Faculty Bibliography

We evaluated a technique for implantation of right kidneys with short renal veins without the need for venous reconstruction. METHOD: The technique of iliac vein transposition was performed in six recipients who received right kidneys with short renal veins. Two cases were living related donors, two were living unrelated, one was an autotransplant, and one was a cadaver kidney recipient. The common and external iliac veins and arteries of the recipient were thoroughly mobilized, allowing for the lateral transposition of the external iliac vein with respect to the external iliac artery. The renal vessels were subsequently implanted in an end to side fashion onto the corresponding transposed external iliac vessels. After implantation, the iliac vein remained lateral with respect to the iliac artery. CONCLUSIONS: The technique described allows for the implantation of right kidneys without the need for venous reconstruction. Such an approach is especially useful in cases of grafts with short veins.

OBJECTIVE: To review a single-institution 6-year experience with laparoscopic live donor nephrectomy detailing the technical modifications, clinical results, as well as the trends in donor and recipient morbidity. SUMMARY BACKGROUND DATA: Since 1995, laparoscopic donor nephrectomy has had a significant impact on the field of renal transplantation, resulting in decreased donor morbidity, without jeopardizing procurement of a high-quality renal allograft. This technique has become the preferred method of allograft procurement for many transplantation centers worldwide but still remains technically challenging with a steep learning curve. METHODS: Records from 381 consecutive laparoscopic donor nephrectomies were reviewed with evaluation of both donor and recipient outcomes. Trends in donor and recipient complications were assessed over time by comparing the outcomes between four equally divided groups. RESULTS: All 381 kidneys were procured and transplanted successfully with only 8 (2.1%) open conversions. Mean operative time was 252.9 +/- 55.7 minutes, estimated blood loss 344.2 +/- 690.3 mL, warm ischemia time 4.9 +/- 3.4 minutes, and donor length of stay was 3.3 +/- 4.5 days. There was a significant decline in total donor complications, allograft loss, and rate of vascular thrombosis with experience. The rate of ureteral complications declined significantly when comparing our early (Group A) versus later (Groups B-D) experience. CONCLUSION: Laparoscopic donor nephrectomy has remained a safe, less invasive, and effective technique for renal allograft procurement. Over our 6-year experience and with specific refinements in surgical technique, we have observed a decline in both donor and recipient morbidity following laparoscopic live donor nephrectomy

BACKGROUND: Donor-specific antibody (DSA) is the major barrier to success of kidney transplants. Attempts to deal with this problem have used plasmapheresis to remove antibodies or high-dose pooled immunoglobulin (IVIg) to down-regulate DSA. However, elimination of antibodies by these methods has been limited in duration or scope. METHODS: We have confirmed the presence of immunoglobulin (Ig)G antibody to one or more donor HLA antigens in 49 patients treated with alternate-day, single-volume plasmapheresis followed by low-dose cytomegalovirus (CMV) hyperimmune globulin (CMV-Ig) combined with quadruple immunosuppression. We examined the effect of the treatment protocol on antibodies to donor HLA, third-party HLA, and nominal antigens. RESULTS: At the end of treatment, 63% of patients had lost antibody to donor HLA, whereas only 27% had lost antibody to third-party HLA (P<0.001). More strikingly, loss of antibody to donor and third-party HLA antigens occurred in 89% and 19%, respectively, of patients followed for 2 or more months after end of treatment (P<0.0001). No elimination of antiviral antibodies tested was seen. With one exception, elimination of DSA appeared to be independent of antibody titer or specificity, the number of different antibody specificities, or whether or not the target antigen was a repeat mismatch. The effect appears to be long lasting, with no return of DSA observed in patients followed for an average of 13 months. CONCLUSIONS: Plasmapheresis and low-dose CMV-Ig combined with traditional immunosuppression is effective in producing a specific and durable elimination of antibody to donor HLA.

BACKGROUND: Pulsatile perfusion (PP) is used by some centers to provide information that may aid in the selection of cadaveric renal allografts for transplantation. However, basing organ acceptance on PP parameters alone may lead to the discarding of kidneys from otherwise suitable donors. In this case series, we report the reevaluation and transplantation of kidneys refused by other centers after evaluation with PP. METHODS: Retrospective review of 14 cadaveric kidneys imported for repeat PP at our center after initially poor PP parameters from an outside organ procurement organization resulted in refusal by multiple centers. RESULTS: Median age of donors was 46 (range 21-64), and mean terminal serum creatinine was 1.3+/-0.6 mg/dL. Despite favorable donor characteristics, each kidney was refused by an average of 9.3 centers. Poor PP parameters and concerns about donor quality were the reasons for refusal in the majority of cases. Pulsatile-perfusion parameters at the outside center were poor: mean flow of 103 mL/min/100 g and mean resistance of 0.321 mm Hg/(mL/min/100 g). Repeat PP parameters at our center after importation were markedly improved (flow=167 mL/min/100 g and resistance=0.195 mm Hg/[mL/min/100 g]). Eleven of 14 kidneys were transplanted and currently have acceptable graft function (mean serum creatinine=1.6 mg/dL at a median follow-up of 12 months). CONCLUSIONS: This series describes the successful transplantation of 11 kidneys from acceptable donors that were initially discarded by multiple centers after poor PP parameters were obtained. The good allograft function in these organs emphasizes the importance of considering all donor factors when making allocation decisions.

OBJECTIVE: The purpose of this study was to determine the accuracy of multidetector CT (MDCT) angiography as the primary imaging technique in the evaluation of living kidney donors. SUBJECTS AND METHODS: Seventy-four consecutive living kidney donors (30 men, 44 women; mean age, 41.7 years) who underwent MDCT were evaluated. CT examination was performed with 120 mL of IV contrast material at an injection rate of 3 mL/sec and a pitch of 6. In every case, arterial and venous phase volumetric data sets were acquired at 25 and 55 sec, respectively. Scans were reconstructed at 1-mm intervals for three-dimensional (3D) imaging using a volume-rendering technique. Axial CT images and 3D CT angiography were evaluated prospectively by one reviewer and retrospectively by two reviewers who had no knowledge of surgical results. Surgical correlation for the location of primary and accessory renal arteries, early branching of the renal arteries, and renal vein anomalies was made. RESULTS: Seventy-two subjects underwent left nephrectomy, and two subjects underwent right nephrectomy because supernumerary left renal arteries were detected on preoperative CT angiography. Eighteen supernumerary renal arteries (two arteries to 16 kidneys and three arteries to one kidney) to 74 kidneys underwent nephrectomy. CT and surgical findings agreed in 93% of subjects (the average of three reviewers; range, 89-97%). Two small accessory renal arteries were missed by all three reviewers. Those arteries were diminutive and were thought to be insignificant by the surgeons. Early branching of the renal arteries was shown in 14 arteries, and CT and surgical findings agreed in 96% (the average of three reviewers; range, 93-97%). Renal vein anomalies were present in eight subjects, and CT and surgical findings agreed in 99% of the cases (range, 96-100%). CONCLUSION: MDCT angiography is highly accurate for detecting vascular anomalies and providing anatomic information for laparoscopic living donor nephrectomy.

Antibody-mediated rejection (AbAR) is increasingly recognized in the renal allograft population, and successful therapeutic regimens have been developed to prevent and treat AbAR, enabling excellent outcomes even in patients highly sensitized to the donor prior to transplant. It has become critical to develop standardized criteria for the pathological diagnosis of AbAR. This article presents international consensus criteria for and classification of AbAR developed based on discussions held at the Sixth Banff Conference on Allograft Pathology in 2001. This classification represents a working formulation, to be revisited as additional data accumulate in this important area of renal transplantation.

There is a significant shortage of donor kidneys. As a result, kidney transplant candidates wait for prolonged periods of time for an organ, and over eight die every day while awaiting a kidney transplant. To improve this situation, the transplant community has actively sought creative solutions to the organ shortage. Many patients have willing live donors who are excluded from donation due to a positive crossmatch or blood group incompatibility. Plasmapheresis and intravenous immunoglobulin in combination can efficiently remove antibodies against donor tissue and blood group antigens and prevent these antibodies from returning after transplantation. Both strategies are complex but have good success rates and provide an opportunity for transplantation to those who might wait years for an organ or die waiting on the list Knowledge of these novel protocols is essential for the nephrology nurse who is often the first health care provider to discuss transplantation with end stage renal disease (ESRD) patients.

A stagnant supply of transplantable organs in the face of a relentless burgeoning of transplant waiting lists has created a crisis. Necessity continues to be the mother of invention and as the crisis has deepened it has served as a crucible for the development of new ways to think about perennial problems. Our program has taken a 2-pronged approach to increasing the organ supply for our patients. First, through innovations like the laparoscopic donor nephrectomy, ABO-incompatible and positive-crossmatch transplantation protocols, unconventional paired kidney exchanges, and the use of altruistic donors we have more than doubled our utilization of live donor organs. At the same time, we have developed algorithms and interrogative techniques to enhance the intelligent use of kidneys from expanded criteria donors for patients who do not have an available live donor. The laparoscopic nephrectomy has proven to be a safe and effective way of removing a significant barrier to live donation. Our results from 100 ABOi, (+)XM, and PKE transplants are similar to national statistics for compatible live donor transplants, suggesting that existing paradigms of compatibility can be safely expanded. These encouraging early outcomes and the savings they transmit to the health care system have allowed us to obtain insurance coverage for the InKTP programs, setting the stage for further expansion of these opportunities to broaden the options for patients with end-stage renal disease.

BACKGROUND AND PURPOSE: Complications related to laparoscopic donor nephrectomy (LDN) have been similar to those associated with open renal donor nephrectomy (ODN). However, during clinical follow-up, we noted a group of male patients who developed acute ipsilateral orchialgia after LDN. In an effort to assess the incidence of this problem, determine the etiology, and adapt preventive measures, we reviewed our experience. PATIENTS AND METHODS: A retrospective chart review was performed on 381 consecutive LDNs performed between February 1995 and November 2001 to assess for postoperative orchialgia. There were 157 male patients (41.2%) in our series. Our technique involves ligation of the gonadal vessels, periureteral tissue, and ureter over the iliac artery using either surgical clips or a linear laparoscopic GIA stapler. RESULTS: Left-sided nephrectomy was performed in 145 (92.3%) male patients, of whom 14 (9.6%) complained of ipsilateral orchialgia. Statistical analysis (t-test) of the orchialgia and non-orchialgia groups with respect to operative time, estimated blood loss, warm ischemia time, and ureteral length revealed no statistical differences (P>0.1). Onset of testicular pain occurred on average at postoperative day 5 (range days 1-14). The mean follow-up was 24.4 +/- 14.8 months (range 6-52 months). Ten patients were evaluated with transcrotal duplex ultrasonography. One patient with decreased flow and was managed conservatively, while one patient without detectable testicular flow underwent surgical exploration. One patient underwent spermatocelectomy and had improvement but not resolution of pain. The remaining patients were treated conservatively with nonsteroidal anti-inflammatory medication and empiric antibiotics. Seven patients (50%) had complete spontaneous resolution of orchialgia on average 6.3+/-7.2 months after LDN. CONCLUSION: Laparoscopic donor nephrectomy has proven to be an effective and safe surgical procedure. However, further evaluation has demonstrated a complication not previously reported, namely ipsilateral orchialgia. The etiology remains unclear but may be injury to the sensory nerves of the testicle during dissection of the periureteral tissue or transection of the spermatic cord. Further anatomic and physiological studies are needed to elucidate the pathophysiology of this problem

PURPOSE: Inadvertent injuries during trocar and Veress needle placement are a rare but potentially serious complication of laparoscopic surgery. An access alternative is an optical trocar under direct vision. Limited data are available regarding the safety of this technique. We reviewed complications related to optical access trocars during standard transperitoneal urological laparoscopic procedures performed at a single institution. MATERIALS AND METHODS: From 1995 to 2001 the optical access trocar was used as the initial trocar in 1,283 urological laparoscopic procedures. The procedures included simple and radical nephrectomy in 309 cases, donor nephrectomy in 386, partial nephrectomy in 79, pyeloplasty in 173 and various other procedures in 336. Intra-abdominal complications caused by optical access trocar were assessed. RESULTS: The optical trocar was inserted at the umbilicus in 88 patients (7.4%), in the right upper quadrant in 445 (34.7%) and in the left upper quadrant in 750 (58.5%). There were 4 injuries (0.31%) associated with the optical access trocar. Complications occurred on the left side in 3 cases and on the right side in 1, including 1 injury to bowel, 1 mesenteric injury resulting in a retroperitoneal hematoma and 2 injuries to epigastric vessels. Three cases were recognized and repaired immediately but in a case of epigastric vessel injury the expanding abdominal wall hematoma required postoperative repair. CONCLUSIONS: Optical access trocars provide a safe and rapid technique for initial trocar placement. Results of this large series support the finding that few trocar related complications are associated with the optical access trocar