Randomized Controlled Trial Comparing Hand-Assisted Retroperitoneoscopic Versus Standard Laparoscopic Donor Nephrectomy

Transplantation - Current Issue Randomized Controlled Trial Comparing Hand-Assisted Retroperitoneoscopic Versus Standard Laparoscopic Donor Nephrectomy

BackgroundLaparoscopic donor nephrectomy (LDN) has become the gold standard for live-donor nephrectomy, as it results in a short convalescence time and increased quality of life. However, intraoperative safety has been debated, as severe complications occur incidentally. Hand-assisted retroperitoneoscopic donor nephrectomy (HARP) is an alternative approach, combining the safety of hand-guided surgery with the benefits of endoscopic techniques and retroperitoneal access. We assessed the best approach to optimize donors' quality of life and safety. MethodsIn two tertiary referral centers, donors undergoing left-sided nephrectomy were randomly assigned to HARP or LDN. Primary endpoint was physical function, one of the dimensions of the Short Form-36 questionnaire on quality of life, at 1 month postoperatively. Secondary endpoints included intraoperative events and operation times. Follow-up was 1 year. ResultsIn total, 190 donors were randomized. Physical function at 1 month follow-up did not significantly differ between groups (estimated difference, 1.79; 95% confidence interval, −4.1 to 7.68; P=0.55). HARP resulted in significantly shorter skin-to-skin time (mean, 159 vs. 188 min; P<0.001), shorter warm ischemia time (2 vs. 5 min; P<0.001) and a lower intraoperative event rate (5% vs. 11%, P=0.117). Length of stay (both 3 days; P=0.135) and postoperative complication rate (8% vs. 8%; P=1.00) were not significantly different. Potential graft-related complications did not significantly differ (6% vs. 13%; P=0.137). ConclusionsCompared with LDN, left-sided HARP leads to similar quality of life, shorter operating time, and warm ischemia time. Therefore, we recommend HARP as a valuable alternative to the laparoscopic approach for left-sided donor nephrectomy.


http://journals.lww.com/transplantjournal/Fulltext/2014/01270/Randomized_Controlled_Trial_Comparing.9.aspx

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Pulsatile Perfusion Reduces the Risk of Delayed Graft Function in Deceased Donor Kidney Transplants, Irrespective of Donor Type and Cold Ischemic Time

Transplantation - Published Ahead-of-Print Pulsatile Perfusion Reduces the Risk of Delayed Graft Function in Deceased Donor Kidney Transplants, Irrespective of Donor Type and Cold Ischemic Time

Background: The role of pulsatile perfusion (PP) across different cold ischemic times (CIT) within different donor groups is unclear. This study examined the association of PP with delayed graft function (DGF) in all (n=94,709) deceased donor kidney transplants in the US between 2000 and 2011, as a function of CIT and donor type. Methods: Using the Scientific Registry of Transplant Recipients data, all adult standard criteria donors (SCD, n=71,192), expanded criteria donors (ECD, n=15,122), and donors after circulatory death (DCD, n=8,395) kidney transplant recipients were identified. Within each donor group, transplants were stratified based on duration of CIT: 0 to 6 hours, 6.1 to 12 hours, 12.1 to 18 hours, 18.1 to 24 hours, 24.1 to 30 hours, 30.1 to 36 hours, and greater than 36 hours. Within each group, the odds of DGF with and without PP was determined after adjusting for donor, recipient, and transplant factors, including a propensity score for the likelihood of PP use, and clustering on transplant center using multivariable logistic regression. Results: When stratified by donor type and CIT, the adjusted odds of DGF were lower with PP across all CIT in SCD transplants, when CIT was greater than 6 hours in ECD transplants, and when CIT was between 6 and 24 hours in DCD transplants. CIT was independently associated with a greater risk of DGF irrespective of storage method, but this effect was substantially modified by PP. Conclusion: PP is associated with a reduced risk of DGF irrespective of donor type and CIT. Although PP modifies the impact of CIT on the risk of DGF, it does not eliminate its association with DGF, suggesting the optimal strategy to reduce DGF is to minimize CIT and utilize PP in all deceased donor transplants. (C) 2014 by Lippincott Williams & Wilkins


http://pdfs.journals.lww.com/transplantjournal/9000/00000/Pulsatile_Perfusion_Reduces_the_Risk_of_Delayed.98339.pdf

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Alemtuzumab and Sirolimus in Renal Transplantation: Six-Year Results of a Single-Arm Prospective Pilot Study

AJT - Early Alemtuzumab and Sirolimus in Renal Transplantation: Six-Year Results of a Single-Arm Prospective Pilot Study

mTOR inhibitors avoid calcineurin nephrotoxicity, but sirolimus de novo is associated with unacceptable side effects and higher rejection rates. We have investigated a modified strategy: alemtuzumab induction with tacrolimus and mycophenolate maintenance, switching from tacrolimus to sirolimus at 6 months and stopping mycophenolate at 12 months. Here, we report the 6-year follow-up of 30 patients prospectively recruited to this single-arm pilot study and compare outcomes to a matched contemporaneous control group of 30 patients who received standard induction and calcineurin-inhibitor-based immunosuppression. Six-year patient and graft survival were 83% and 80% (alemtuzumab) versus 77% and 70% (control). Rejection rates in the first 6 months were similar in alemtuzumab (6.6%) and control groups (10%). A higher than expected incidence of rejection in the alemtuzumab group following cessation of mycophenolate at 1 year (17%) was mitigated in later patients by retaining low dose mycophenolate. Mean eGFR was higher in the alemtuzumab group at all time points but not significantly (p = 0.16). Tacrolimus levels in the first 6 months were significantly higher in the contemporaneous control group (p < 0.001). Alemtuzumab induction with initial treatment with tacrolimus enables conversion to sirolimus without the side effects and incidence of acute rejection seen in earlier protocols.

http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2Fajt.12572

Kidney International - High rates of death and hospitalization follow bone fracture among hemodialysis patients

http://www.nature.com/ki/journal/v85/n1/full/ki2013279a.html

Maintaining calcineurin inhibition after the diagnosis of post-transplant lymphoproliferative disorder improves renal graft survival : Kidney International

http://www.nature.com/ki/journal/v85/n1/full/ki2013253a.html

Prurigo nodularis in a peritoneal dialysis patient

http://www.nature.com/ki/journal/v85/n1/full/ki2013228a.html