duration of pretransplantation hemodialysis was 29 months (range, 2 to 192 months) in research subjects and 20 months (range, 1 to 180 months) in controls (P = .003). Positive past history of tuberculosis was detected in 4 (3.3%) research subjects and in 7 (1.5%) controls (P = .2). Fifty-two research subjects (43.3%) and 241 controls (54.8%) had pretransplantation purified protein derivative of tuberculin less than 5 mm (P = .02). Mean dosages of initial and maintenance immunosuppressive drugs in research subjects and in controls were not significantly different. Sixty research subjects (50%) and 152 controls (34.5%) had rejection prior to diagnosis of TB (P = .03).

CONCLUSION

To our knowledge, this is the first study that demonstrates an increased risk of posttransplant TB by prolonged duration of pretransplant hemodialysis and number of posttransplant rejection episodes. Further study is needed to clarify these findings specifically with respect to various immunosuppressive regimens.

Laparoscopic Ureteral Resection and Anastomosis for Management of Low-Grade Transitional-Cell Carcinoma

Laparoscopic segmental ureterectomy and ureteroureterostomy was carried out in a patient with a low-grade ureteral tumor. To our knowledge, this approach is the first application of laparoscopic segmental ureterectomy for proximal ureteral tumor.

A comparison between laparoscopic and open pyeloplasty in patients with ureteropelvic junction obstruction

INTRODUCTION

Our aim was to compare clinical and radiological outcomes, complications, and hospital stay in laparoscopic and open pyeloplasty.

MATERIALS AND METHODS

From February 2002 to February 2003, 69 patients with ureteropelvic junction obstruction (UPJO) were assigned into two groups. Thirty-seven patients underwent transperitoneal laparoscopic pyeloplasty and 32 underwent open surgical pyeloplasty. Clinical symptoms were assessed before and after surgery, subjectively. Radiological assessment was also done three months postoperatively.

RESULTS

Mean operative time was 3.2 hours and 2.2 hours in laparoscopic and open pyeloplasty groups, respectively. Intraoperative bleeding was trivial in both groups and no complication or conversion to open surgery occurred. Postoperative complication rates were 24% and 6% in laparoscopic and open pyeloplasty groups, respectively. Mean hospital stay was similar (6.2 days) in the two groups. Mean follow-up was 16.5 months versus 11.4 months. Clinical and radiological success rates were 89% and 83.8% for laparoscopy group versus 96.5% and 87% for open pyeloplasty group. Due to recurrence of stricture, repeated surgery was performed in 4 patients of laparoscopy and 1 of open pyeloplasty groups.

CONCLUSION

Laparoscopic pyeloplasty is a less invasive method with less pain, cosmetic advantages, no long incision, and outcome comparable with open surgery. Hospital stay is also not longer than that in open surgeries. Hence, laparoscopic pyeloplasty can be a substitute for skilled surgeons.

Transcutaneous ultrasound guided nephrolithotomy: the first report from Iran

PURPOSE

To evaluate the safety and efficacy of transcutaneous ultrasound guided nephrolithotomy.

MATERIALS AND METHODS

From December 1999 to December 2000, 12 patients with renal stone were selected for PCNL. Six patients had failed ESWL and the remainder had multiple and large stones in pelvis and lower calyx. Ultrasonography was used in 11 patients during the entrance to the system and dilatation of the tract. Entrance to the system was impossible in one case for which open surgery with dorsal lumbotomy was performed.

RESULTS

The stone was removed by just one session of PCNL in 8 and the residual stone was less than 1 cm in the 3 other cases. Repeated PCNL from the same tract was performed in one case and ESWL was carried out in the other 2 cases. After three months, all of the 11 patients were stone free.

CONCLUSION

It seems that ultrasonography could replace fluoroscopy in patients with dilated collective urinary system and a single large stone in calyx or pelvis.

Laparoscopic adrenalectomy: a report of the first experience in Iran

PURPOSE

To report the first experience in laparoscopic adrenalectomy and to study its efficacy and safety in the treatment of different adrenal diseases.

MATERIALS AND METHODS

From March 1997 to July 2001, 11 patients underwent laparoscopic adrenalectomy through transperitoneal approach, five of whom were males and 6 were females. Their mean age was 35.5 (range 28 to 52) years. Lesion was located on the left side in 6 patients and on the right side in 5. All necessary evaluations were done preoperatively including CT scan, MRI, MIBG scan, and endocrine tests such as ACTH, cortisol, mineralocorticoid, 17-hydroxyprogesterone, and urinary VMA. Three (5, 10, and 12 mm) trocars were used in left laparoscopic adrenalectomy and three or four (12, 10, 5, and 5 mm) trocars were applied in right laparoscopic adrenalectomy. All the patients were followed up for three months with physical examination and paraclinical tests.

RESULTS

Mean operative time (including anesthesia and surgery) was 205+/-65.95 (range 130 to 310) minutes. No significant difference was seen between the operative time in the left side and the right side adrenalectomy (p=0.5). Mean hospitalization was 5.54+/-3.4 (range 3 to 15) days. Mean size of mass was 5.45+/-1.7 (range 2 to 8) cm. Blood transfusion was performed in 2 patients and open surgery was conducted for one because of extensive adhesions. No mortality was reported. During a 3-month follow-up, hormonal tests and blood pressure were normal for all the patients, with no medical treatment being required.

CONCLUSION

Our study demonstrated that transperitoneal laparoscopic adrenalectomy is an effective and safe approach in the treatment of adrenal masses with the least morbidity.

PCNL in the management of lower pole caliceal calculi

INTRODUCTION

Several therapeutic methods are used in the management of lower pole caliceal calculi. This survey has been conducted to evaluate the safety and efficacy of percutaneous nephrolithotomy in the management of lower pole calculi.

MATERIALS AND METHODS

Fifty-five patients, 43 males and 12 females with a mean age of 41.5 (range 11 to 75) years, who had suffered from lower pole caliceal calculi and treated by standard percutaneous nephrolithotomy (PCNL) between 1997 and 2001, were enrolled in this study. The stones were classified as follows: small (less than 25 mm), intermediate (25 to 34 mm) and large (more than 35 mm). Mean follow-up was 6.2 months (range 2 weeks to 34 months).

RESULTS

The stones were completely extracted by one session PCNL in 43 patients (79%). Repeat PCNL was needed in one patient and another method was used for stone extraction in another patient. Regarding the size of stone, 88%, 79%, and 74% of small, intermediate, and large stones were completely extracted, respectively. No major complication was noted.

CONCLUSION

PCNL has high success rate in patients with stones larger than 2 cm and its morbidity would be low, provided that it is performed by skilled surgeons.