Faculty Bibliography

BACKGROUND:Although a longer time on dialysis before kidney transplant waitlisting has been shown for Blacks versus non-Blacks, relatively few studies have compared this outcome between Hispanics and Whites. METHODS:A multivariable analysis of 1910 (684 Black, 452 Hispanic, and 774 White) consecutive patients waitlisted at our center for a primary kidney transplant between 2005 and mid-2010 was performed for time from starting dialysis to waitlisting (months), the percentage who were preemptively waitlisted (waitlisted before starting dialysis), and time from starting dialysis to waitlisting after excluding the preemptively waitlisted patients. RESULTS:The variables associated with significantly longer median times from starting dialysis to waitlisting and less preemptive waitlisting included Medicare insurance for patients ages <65 years (by far, the most significant variable in each analysis), Black race, higher percentage of households in the patient's zip code living in poverty, being a non-U.S. citizen (for preemptive waitlisting), Medicaid insurance, waitlisted for kidney-alone (vs. kidney-pancreas) transplant, and higher body mass index (longer median times for the latter three variables). Although the effect of Black race was mostly explained by significant associations with lower socioeconomic status (Medicare insurance for patients ages <65 years and greater poverty in the patient's zip code), an unexplained component still remained. The univariable differences showing poorer outcomes for Hispanics versus Whites were smaller and completely explained in multivariable analysis by significant associations with lower socioeconomic status and non-U.S. citizenship. CONCLUSION/CONCLUSIONS:Black and Hispanic patients had significantly longer times from starting dialysis to waitlisting, in large part related to their lower socioeconomic status and less preemptive waitlisting. A greater focus on earlier nephrology care may help to erase much of these disparities.

Intraoperative tumor embolization is a rare complication during the surgical management of renal cell carcinoma with tumor thrombus of the inferior vena cava (IVC). We present a case of pulmonary tumor embolism which occurred during liver mobilization immediately following division of the IVC ligament. We hypothesize that this patient's IVC ligament acted as an external barrier to propagation of the tumor thrombus and that its release caused the tumor to rapidly expand leading to embolization. To our knowledge, this is the first report of a pulmonary tumor embolism occurring immediately following division of the IVC ligament.

UNLABELLED/: BACKGROUND:The surgical management of renal cell carcinoma with invasion of the renal vein or inferior vena cava is associated with significant rates of perioperative morbidity and mortality. In this report we propose a surgical checklist aimed at reducing adverse events associated with the resection of these tumors. METHODS:This review describes the development of an evidence- and experience-based surgical checklist aimed at improving the perioperative safety of patients undergoing radical nephrectomy and tumor thrombectomy. RESULTS:Reducing the risk of complications during the surgical management of renal tumors with venous invasion begins with appropriate pre-operative imaging aimed at defining the cranial extent of the tumor thrombus, thus facilitating accurate preoperative planning. Other key elements of the checklist are aimed at ensuring clear and precise pre-, intra- and postoperative communication between members of the multidisciplinary-care team. CONCLUSION/CONCLUSIONS:A standardized surgical checklist may help to increase the perioperative safety of patients undergoing radical nephrectomy and tumor thrombectomy. Future validation studies are required to determine the clinical feasibility and post-implementation safety profile of this new checklist.

Primary lymphoma of the spermatic cord is rare. We report a case of primary lymphoma of the spermatic cord and review the literature. A 77-year-old man presented with a 5 month history of an enlarging right inguino-scrotal mass. On physical exam, the mass involved the spermatic cord. Computerized tomography and magnetic resonance imaging revealed a 10 cm x 4 cm inguinoscrotal mass related to the spermatic cord. A right inguinal orchidectomy with wide local excision was performed. Pathological and immunohistochemical evaluation identified the tumor as a diffuse large B cell lymphoma of the spermatic cord. Postoperatively, patient began a chemoradiotherapy regimen consistent with metastatic lymphoma.

PURPOSE/OBJECTIVE:Deceased patients with acute kidney injury (AKI) from rhabdomyolysis can be considered as potential kidney donors. METHODS:We performed a retrospective chart review from January 2005 to January 2011 of three donors with AKI from rhabdomyolysis and the four recipients of the donated kidneys. Three donors had AKI from rhabdomyolysis as evidenced by elevated serum creatinine levels, myoglobinuria, and plasma creatinine kinase levels greater than five times the upper limit of normal. All grafts were maintained on pulsatile machine perfusion (MP) prior to transplantation. In one of the patients, serial venous perfusate myoglobin levels were measured from the donor kidney while on MP. RESULTS:Three of the four recipients had delayed graft function, but all had normalized creatinine function after 1 month. One recipient had a creatinine of 1.2 after 79 months, the longest documented follow-up of this kind. Although we measured venous perfusate myoglobin levels from one of the grafts, we found the levels to decrease with increasing time spent on MP. CONCLUSION/CONCLUSIONS:Potential donors with AKI secondary to rhabdomyolysis should not be restricted from the donor pool. MP may play a role in minimizing the effects of AKI in these types of donors.

Renal transplantation is the gold standard treatment for patients with end-stage renal disease and is associated with several advantages over dialysis, including increased quality of life, reduced morbidity and mortality, and lower healthcare costs. Barring the constraints of a limited organ supply, the goals of the patient care should focus on attaining renal transplantation while minimizing, or even eliminating, time spent on dialysis. Disparities in access to renal transplantation between African Americans and Caucasians have been extensively documented, with African Americans having significantly poorer access. There is a growing corpus of literature examining the determinants of reduced access among other racial ethnic minority groups, including Hispanics. These determinants include patient and physician preference, socioeconomic status, insurance type, patient education, and immunologic factors. We review these determinants in access to renal transplantation in the United States among all races and ethnicities.