Introduction: The aim of this study was to analyse patients' views on financial incentives in kidney transplantation in the UK. Methods: A questionnaire was developed, asking patients on the National transplant list what they think about a recipient's ability to pay in order to be allocated a deceased kidney for transplantation. This was approved by a Research Ethics Committee (Reference 10/H083/61) and sent to all the patients awaiting deceased donor kidney transplantation at five renal units in the UK. Results: The response rate was 318/780 (41%). 18 responded that they did not want to participate. The ability to pay for a kidney was an issue that 247 responders (78%) did not think should be part of the National allocation guidelines. 24 (7.5%) patients felt that payment should be part of the National allocation system and 45 (14.2%) patients said they didn't know whether payment should be part of this. Twenty-four (7.5%) responders thought that payment for a kidney is part of the current National kidney allocation system. 231 (72.6%) patients stated that the recipient's ability to pay was not part of the allocation system. Finally, 63 (19.8%) said that they didn't know whether payment is part of the allocation system. Conclusions: The study showed that most patients do not feel that paying to receive a kidney should be allowed. More concerning however is that a small group of patients currently think that affluence or ability to pay influences kidney allocation and that a proportion do not know if payment is part of the allocation system or not. We suggest that patients are provided with information about the National allocation system before listing. Additionally, patients should be informed that payment is not part of this and made aware of the Declaration of Istanbul (2008), which prohibits organ trafficking and transplant tourism.
Brain natriuretic peptide (BNP) is expected to be related to left atrial pressure, which can also be estimated using tissue Doppler echocardiography.Aims: To assess the relationship between BNP level and measures el systolic and diastolic function on Tissue Doppler Imaging (Tdi) in patients with aortic stenosis.Methods: We studied 50 patients with asymptomalic moderate to severe aortic slenosis (EOA <1.5 cm 2) and normal transverse LV systolic function.The median age was 73 years (range 29-87) and 38 were male.We recorded trans-milral pulsed Doppler and Tdi at the lateral and seplal mitral annulus.BNP levels were quantified using a fluorescence immunoassay technique (Triage BNP lest, Biosile Diagnostics, Inc).Results: Log BNP was inversely correlated to both the lateral and mitral annular systolic velocities P<0.01 and P<0.01 respectively, and directly related to the septal E/E' ratio (P=0.034).ROC curve analysis for an abnormal BNP (>100pgml) gave an AUC of 08 for the septal systolic velocity and 0.7 lor the E/E' ratio.An E,,E' ratio > 10 gave a sensitivity of 76% and specificity 30% for a high BNP while a ratio > 15 gave a sensitivity 67% and specificity 87%.A systolic velocily < 5 cm/s was 100% specific and below 8 cm/s 100% sensitive for a high BNP Conclusions: These results show that Tissue Doppler indices are related to the BNP level.A systolic velocity < 5 cnYs or E/E' ratio > 15 reliably predict a high BNP level.
Introduction: The first hand assisted retroperitoneoscopic (HARP) living donor nephrectomy was performed in Sweden in 2002 and showed better outcomes compared to the trans-peritoneal approach. The first HARP nephrectomy was performed in the UK in 2005, and the initial UK experience of this technique was published by our unit in 2006, showing that HARP nephrectomies were safe and resulted in shorter post-operative hospital stays, even in a cohort of patients with a range of vascular anomalies. This resulted in an increase in our living donor pool. This report summarises our experience to date. Methods: Data were compiled prospectively for 295 consecutive HARP nephrectomies performed from May 2005 to January 2012. This included information on donor demographics, intra-operative parameters, and post-operative outcomes including length of stay, death, and major complications. All procedures were performed according to Wadström et al (2002). Results: There were 148 male donors and 147 female donors. Mean age was 48.25 years (range 18 - 77). Mean BMI was 26.17 ± 3.58 kg/m2 (range 17.7 - 38). 257 (87%) cases were left sided nephrectomies, and 38 (13%) were right nephrectomies. Mean operating time was 144.06 ± 53.7 minutes (range 60-361). Mean warm ischaemia time was 102.7 ± 50.7 seconds (range 1 - 422). One case had a recorded WIT of 30 minutes and was excluded because the patient involved had sickle cell disease and therefore the kidney was not cooled. Median blood loss was 20 mL (IQR = 100). 171 (58%) donors had simple renal anatomy with 1 artery, 1 vein, and 1 ureter while 117 (40%) had complex anatomy involving multiple vessels and/or ureters. Other anatomical difficulties encountered included dense peri-renal adhesions, retro-aortic renal veins, large renal cysts, early arterial bifurcation, horseshoe kidney, double IVC, renal stone, a 6 cm angiomyolipoma, and urethral stricture. Post-operatively, median length of stay was 2 days (IQR = 1). 11 patients (3.7%) had minor complications (including urinary tract infection, urinary retention, wound infection, neuropraxia, and excess serous wound discharge), and 10 patients (3.4%) had major complications (including chest infection, incisional hernia, one conversion to open, and 3 cases of bleeding: 2 from small branches of the iliac artery requiring re-operation and radiological embolisation respectively, and 1 from subcutaneous fat necessitating re-operation). There were no deaths. There was no significant difference in mean operating time, warm ischaemia time, blood loss, and length of hospital stay, between right and left sided nephrectomies, between cases with simple and complex anatomy, and between patients with BMI ≥ 30 kg/m2 or ≤ 30 kg/m2. Conclusion: Small scale studies have shown that HARP nephrectomy is superior to transperitoneal laparoscopic donor nephrectomy in terms of operation time, warm ischaemia time, blood loss, and complications. Our report reinforces that the hand-assisted retroperitoneoscopic approach continues to be a safe and effective way of performing live donor nephrectomies, even in obese donors, and despite a range of anatomical variations.
Background. After renal transplantation half of all deaths are cardiac, so prior detection and treatment of severe coronary artery disease (CAD) is advocated. The aim of this study was to identify non-invasive predictors of severe CAD in a group of renal transplant candidates. Methods. One hundred and twenty-five renal transplant candidates (mean age 52±12 years, 80 male, mean creatinine 608±272 µmol/l) were studied. All had coronary angiography, dobutamine stress echocardiography, and resting and exercise electrocardiograph (ECG). Severe CAD was defined as luminal stenosis >70% by visual estimation in at least one epicardial artery. The resting ECG was recorded as abnormal if there was evidence of pathological Q waves, left ventricular hypertrophy, ST depression or elevation ≥1 mm, T wave inversion or bundle branch block. Total exercise time, maximal ST segment change, maximal heart rate and systolic blood pressure, limiting symptoms and Duke score were calculated during the exercise ECG test. Results. Of the patients, 36 (29%) had severe CAD, 55% were on dialysis and 39% were diabetic. Patients with severe CAD were significantly older (P<0.001), had higher total cholesterol (P = 0.05), higher CRP level (P = 0.05), larger left ventricular (LV), end systolic and end diastolic diameter (P = 0.007 for each), and lower LV ejection fraction (P = 0.01). A significantly higher percentage were diabetic (P = 0.05), had previous graft failure (P = 0.05), mitral annular calcification (P = 0.04), an abnormal resting ECG (P = 0.001) and positive stress echo result (P<0.001). Cardiac symptoms and exercise ECG parameters were not significantly different in the two groups. Stepwise logistic regression identified an abnormal resting ECG (OR 7, 95% CI 2, 34, P = 0.013) and positive stress echo result (OR 23, 95% CI 6, 88, P<0.001) as independent predictors of severe CAD. Conclusions. In selecting which potential renal transplant candidates should undergo coronary angiography, resting ECG and dobutamine stress echocardiography are the best predictors of severe CAD.
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