Disparities in living donation

PURPOSE OF REVIEW

Living organ donation provides improved access to transplantation, thereby shortening transplant wait times and allowing for more deceased organ transplants. However, disparity in access to living donation has resulted in decreased rates of living donor transplants for some populations of patients.

RECENT FINDINGS

Though there have been marked improvements in deceased donor equity, there are still challenges as it relates to gender, racial/ethnic, and socio-economic disparity. Improvements in living donation rates in Hispanic and Asian populations are tempered by challenges in African American rates of organ donation. Socio-economic disparity may drive gender disparities in organ donation resulting in disproportionate female living donors. Tailored approaches relating to language-specific interventions as well as directed educational efforts have helped mitigate disparity. Additionally, the use of apolipoprotein1 testing and modifications of glomerular filtration rate calculators may improve rates of African American donation. This review will evaluate recent data in living donor disparity as well as highlight successes in mitigating disparity.

SUMMARY

Though there are still challenges in living donor disparity, many efforts at tailoring education and access as well as modifying living donor evaluation and identifying systemic policy changes may result in improvements in living donation rates.

Hand-assisted robotic right donor nephrectomy in patient with total situs inversus: A case report

Total situs inversus" is an infrequent congenital condition. The robot has been already proved as a safe and attractive approach for living donor nephrectomies. We report here the first right donor nephrectomy in a patient with total situs inversus that is performed using the Da Vinci platform.

Successful living donor intestinal transplantation in cross-match positive recipients: Initial experience

Sensitized patients tend to have longer waiting times on the deceased donor list and are at increased risk of graft loss from acute or chronic rejection compared to non-sensitized candidates. Desensitization protocols are utilized to decrease the levels of alloantibodies and to convert an initial positive cross-match to prospective donors into a negative crossmatch. These procedures are mostly available in the setting of living donation. Due to the elective nature of the procedure, desensitization protocols can be extended until the desire result is obtained prior to transplantation. We present two cases of successful desensitization protocol applied to living donor intestinal transplant candidates that converted to negative cross-match to their donors. We present two cases of intestinal transplant candidates with a potential living donor to whom they are sensitized. Both cases underwent successful transplantation after desensitization protocol. No evidence of humoral rejection has occurred in either recipient. Living donor intestinal transplantation in sensitized recipients against the prospective donors provides the ability to implement a desensitization protocol to convert to negative cross-match.

Sleeve gastrectomy surgery in obese patients post-organ transplantation

BACKGROUND

Among organ transplant recipients, a common side effect of immunosuppressive therapy is the development of obesity, which affects a third of the patients within 3 years after transplantation. Bariatric surgery represents a possible surgical option for weight loss among posttransplant patients.

OBJECTIVES

The aim of this study was to examine percent excess weight loss (%EWL), and percent weight loss (%WL) and perioperative and postoperative complications in posttransplant obese patients after sleeve gastrectomy (SG) compared with nontransplant patients. We hypothesize that transplant patients who undergo SG will not significantly differ in their perioperative or postoperative complications or in their %EWL and %WL compared with nontransplant patients who undergo SG. The second aim was to evaluate the impact of SG on graft function and immunosuppressive therapy in transplant patients.

SETTING

University hospital.

METHODS

Among 500 consecutive patients who underwent SG from January 2008 to June 2014, 10 patients were organ transplant recipients. The following variables were compared between groups: patient demographic characteristics and co-morbidities, type of transplant surgery, date of transplant surgery, pretransplant body mass index (BMI), date of bariatric surgery, prebariatric surgery BMI, operative time, length of hospitalization, postoperative complications, and change in BMI, %EWL, and %WL. Data were also collected on renal, liver, and pancreas graft function parameters and changes in immunosuppressive medications.

RESULTS

Six patients had a kidney transplant, 2 patients had a liver transplant, and 2 had a pancreas transplant. No significant differences were observed in %EWL or %WL at 6 and 12 months follow-up between transplant and nontransplant patients. No transplant patients were lost to follow-up at 6 and 12 months. Among nontransplant patients, 36.7% and 35.7% were lost to follow-up at 6 and 12 months, respectively. No postoperative complications were registered in the transplant group. SG did not negatively affect the graft function.

CONCLUSION

Initials results found that there were no significant differences in %EWL or %WL at 6 and 12 months follow-up between transplant and nontransplant patients. There were also no perioperative and postoperative complications among transplant patients after SG.

Five-year follow-up of patients with type 1 diabetes transplanted with allogeneic islets: the UIC experience

This report summarizes a 5-year phase 1/2 allogeneic islet transplantation clinical trial conducted at the University of Illinois at Chicago (UIC). Ten patients were enrolled in this single center, open label, and prospective trial in which patients received 1-3 transplants. The first four subjects underwent islet transplantation with the Edmonton immunosuppressive regimen and the remaining six subjects received the UIC immunosuppressive protocol (Edmonton plus etanercept and exenatide). All 10 patients achieved insulin independence after 1-3 transplants. At 5 years of follow-up, 6 of the initial 10 patients were free of exogenous insulin. During the follow-up period, 7 of the 10 patients maintained positive C-peptide levels and a composite hypoglycemic score of 0. Most patients maintained HbA1c levels <6.0 % (42.1 mmol/mol) and a significantly improved β-score. In conclusion, this study demonstrated long-term islet graft function without using T cell depleting induction, with an encouraging outcome that includes 60 % of patients remaining insulin independent after 5 years of initial transplantation.

The application of indocyanine green to evaluate duodenal perfusion in pancreas transplantation

In cases of suspected duodenal ischemia during pancreas transplantation, surgical decisions severely affect the outcome of the patient and the graft. The use of a nontoxic intravenous tracer, indocyanine green, allows the surgeon to evaluate the perfusion of tissues within seconds of injection. Its application to pancreas transplantation has not been reported previously.

Minimally invasive robotic kidney transplantation for obese patients previously denied access to transplantation

Obese patients with end-stage renal disease (ESRD) are often excluded from kidney transplantation due to concerns about surgical site infections. To reduce infections, we developed a robotic kidney transplantation method for obese recipients. From June 2009-December 2011, a prospective cohort of 39 obese patients underwent robotic kidney transplantation at a single center. The outcomes of patients with at least six months of follow-up (n=28) were compared to a frequency-matched retrospective cohort of obese patients who underwent open kidney transplantation from 2004-2009 (n=28). The 28 robotic patients were predominately African-American (46.4%) or Hispanic (35.7%), with a mean age of 47.9±10.7 years, similar to the control group. BMI in the robotic group was 42.6±7.8 kg/m2 compared to 38.1±5.4 kg/m2 in the control group (p=0.02). There were no surgical site infections in the robotic group (0/28), while 28.6% (8/28) in the control group developed an infection (p=0.004). Six-month creatinine (1.5±0.4 vs.1.6±0.6 mg/dL; p=0.47), and patient and graft survival (100%) were comparable between the two groups. Outcomes following robotic surgery compared favorably to conventional transplantation. Robotic surgery may therefore enable obese patients with ESRD to access kidney transplantation and may thereby reduce health disparities in groups with a high prevalence of obesity and ESRD.

Renal artery aneurysm in robotic donor nephrectomy: a case report

OBJECTIVES

With the current disparity between donor organ availability and recipient need, creative techniques help optimize the use of available organs. We present a case of a woman, who was worked-up as a kidney donor, who was incidentally found to have a saccular aneurysm on her renal artery. The patient was asymptomatic, normotensive, and had normal renal function.

MATERIALS AND METHODS

We performed a laparoscopic robotic donor nephrectomy, repaired the aneurysm on the back table, and transplanted the organ into the recipient.

RESULTS

The donor underwent a successful robotic nephrectomy, successfully eradicating any risk of aneurysmal complications; the recipient received an anatomically normal organ with excellent function.

CONCLUSIONS

An altruistic act by the donor identified a potentially fatal lesion, which was not only remedied, but the intended donation proceeded when a creative approach was used.

Pancreatic islet cell transplantation: an update for interventional radiologists

Pancreatic islet cell transplantation is a promising cellular-based therapy for type 1 diabetes mellitus. This procedure involves portal venous injection of islet cells and affords 1-year insulin independence in as many as 80% of recipients. Although transplant surgeons represent historical drivers of islet therapy, requirement for image guidance and transcatheter techniques has fostered collaboration with interventional radiologists, who are positioned to play a significant role in clinical performance of islet transplantation and in basic science research in this field. This review article aims to familiarize interventional radiologists with islet cell transplantation patient selection, procedure technique, clinical outcomes, and future clinical and research avenues.

Orthotopic placement of a segmental pancreas graft for transplant: a case report

Pancreas retransplantation has become more frequent and represents a technical challenge for surgeons. Knowledge of alternative surgical options could be useful in difficult cases. We present a case of brutal diabetes mellitus in a patient with severe vascular disease that underwent a third pancreas transplant. Difficulties in obtaining arterial inflow were solved utilizing the native splenic vessels, placing the graft in orthotopic position, and a combination of historical surgical techniques in pancreas transplantation; that is, segmental grafts and duct injection for exocrine management made transplantation successful.

A Prospective Evaluation of Ultrasonography for the Diagnosis of Penetrating Torso Injury

BACKGROUND

Ultrasound (US) is commonly used for the diagnosis of hemoperitoneum after blunt abdominal trauma, but the value of US as an aid for identification of operative lesions after penetrating trauma is not well documented. The purpose of this investigation was to determine the accuracy of US for the evaluation of penetrating torso trauma and to assess the impact of this information on patient management.

METHODS

We conducted a prospective cohort observational study of consecutive penetrating torso patients at a Level I trauma center.

RESULTS

During the 6-month trial period, 177 victims of penetrating torso trauma were assessed by our trauma teams. Ninety-two patients had stab wounds, 84 patients had gunshot wounds, and 1 patient had a puncture wound. All 28 patients with positive US examination had an exploratory laparotomy or thoracotomy (one patient had more than one procedure), resulting in 26 therapeutic operations. There were 149 negative US examinations, but in this group, 36 patients underwent laparotomy or thoracotomy, and 28 had therapeutic operations. The overall accuracy of the US examination was therefore 85%, the sensitivity was 48%, and the specificity was 98%. There were only three patients who had their initial management altered by a positive US examination.

CONCLUSION

The US examination lacks sensitivity to be used alone in determining operative intervention after gunshot or stab wounds. Rarely does US information contribute to the management of patients with penetrating abdominal injuries.