Background: Rising numbers of patients reaching end-stage kidney disease intensify the demand for expansion of the living–kidney-donor pool. On the basis of low risk in white donors with essential hypertension, our transplant center undertook a structured program of accepting hypertensive donors if kidney function and urine protein were normal. This study reports outcomes of hypertensive donors 1 year after kidney donation. Methods: We studied detailed measurements of blood pressure (oscillometric, hypertensive therapy nurse [RN], and ambulatory blood pressure monitoring [ABPM]), clinical, and renal characteristics (iothalamate glomerular filtration rate [GFR], urine protein, and microalbumin) in 148 living kidney donors before and 6 to 12 months after nephrectomy. Twenty-four were hypertensive (awake ABPM>135/85 mm Hg and clinic/RN BP>140/90 mm Hg) before donation. Results: After 282 days, normotensive donors had no change in awake ABPM pressure (pre 121±1/75±2 vs. post 120±1/ 5±1 mm Hg), whereas BP in hypertensive donors fell with both nonpharmacologic and drug therapy (pre 142±3/85±2 to post 132±2/80±1 mm Hg, P<.01). Hypertensive donors were older (53.4 vs. 41.4 years, P<.001) and had lower GFR after kidney donation (61±2 vs. 68±1 mL/min/1.73m2, P<.01). After correction for age, no independent BP effect was evident for predicting GFR either before or after nephrectomy. Urine protein and microalbumin did not change in either group after donor nephrectomy. Conclusions: Our results indicate that white subjects with moderate, essential hypertension and normal kidney function have no adverse effects regarding blood pressure, GFR, or urinary protein excretion during the first year after living kidney donation. Although further studies are essential to confirm long-term safety, these data suggest that selected hypertensive patients may be accepted for living kidney donation.
In infants with posterior urethral valves in whom renal function fails to normalize following decompression of the lower urinary tract supravesical urinary diversion is customarily recommended for presumed concomitant ureterovesical junction obstruction. We determined the true incidence of fixed or permanent ureterovesical junction obstruction and the renal prognosis for infants treated with proximal urinary diversion.We evaluated 26 patients with posterior urethral valves treated with supravesical urinary diversion. Mean gestational age at birth was 35 weeks (range 27 to 40). After initial decompression via an indwelling catheter for a median of 7 days (range 4 to 18) persistently high serum creatinine was present (median 2.5 mg./dl., range 1.9 to 3.5). One month after proximal urinary diversion median creatinine was 1.3 mg./dl. (range 0.5 to 2.8). At 1 year, median nadir creatinine was 1.0 mg./dl. (range 0.3 to 2.5). At reconstruction a Whitaker test in all 26 patients (52 renal units) demonstrated fixed ureterovesical junction obstruction in 2 units (4%).Renal biopsy in 44 of the 52 renal units (85%) revealed renal dysplasia. At a median followup of 9 years (range 1 to 14) end stage renal disease developed in 11 patients (42%).In neonates with posterior urethral valves who undergo proximal urinary diversion fixed ureterovesical junction obstruction is rare, renal biopsy invariably demonstrates areas of renal dysplasia and end stage renal disease frequently develops despite proximal diversion. These findings lead us to question the necessity of supravesical urinary diversion.
Background. The transplantation of living donor renal allografts across blood group barriers requires protocols to reduce and maintain anti-blood group antibody at safe levels. These protocols lead to an increase in resource utilization and cost of transplantation and may result in increased complications. Methods. In this retrospective study, we compared 40 ABO-incompatible to 77 matching ABO-compatible living donor renal allografts with respect to complications, resource utilization, and cost from day −14 to 90 days after transplantation. Results. Overall, surgery-related complications and resource utilization were increased in the ABO-incompatible group, primarily due to the desensitization protocol and antibody-mediated rejection. In the absence of rejection, the mean number of complications was similar for both groups. ABO-incompatible kidney transplantation was approximately $38,000 more expensive than ABO-compatible transplants, but was cost effective when compared to maintaining the patient on dialysis while waiting for a blood group compatible deceased donor kidney. Actuarial graft and patient survival was similar in the two groups. Conclusions. We conclude that ABO-incompatible living donor kidney transplantation is a viable option for patients whose only donor is blood group incompatible despite the additional resource utilization and cost of therapy.
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