Background: Living donor kidney transplantation is the preferred treatment for end-stage kidney disease. Existing literature suggests that donation within the bounds of current guidelines is relatively safe. However, efforts to maximise access to transplantation may result in acceptance of donors who do not fit within current guidelines. Methods: Since 2004 the Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry has maintained a registry of living kidney donors. We examined the donor risk profile of Australian and New Zealand kidney donors over 2004-2010 and compared this profile with the Australasian clinical practice guidelines for donor acceptance. Results: There were 2,408 transplant operations from living donors during 2004-2010. Fifty-nine involved the use of non-directed donor kidneys after surgical management of a pathological process and were excluded from further analysis. The remaining 2,349 donors were aged from 18 to 81 with a mean age of 48.5 years. 1356 donors (57.7%) were female, and the majority were Caucasian (2,051 donors, 87.3%). 46 donors (2.0%) had a measured GFR< 80mL/min and 32 (1.4%) had proteinuria >300mg/day. Cardiovascular risk factors were common - 323 (13.8%) were hypertensive; 978 (41.6%) were overweight (BMI 25-29.9 kg/m2) and a further 402 (17.1%) were obese (BMI≥30 kg/m2); 7 (0.3%) were diabetic while a further 46 (2.0%) had impaired glucose tolerance; and 187 (8.0%) were smokers at the time of donation. Only 980 donors (41.7%) had no reported cardiovascular risk factors. According to current Australasian guidelines 457 donors (19.5%) had at least one relative contraindication to donation and 283 (12.0%) had at least one absolute contraindication to donation. Conclusions: The majority of living kidney donors in Australia and New Zealand have at least one cardiovascular risk factor, and a substantial minority have a relative or absolute contraindication to donation according to current clinical practice guidelines. In the context of the known increase in cardiovascular risk associated with chronic kidney disease among the general community, these findings mandate tight follow-up of this cohort. Heightened awareness of donor risk may be appropriate.
Traditionally performed by vascular surgeons or urologists, laparoscopic nephrectomy for live kidney donor transplantation has emerged as a new effective and safe technique. This study examines the implementation of this technique at our centre, as performed by a single general surgeon with expertise in advanced laparoscopic surgery.Patient records for 78 live donor transplants performed between February 2002 and September 2008 were divided into two groups (with 39 patients each) analyzed. A variety of outcome variables were compared. The same individual surgeon performed all laparoscopic donor nephrectomy (LDN) procedures.A significant advantage was noted for LDN with respect to hospital stay (LDN 5.1 ± 1.1 days vs open donor nephrectomy [ODN] 6.4 ± 2.6 days, P=0.01) while ODN had a significant advantage with respect to operative time (LDN 241.1 ± 55.7 min vs ODN 152.0 ± 27.7 min, P<0.01). Within the LDN group, we noted a significant shortening in the operation time with each case as experience increased (see graph; P<0.01). The total postoperative complication rate was similar in both groups (LDN: 31% vs ODN: 44%, P=0.25). There was a trend towards more respiratory complications in ODN (ODN 11/39 [28%] vs LDN 5/39 [13%], P=0.09).While implementing a new procedure may result in longer operative times initially, these improve with time, and our data demonstrates no compromise in patient safety or outcomes. The LDN procedure proved to be a desirable alternative to ODN, with shorter hospital stay and improved operator skills with each case, and without significant compromise in allograft recovery.
Successful haemodialysis is dependent on optimal arteriovenous (AV) access flow. Although 600 ml/min is frequently quoted as the critical level for functional flow volume (Qa) according to the National Kidney Foundation guideline, this may not be applicable for the different configurations of AV fistulas (AVF) or AV grafts (AVG). This study evaluates ultrasound derived Qa measurement in the inflow brachial artery to autologous AVF in the forearm radiocephalic and arm brachiocephalic/basilic configurations in relation to significant flow related AV dysfunction.Five hundred and eleven duplex ultrasound (DUS) scans were analysed in 193 patients. The end points were therapeutic intervention and/or thrombosis of AVF versus no complication within 3 months of the scan. Receiver operating characteristic (ROC) curves were used to determine the optimal threshold Qa of the brachial artery supplying the AVF.Of the 511 scans, 155 scans were assigned to the intervention group, that is, AVF requiring intervention or thrombosing within 3 months of the DUS. Using ROC curve analysis, the area under the curve (AUC) for all AVF is 0.90 (CI: 0.88-0.93) with an optimal threshold Qa of 686 ml/min. In forearm AVF, the threshold Qa is 589 ml/min while in arm AVF the threshold Qa is 877 ml/min. Forearm Qa is statistically different from arm Qa.Forearm AVF Qa threshold at 589 ml/min is distinct from arm AVF Qa at 877 ml/min and these are predictive of the need for impending intervention or thrombosis due to flow-limiting stenosis.
It is essential that the clinical presentations of leg swelling and leg ulcers are 'translated' into diagnoses that allow targeted treatment. Bilateral leg swelling usually has a systemic basis whereas unilateral leg swelling and leg ulcers are generally manifestations of local pathology. In all instances of leg ulcers, the assurance of an adequate arterial supply is crucial to optimal management.
To determine factors associated with early pancreatic allograft thrombosis (EPAT). Thrombosis is the leading non-immunological cause of early pancreatic allograft failure. Multiple risk factors have been postulated. We hypothesized that recipient perioperative hypotension was a major risk factor and evaluated the correlation of this and other parameters with EPAT.We retrospectively reviewed the records of the 118 patients who received a pancreatic allograft at our center between October 1992 and January 2010. Multiple donor and recipient parameters were analyzed as associates of EPAT by univariate and multivariate analysis.There were 12 episodes of EPAT, resulting in an incidence of 10.2%. On univariate analysis, EPAT was associated with perioperative hypotension, vasopressor use, and neuropathy in the recipient (p ≤ 0.04 for all). On multivariate analysis corrected for age, sex, and peripheral vascular disease, only vasopressor use retained a significant association with EPAT with a hazard ratio of 8.74 (CI 1.11-68.9, p = 0.04). Factors associated with vasopressor use included recipient ischemic heart disease, peripheral vascular disease, retinopathy or neuropathy, and any surgical complication.Significant hypotension, measured by the need for perioperative vasopressor use was associated with EPAT, suggesting that maintenance of higher perfusion pressures may avoid this complication.
Abstract Background: Pancreas–kidney transplantation is currently the most effective method to re‐establish euglycaemia in insulin‐dependent diabetics with associated renal failure. The standard technique employed has been bladder drainage of exocrine secretions coupled with systemic venous drainage (‘systemic‐bladder’ (SB) drainage). The more physiological technique, enteric exocrine with portal venous drainage (‘portal‐enteric’ (PE) drainage), has been utilized sparingly in the past as a result of fears of technical complications. This paper compares the Monash Medical Centre experience with both techniques. Methods: A total of 68 simultaneous pancreas–kidney transplantations were performed at Monash Medical Centre from 1991 until 2004. The first 37 received SB drainage. Since March 2001, 27 have received PE drainage. This retrospective study compared the SB group ( n = 37) with the PE group ( n = 27), with a 2‐year follow‐up, examining a number of surgical outcomes. Results: Two‐year patient (94.3 versus 96.0%), kidney (89.2 versus 85.2%), pancreas (77.9 versus 71.4%) and event‐free (73.0 versus 67.7%) survivals were all similar between the SB and PE groups, respectively. Although surgery took longer in PE subjects (4 h : 47 min ± 0:48 versus 5 h : 16 min ± 1:00; P = 0.045), less intraoperative transfusions were required (1.3 ± 1.43 versus 0.52 ± 0.90; P = 0.024). Length of hospital stay and time to insulin independence were similar. Pancreas graft thrombosis rates were similar (10.8% SB versus 7.4% PE, P = 0.497). Conclusions: PE drainage is a safe and viable method for pancreas transplantation, which can be performed with excellent outcomes. An increased rate of complications with PE drainage has not been demonstrated in this series.
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