Donor noradrenaline use is associated with better allograft survival in recipients of pancreas transplantation

INTRODUCTION

Outcomes following pancreas transplantation are suboptimal and better donor selection is required to improve this. Vasoactive drugs (VaD) are commonly used to correct the abnormal haemodynamics of organ donors in intensive care units. VaDs can differentially affect insulin secretion positively (dobutamine) or negatively (noradrenaline). The hypothesis was that some VaDs might induce beta-cell stress or rest and therefore impact pancreas transplant outcomes. The aim of the study was to assess relationships between VaD use and pancreas transplant graft survival.

METHODS

Data from the UK Transplant Registry on all pancreas transplants performed between 2004 and 2016 with complete follow-up data were included. Univariable- and multivariable-adjusted Cox regression analyses determined risks of graft failure associated with VaD use.

RESULTS

In 2,183 pancreas transplants, VaDs were used in the following numbers of donors: dobutamine 76 (3.5%), dopamine 84 (3.8%), adrenaline 161 (7.4%), noradrenaline 1,589 (72.8%) and vasopressin 1,219 (55.8%). In multivariable models, adjusted for covariates and the co-administration of other VaDs, noradrenaline use (vs non-use) was a strong predictor of better graft survival (hazard ratio [95% confidence interval] 0.77 [0.64-0.94], p = 0.01).

CONCLUSIONS

Noradrenaline use was associated with better graft survival in models adjusted for donor and recipient variables - this may be related to inhibition of pancreatic insulin secretion initiating pancreatic beta-cell 'rest'. Further research is required to replicate these findings and establish whether relationships are causal. Identification of alternative methods of inducing beta-cell rest could be valuable in improving graft outcomes.

High-temporal resolution profiling reveals distinct immune trajectories following the first and second doses of COVID-19 mRNA vaccines

Knowledge of the mechanisms underpinning the development of protective immunity conferred by mRNA vaccines is fragmentary. Here, we investigated responses to coronavirus disease 2019 (COVID-19) mRNA vaccination via high-temporal resolution blood transcriptome profiling. The first vaccine dose elicited modest interferon and adaptive immune responses, which peaked on days 2 and 5, respectively. The second vaccine dose, in contrast, elicited sharp day 1 interferon, inflammation, and erythroid cell responses, followed by a day 5 plasmablast response. Both post-first and post-second dose interferon signatures were associated with the subsequent development of antibody responses. Yet, we observed distinct interferon response patterns after each of the doses that may reflect quantitative or qualitative differences in interferon induction. Distinct interferon response phenotypes were also observed in patients with COVID-19 and were associated with severity and differences in duration of intensive care. Together, this study also highlights the benefits of adopting high-frequency sampling protocols in profiling vaccine-elicited immune responses.

OC-059 TEMPORARY ABDOMINAL CLOSURE NEGATIVE THERAPY IMPROVES DEFINITIVE FASCIAL CLOSURE RATES IN PATIENTS WITH OPEN ABDOMEN MANAGEMENT

Aims

Encapsulating peritoneal sclerosis (EPS) is a rare phenomenon characterised by encasement of the bowel by a thickened peritoneum due to prolonged peritoneal dialysis exposure. We are an international referral centre, typically managing cases with a planned open abdomen (OAM) and scheduled relook after 24–48 hours. We compare outcomes for those patients whose OAM was with simple packing (betadine-soaked-gauze) with negative pressure therapy providing temporary abdominal closure (TAC).

Methods

A retrospective review of a contemporaneous database of patients who underwent surgery for EPS between 2010–2020 was performed. Primary endpoints were time to definitive closure and closure method (primary fascial closure vs. bridged biologic mesh closure vs. failure to close fascia). Secondary endpoints included comparison of stoma formation, bowel resection, fistulation rate, enterotomy formation, re-operation post closure, and wound infection.

Results

99 patients had OAM (56 static packing; 43 TAC.) Patients with TAC were significantly more likely to undergo primary closure of fascia when compared to those patients managed with static packing, (63% vs 13%, p<0.0001, Chi Sq). The TAC group required fewer theatre episodes (n=2.27 vs. 4.78, p<0.0001, t-test) and time in days to achieve closure (n=2.78 vs n=4.68, p<0.005, Chi Sq), with less failure to close episodes and returns to theatre 30 days post closure.

Conclusion

This study provides definitive evidence of TAC efficacy for fascial closure following OAM. This provides definitive benefit over traditional open abdominal methods. It may provide benefit in definitive open abdominal management in other areas (sepsis and trauma) and requires further study.

Asthma and the Missing Heritability Problem: Necessity for Multiomics Approaches in Determining Accurate Risk Profiles

Asthma is ranked among the most common chronic conditions and has become a significant public health issue due to the recent and rapid increase in its prevalence. Investigations into the underlying genetic factors predict a heritable component for its incidence, estimated between 35% and 90% of causation. Despite the application of large-scale genome-wide association studies (GWAS) and admixture mapping approaches, the proportion of variants identified accounts for less than 15% of the observed heritability of the disease. The discrepancy between the predicted heritable component of disease and the proportion of heritability mapped to the currently identified susceptibility loci has been termed the ‘missing heritability problem.’ Here, we examine recent studies involving both the analysis of genetically encoded features that contribute to asthma and also the role of non-encoded heritable characteristics, including epigenetic, environmental, and developmental aspects of disease. The importance of vertical maternal microbiome transfer and the influence of maternal immune factors on fetal conditioning in the inheritance of disease are also discussed. In order to highlight the broad array of biological inputs that contribute to the sum of heritable risk factors associated with allergic disease incidence that, together, contribute to the induction of a pro-atopic state. Currently, there is a need to develop in-depth models of asthma risk factors to overcome the limitations encountered in the interpretation of GWAS results in isolation, which have resulted in the missing heritability problem. Hence, multiomics analyses need to be established considering genetic, epigenetic, and functional data to create a true systems biology-based approach for analyzing the regulatory pathways that underlie the inheritance of asthma and to develop accurate risk profiles for disease.

Microbial Dysbiosis Tunes the Immune Response Towards Allergic Disease Outcomes

The hygiene hypothesis has been popularized as an explanation for the rapid increase in allergic disease observed over the past 50 years. Subsequent epidemiological studies have described the protective effects that in utero and early life exposures to an environment high in microbial diversity have in conferring protective benefits against the development of allergic diseases. The rapid advancement in next generation sequencing technology has allowed for analysis of the diverse nature of microbial communities present in the barrier organs and a determination of their role in the induction of allergic disease. Here, we discuss the recent literature describing how colonization of barrier organs during early life by the microbiota influences the development of the adaptive immune system. In parallel, mechanistic studies have delivered insight into the pathogenesis of disease, by demonstrating the comparative effects of protective T regulatory (Treg) cells, with inflammatory T helper 2 (Th2) cells in the development of immune tolerance or induction of an allergic response. More recently, a significant advancement in our understanding into how interactions between the adaptive immune system and microbially derived factors play a central role in the development of allergic disease has emerged. Providing a deeper understanding of the symbiotic relationship between our microbiome and immune system, which explains key observations made by the hygiene hypothesis. By studying how perturbations that drive dysbiosis of the microbiome can cause allergic disease, we stand to benefit by delineating the protective versus pathogenic aspects of human interactions with our microbial companions, allowing us to better harness the use of microbial agents in the design of novel prophylactic and therapeutic strategies.

Gut microbial influences on the adaptive immune system and the development of cow milk allergy

Allergic diseases constitute significant health and economic issues in both developed and developing nations, with epidemiological studies demonstrating a rapid increase in the global prevalence of food allergy among the pediatric population. Cow milk protein allergy (CMPA), one of the most common forms of food allergies observed in early childhood, affects between 2%–6% of infants and children under 3 years of age. CMPA can present as either an IgE-mediated atopic allergy or a non-IgE mediated allergic response. Antigen-specific T cells play a pivotal role in directing the type of inflammatory immune response that occurs as well as in the formation of immunological memory. IgE-mediated CMPA is thought to develop because of an abnormal expansion of allergen-specific type-2 helper T (Th2) cells and a corresponding deficiency in immune regulation by regulatory T cells (Tregs), thereby altering the Th2/Treg balance. The gut microbiota, established very early during childhood through host-microbe interactions, can influence the incidence of allergic diseases. In this study, we aimed to analyze both the microbiome composition and CD4+T cell differentiation patterns in pediatric patients with and without cow milk allergy to establish the association between these factors. Using 16S rRNA sequencing, we analyzed the microbiome composition in stool samples of allergic and non-allergic pediatric patients aged between 1–4 years and identified the microbial species abundant in IgE and non-IgE mediated cow milk allergies. To assess the CD4+T cell differentiation patterns, peripheral blood mononuclear cells (PBMCs) from these patients were re-stimulated with cow milk antigen, and T cell subsets were assessed using flow cytometry. Antigen-specific CD4+T cells were identified and sorted for high throughput sequencing and subsequent gene expression analysis. The CD4+T cell differentiation patterns of the total and antigen-specific T cells were analyzed and statistically compared with controls. The identification of the correlation between the CD4+T cell differentiation patterns and species-specific microbial abundance in IgE and non-IgE mediated cow milk allergies can help in determining how the gut microbiome influences the CD4+T cell immune compartment development, ultimately leading to the development of cow milk allergy in pediatric patients.

Dendritic cell activation and screening for key molecular signatures required for the induction of allergic responses

The chain of events that leads to the sensitization of the immune system to environmental antigens, resulting in the onset of allergic disease, has been studied in great detail over the past 30 years. However, during this time, the rate of allergic diseases has increased exponentially, indicating the need to concentrate our studies on host-environmental factors that contribute to the onset of disease. Monocyte-derived dendritic cells (DCs) play a key role in driving localized and systemic immune responses. In this study, we developed a platform for screening the molecular signature and phenotypic profile of DCs activated by allergenic stimuli, including TSLP, IL-25, IL-33, IL-1a, Vit-D3 (1α,25-Dihydroxyvitamin D3), PAR1-AP Peptide, Papain, and recombinant human DerP1 protein to induce a type II associated inflammatory signature. Following activation with allergenic stimuli, modulated DCs are subjected to deep phenotyping via flow cytometry for surface and intracellular markers to detect and/or validate immunomodulatory properties. RNA sequencing is further used to compare the gene expression profiles of DCs responding to either allergenic or microbial stimuli, including the TLR3 agonist dsRNA Poly I:C and TLR4 agonist LPS. In our study, we aimed to identify key molecular signatures of DCs involved in the development of asthma and allergy based on their comparative activation with this broad panel of allergens. We expect to determine central control modules of transcription factors in DCs associated with Th2 induction.

958 Encapsulating Peritoneal Sclerosis with Pericardial Tamponade: A Case Report

Aim

Encapsulating peritoneal sclerosis (EPS) is a rare morbidity associated primarily with peritoneal dialysis. Definitive diagnosis and management can often be prolonged and complicated. The pathogenesis is a two-hit hypothesis of inflammation and myofibroblast differentiation. This report aims to demonstrate the pathogenesis of EPS and provide insight into management.

Method

We present a unique case of a patient with EPS who follows a ‘classical’ disease course before developing a concomitant pericardial sclerosis, presenting with cardiac tamponade. We explore the proposed pathophysiology and provide a hypothesis for both uncommon pathologies presenting in the same patient.

Results

A 45-year-old male was treated for EPS and went on to develop a concomitant pericardial sclerosis. Following referral to our centre, the patient underwent a semi-elective surgical enterolysis and peritonectomy for EPS, with excision of all sclerotic and obstructing peritoneal membrane. Two weeks following the surgery, he developed a pericardial tamponade with cardiovascular compromise, unresolved by two separate episodes of pericardiocentesis, leading to surgical intervention. A pericardial pleural window was created via open thoracotomy and 800ml of thick clotted blood was removed from the pericardial cavity. Histology demonstrated pericardial sclerosis.

Conclusions

This case of EPS is unique given the concomitant pericardial sclerosis. Uraemia may be a common mediator of inflammation in the peritoneum and pericardium, predisposing to sclerosis of both membranes of identical embryological origin. Pericardial sclerosis may be present in EPS patients but may not manifest itself clinically by and large. It also demonstrates that effective surgical intervention can lead to excellent patient outcomes.

Impact of Impaired Kidney Function on Outcomes of Nigerians with COVID-9 Infection: Report of Two Cases from the University College Hospital, Ibadan

COVID-19 infection predominantly affects the respiratory system; however, other systems and organs are also affected. The kidneys are among the organs commonly affected by SARS-CoV-2 and this has been reported to be a predictor of increased severity, need for intensive care (ICU), admission, and death. We presented two cases of COVID-19 that were associated with co-morbidities that include diabetes mellitus, systemic hypertension and impaired kidney function. The relationship of the multiple co-morbidities particularly the impaired kidney function with the outcomes of COVID-19 infection and the challenges of offering dialysis for patients with COVID-19 infection with kidney failure were discussed. The two cases presented also highlighted the state of preparedness for the management of COVID-19 and its various complications and co-morbidities, particularly kidney failure in a tertiary hospital in Nigeria at onset of the COVID-19 outbreak.

The Transplant Surgeon: An Unlikely, Yet Suitably Qualified, Member of The Complex Neuro Endocrine Multi-Disciplinary Team

Curative surgery for retro-peritoneal tumours involving vascular structures is challenging and multi-visceral resection is often required to obtain clear resection margins. Abdominal transplant surgeons have considerable experience in all aspects of visceral, vascular and retro-peritoneal surgery. Application of these skills to resect tumours involving vascular structures, and re-implant organs to preserve function is unique. We present the case of a 15- year old girl with a complex retro-peritoneal tumour which was resected en-bloc with the kidneys and vena-cava followed by auto-transplantation of the left kidney. Seven years later, the patient represented with a recurrent tumour which was successfully excised in its entirety. We discuss how innovative surgical strategies can be performed safely on an individualized basis. We highlight the importance of balancing the benefits of the ‘technically possible procedure’ with its risks, along with consideration of the outcomes of treatment and non-treatment alike.

Systematic review to assess the possibility of return of cerebral and cardiac activity after normothermic regional perfusion for donors after circulatory death

BACKGROUND

Normothermic regional perfusion (NRP) is a novel technique that aids organ recovery from donors after circulatory death (DCDs). However, ethical concerns exist regarding the potential return of spontaneous cerebral and cardiac activity (ROSCCA). This study aimed to determine the likelihood of ROSCCA in NRP-DCDs of abdominal organs.

METHODS

Extracorporeal cardiopulmonary resuscitation (ECPR) for refractory out-of-hospital cardiac arrest (OOHCA) was identified as a comparator for NRP-DCDs and as a validation cohort. A systematic search identified all articles relating to NRP-DCDs and ECPR-OOHCA. Rates of ROSCCA and survival outcomes (ECPR-OOHCA only) were recorded and analysed according to the duration of no perfusion.

RESULTS

In NRP-DCDs, 12 of 410 articles identified by database searching were eligible for inclusion. There were no instances of ROSCCA recorded among 493 donors. In ECPR-OOHCA, eight of 947 screened articles were eligible for inclusion (254 patients). Where the absence of perfusion exceeded 5 min in ECPR-OOHCA, there were no survivors with a favourable neurological outcome.

CONCLUSION

ROSCCA is unlikely following commencement of NRP and has not occurred to date. Strict observance of the 5-min interval following asystole provides satisfactory assurance that ROSCCA will not occur following NRP.

An ethical dilemma: malignant melanoma in a 51-year-old patient awaiting simultaneous kidney and pancreas transplantation for type 1 diabetes

Malignant melanoma is a high-risk skin cancer that, in potential transplant recipients, is considered a substantial contraindication to solid organ transplantation due to significant risk of recurrence with immunosuppression. Current guidelines stipulate waiting between 3 and 10 years after melanoma diagnosis. However, in young patients with end-stage organ failure and malignant melanoma, complex ethical and moral issues arise. Assessment of the true risk associated with transplantation in these patients is difficult due to lack of prospective data, but an autonomous patient can make a decision that clinicians may perceive to be high risk. The national and worldwide shortage of available organs also has to be incorporated into the decision to maximize the net benefit and minimize the risk of graft failure and mortality. The incidence of malignant melanoma worldwide is increasing faster than that of any other cancer and continues to pose ethically challenging decisions for transplant specialists evaluating recipients for solid organ transplantation.

Renal Allograft Failure After Ipilimumab Therapy for Metastatic Melanoma: A Case Report and Review of the Literature

Transplant recipients are at an increased risk of malignant melanoma, a result of chronic immunosuppression. Ipilimumab is a newer biological agent targeting T lymphocytes to potentiate an immune response against melanoma, and the use of this agent results in a new adverse effect profile that the clinician must be aware of while a patient is on therapy. We report the case of a male renal transplant recipient who developed graft failure while treated with ipilimumab and minimal immunosuppressive therapy for metastatic ocular melanoma, with biopsy evidence of glomerulonephritis and acute rejection. We highlight the immunological side effects that can manifest from ipilimumab therapy and conclude that it did influence graft function in this patient. Our case illustrates the importance of weighing the risks and benefits to graft function and long-term survival as well as the importance of considering other treatment modalities in this specific group of melanoma patients.

Cyclin F/FBXO1 Interacts with HIV-1 Viral Infectivity Factor (Vif) and Restricts Progeny Virion Infectivity by Ubiquitination and Proteasomal Degradation of Vif Protein through SCFcyclin F E3 Ligase Machinery

Cyclin F protein, also known as FBXO1, is the largest among all cyclins and oscillates in the cell cycle like other cyclins. Apart from being a G₂/M cyclin, cyclin F functions as the substrate-binding subunit of SCF^{cyclin F} E3 ubiquitin ligase. In a gene expression analysis performed to identify novel gene modulations associated with cell cycle dysregulation during HIV-1 infection in CD4⁺ T cells, we observed down-regulation of the cyclin F gene (CCNF). Later, using gene overexpression and knockdown studies, we identified cyclin F as negatively influencing HIV-1 viral infectivity without any significant impact on virus production. Subsequently, we found that cyclin F negatively regulates the expression of viral protein Vif (viral infectivity factor) at the protein level. We also identified a novel host-pathogen interaction between cyclin F and Vif protein in T cells during HIV-1 infection. Mutational analysis of a cyclin F-specific amino acid motif in the C-terminal region of Vif indicated rescue of the protein from cyclin F-mediated down-regulation. Subsequently, we showed that Vif is a novel substrate of the SCF^{cyclin F} E3 ligase, where cyclin F mediates the ubiquitination and proteasomal degradation of Vif through physical interaction. Finally, we showed that cyclin F augments APOBEC3G expression through degradation of Vif to regulate infectivity of progeny virions. Taken together, our results demonstrate that cyclin F is a novel F-box protein that functions as an intrinsic cellular regulator of HIV-1 Vif and has a negative regulatory effect on the maintenance of viral infectivity by restoring APOBEC3G expression.

HSP70 binding protein 1 (HspBP1) suppresses HIV-1 replication by inhibiting NF-κB mediated activation of viral gene expression

HIV-1 efficiently hijacks host cellular machinery and exploits a plethora of host–viral interactions for its successful survival. Identifying host factors that affect susceptibility or resistance to HIV-1 may offer a promising therapeutic strategy against HIV-1. Previously, we have reported that heat shock proteins, HSP40 and HSP70 reciprocally regulate HIV-1 gene-expression and replication. In the present study, we have identified HSP70 binding protein 1 (HspBP1) as a host-intrinsic inhibitor of HIV-1. HspBP1 level was found to be significantly down modulated during HIV-1 infection and virus production inversely co-related with HspBP1 expression. Our results further demonstrate that HspBP1 inhibits HIV-1 long terminal repeat (LTR) promoter activity. Gel shift and chromatin immunoprecipitation assays revealed that HspBP1 was recruited on HIV-1 LTR at NF-κB enhancer region (κB sites). The binding of HspBP1 to κB sites obliterates the binding of NF-κB hetero-dimer (p50/p65) to the same region, leading to repression in NF-κB mediated activation of LTR-driven gene-expression. HspBP1 also plays an inhibitory role in the reactivation of latently infected cells, corroborating its repressive effect on NF-κB pathway. Thus, our results clearly show that HspBP1 acts as an endogenous negative regulator of HIV-1 gene-expression and replication by suppressing NF-κB-mediated activation of viral transcription.

A prospective cohort study of risk prediction in simultaneous pancreas and kidney transplantation

INTRODUCTION

Current risk prediction scoring systems in pancreas transplantation are limited to organ factors and are specific to predicting graft outcome. They do not consider recipient factors or inform regarding recipient morbidity. The aim of this study was to assess the utility of commonly used general surgical risk prediction models (P-POSSUM [Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity], MODS [multiple organ dysfunction score], Charlson co-morbidity index, revised cardiac risk index, ASA [American Society of Anesthesiologists] grade and Waterlow score), and to correlate them with total length of hospital stay (LOS) and critical care unit (CCU) LOS, important surrogate markers of patient outcome.

METHODS

All risk prediction scores were calculated prospectively for all simultaneous pancreas and kidney (SPK) transplant recipients from November 2011 to October 2013, and correlated with outcome measures.

RESULTS

Overall, 57 SPK transplant recipients were analysed. The mean age was 42.0 years (standard deviation [SD]: 7.60 years), 27 (52%) were male and the mean body mass index was 25.43kg/m(2) (SD: 3.11kg/m(2)). The mean pancreas and kidney cold ischaemic times were 703 minutes (SD: 182 minutes) and 850 minutes (SD: 192 minutes) respectively. The median total LOS and mean CCU LOS was 17 days (range: 8-79 days) and 7 days (SD: 4.04 days) respectively. When correlated with risk prediction scores, Waterlow score was the only significant predictor of total LOS and CCU LOS (p<0.001 [Spearman's correlation] and p=0.001 [Pearson's correlation] respectively).

CONCLUSIONS

Preoperative risk prediction plays an important part in planning perioperative care. To date, no validated risk prediction scoring system exists for SPK transplantation. This prospective study indicates that Waterlow score identifies high risk individuals and has value in the prediction of outcome following SPK transplantation.

Outcomes of methicillin-resistant Staphylococcus aureus infection after kidney and/or pancreas transplantation

BACKGROUND

The true extent of Methicillin-Resistant Staphylococcus aureus (MRSA) colonization and incidence of infection after solid organ transplantation in adults and children is not well-known. The aim of this study was to evaluate the incidence and the outcomes of MRSA infection following kidney and/or pancreas transplantation.

MATERIAL AND METHODS

We reviewed the case notes of all patients who developed MRSA colonization and infection within the first year of transplantation between September 2002 and December 2009. The primary endpoint of this study was mortality. The secondary endpoints included morbidity, graft failure, and length of hospital stay.

RESULTS

During the study period 1116 transplantations were performed. MRSA colonization was detected in 14 patients (1.25%) and infection occurred in 6 cases (0.53%) post-transplantation. Graft failure was not associated with MRSA colonization/infection in any of the cases. The mortality rate attributed to MRSA was 10% (n = 2). The overall median length of stay was 16 days (range, 6-243 days).

CONCLUSIONS

Our study demonstrates that the prevalence of MRSA colonization and infection in our unit is low in spite of immunosuppression. The incidence of MRSA infection was higher among patients who underwent pancreas transplantation. Patients who had MRSA colonization and then developed infection had higher morbidity and mortality rates.

Encapsulating peritoneal sclerosis

Would you recognize this condition?

Complications following pancreatic transplantations: imaging features

Whole organ vascularized pancreatic transplant is a recognized treatment for diabetes and is increasingly being performed worldwide. The procedure itself is complex and is associated with significant mortality and morbidity. Despite improvements in surgical techniques, postoperative complications of pancreatic transplantation are still common and include graft rejection, pancreatitis, peripancreatic fluid collections, exocrine leaks, vascular thrombosis, and hemorrhage. In this pictorial essay, we review clinical presentation and imaging features of these complications. We also briefly discuss technique and complications of islet cell transplants.

3'-Benzoyl-1'-methyl-4'-phenyl-spiro[acenaphthyl-ene-1(2H),2'-pyrrolidin]-2-one

In the title compound, C₂₉H₂₃NO₂, the pyrrolidine ring adopts a twisted conformation about one of the C—N bonds. The acenaphthone ring (r.m.s. deviation = 0.025 Å) lies almost perpendicular to the pyrrolidine ring [dihedral angle = 88.08 (8)°]. The dihedral angle between the phenyl rings is 88.12 (11)°. In the crystal structure, weak C—H⋯π inter­actions connect the mol­ecules.

Encapsulating peritoneal sclerosis: clinical significance and implications

Encapsulating peritoneal sclerosis (EPS) is a rare but serious complication of peritoneal dialysis (PD). This review discusses the current understanding of the aetiology and pathogenesis of EPS, highlighting histological features which differentiate it from simple sclerosis of the peritoneal membrane which develops with time on PD. Diagnostic criteria are presented, including the role of imaging techniques. To date there are no randomised controlled trials to guide therapy; however, surgical techniques are an important treatment option. Collaborative research will be essential if this serious problem facing PD is to be solved.

3-Benzyl-idene-6-methoxy-chroman-4-one

In the title compound, C₁₇H₁₄O₃, the dihedral angle between the phenyl ring and the benzene ring of the chromanone moiety is 67.78 (3)°. The six-membered heterocyclic ring of the chromanone moiety adopts a half-chair conformation. The structure is stabilized by weak inter­molecular C—H⋯O inter­actions that link the mol­ecules into inversion dimers.

Impact of stents on urological complications and health care expenditure in renal transplant recipients: results of a prospective, randomized clinical trial

PURPOSE

We performed a randomized, prospective trial to compare the incidence of early urological complications and health care expenditures in renal transplant recipients with or without ureteral stenting.

MATERIALS AND METHODS

Patients receiving a renal transplant at a single center were randomized preoperatively to undergo Double-J stent or no-stent ureterovesical anastomosis from November 1998 to October 2001. Early urological mechanical complications were recorded, including urinary leakage or obstruction, or urinary tract infections within 3 months of transplantation. Direct health care costs associated with stenting, urological complications and urinary tract infection management were also collected.

RESULTS

A total of 201 patients were randomized to a stent (112) and a no-stent (89) group. In the no-stent group 11 patients received a stent due to intraoperative findings and were excluded from study. At 3 months there were significantly more cases of urinary leakage (8.9% vs 0.9%, p <0.008) and ureteral obstruction (7.7 % vs 0%, p <0.004) in the no-stent than in the stent group. Mean time of stent removal was 74.3 days. A significant increase in urinary tract infections was observed when stent was left greater than 30 days after transplantation compared to the rate in the no-stent group (p <0.02). An additional cost of 151 UK pounds per patient was incurred in the no-stent group vs the stent group.

CONCLUSIONS

Using a ureteral stent at renal transplantation significantly decreases the early urinary complications of urine leakage and obstruction. However, there is a significant increase in urinary tract infections, primarily beyond 30 days after transplantation. Stent removal within 4 weeks of insertion appears advisable.

Azathioprine-induced pure red cell aplasia: case report and review

The major adverse effect of azathioprine is its myelotoxicity, with leukocytes being affected more commonly than the other bone marrow elements. Although megaloblastic change is frequent, reportedly seen in 16% to 82% of bone marrow aspirates, long-term use of azathioprine rarely causes severe anemia. We report a case of refractory pure red cell aplasia resulting from long-term use of azathioprine in a renal transplant recipient and examine the possible underlying mechanisms. There was no response to dose reduction or to erythropoietin administration. However, there was immediate recovery after complete drug withdrawal. A review of the literature revealed that only ten cases of azathioprine-induced red cell aplasia have so far been described, all in transplant recipients.

Kidney transplantation into an ileal conduit: a single center experience of 59 cases

PURPOSE

Congenital and acquired conditions of the lower urinary tract can lead to renal failure requiring transplantation. Under these circumstances transplantation into a urinary diversion or an augmented bladder may be the only option. We report our experience with renal transplantation into ileal conduits in the last 22 years.

MATERIALS AND METHODS

Between January 1980 and August 2002, 59 renal transplants were drained into an ileal conduit in 54 patients at our center, accounting for 2.3% of the total number of transplants during this period. Median patient age was 28 years (range 1 to 63) and 13 patients were children. There were 12 living related and 47 cadaveric kidneys transplanted. Spina bifida, the most common cause of end stage renal disease, was seen in 22 patients (41%). Patient and graft survival following transplantation into an ileal conduit were compared with that in the 2,579 other transplants done at this center between January 1980 and December 2001.

RESULTS

Actuarial graft survival was 90% at 1 year, 63% at 5 years, 52% at 10 years and 52% at 15 years. Actuarial patient survival was 95% at 1 year, 83% at 5 years, 69% at 10 years and 69% at 15 years. Graft and patient survival was statistically similar to the outcome of the 2,579 other transplants done at our center between January 1980 and December 2001. At a mean followup of 4.6 years (range 0.1 to 20) mean serum creatinine in the 39 functioning grafts was 156 mmol/l. Of the surgical complications 21% were directly attributable to the ileal conduit and it could be considered a risk factor contributing to the complication in a further 39%. Symptomatic urinary tract infection was noted in 65% of the patients, although it did not lead to graft loss. At followup 7 patients had died with a functioning graft. Grafts were lost due to chronic allograft nephropathy in 3 cases, renal artery stenosis in 2, renal vein thrombosis in 2, and acute severe rejection, staghorn calculus and ureteroileal stricture in 1 each.

CONCLUSIONS

Kidney transplant drainage into an ileal conduit for urinary diversion is an effective treatment for patients with end stage renal disease due to abnormal lower urinary tracts. Despite preexisting co-morbidity and the increased complication rate long-term graft and patient survival is comparable to that in the normal transplant population.

Horseshoe kidney transplantation

Even though the number of patients awaiting renal transplant is rapidly increasing, the donor pool remains relatively stable. In an attempt to increase this pool, marginal kidneys and kidneys with congenital anatomical variations are being used. Horseshoe kidneys, being the most common renal fusion anomaly, can provide a useful solution to the ever-increasing gap between demand and supply. These kidneys have been successfully transplanted en bloc into a single recipient or, alternatively they have been divided and transplanted into 2 recipients. We report a case of the successful transplantation of an en bloc horseshoe kidney into a single recipient. To the best of our knowledge this is the first of its kind in the U.K. The relevant literature is also reviewed with the aim of raising awareness about the necessity and promising outcomes of such transplants.

Effect of cold ischemic time and HLA matching in kidneys coming from "young" and "old" donors: do not leave for tomorrow what you can do tonight

BACKGROUND

Kidneys from older donors are likely to have a lower nephron mass. Nevertheless they constitute a valuable source of kidney allografts. Long cold ischemic time (CIT), with or without delayed graft function (DGF), has been associated with reduced graft survival. The aim of this study was to review the experience of a single UK center to assess the interaction of cold storage time, donor age, organ exchange, and HLA-DR mismatching on short- and long-term survival.

METHODS

We analyzed 788 first cadaver kidney transplants that were performed in our center from 1990 to 1997 and had complete data available. A donor age of 55 years was the cutoff age for "old" and "young" donor kidneys. The primary outcome measured was graft failure from any cause.

RESULTS

There were 132 grafts from donors 55 years or older (16.7%), with 76.8% of the kidneys implanted after >20 hr of CIT. Kidney grafts from donors older than 55 years had worse graft survival than grafts from donors younger than 55 (87% vs. 78% at 1 year and 80% vs. 58% at 5 years after transplant, P=0.0001). A CIT of >20 hr significantly reduced graft survival (91% vs.74.3% at 5 years after transplant, P=0.0002) in the young donor group and was associated with an overall graft survival in the old donor group of 57.5% at 5 years. In the same group, ignoring the HLA-DR mismatching to achieve shorter CIT, the predicted initial cost on graft survival at 1 year would have been 3.7% but would have increased to 9% 5 years after transplant. For young donors a CIT of >20 hr had a cost of approximately 18% at 5-year graft survival, far higher than a single DR mismatch. Occurrence of DGF decreased survival in both short (P=0.001) and long (P=0.00001) CIT groups.

CONCLUSION

Forming local alliances (common recipient lists) and minimizing delays within the hospital might reduce CIT and DGF while achieving excellent HLA matching. This should improve significantly the outcome of both old and young donor kidney grafts.

Pre-emptive kidney transplantation: the attractive alternative

BACKGROUND

Dialysis can be life-saving for patients with end-stage renal failure. However, not only is it associated with significant morbidity and a greater mortality than transplantation, but it is also expensive. Therefore renal transplantation is generally regarded as the treatment of choice for patients in whom this form of renal replacement therapy is appropriate. Transplantation usually takes place after a variable period of dialytic therapy, but pre-emptive kidney transplantation (PKT) has established itself as an attractive alternative.

MATERIALS AND METHODS

1463 consecutive first kidney transplants performed between January 1980 and December 1995 in a single centre were analysed. The 161 patients (11%) transplanted without prior dialysis were compared with the 1302 patients who had been dialysed prior to being transplanted. The pre-emptive group did not differ from the dialysis group in respect of donor age, donor and recipient gender, HLA mismatch, or cold ischaemic time, although there were more live donor transplants within the pre-emptive group.

RESULTS

Delayed graft function occurred more frequently in the dialysis group (25% vs 16%) but more patients experienced an acute rejection episode in the pre-emptive group (67 vs 55%). The actuarial graft survival in the pre-emptive group at 1, 5, and 10 years (84, 76 and 67%) was significantly higher than the respective values in the dialysis group (83, 69, and 56%). Within the live donor recipient cohort the survival advantage for the pre-emptive group was even more striking.

CONCLUSION

Pre-emptive kidney transplantation not only avoids the risks, cost, and inconvenience of dialysis, but is also associated with better graft survival than transplantation after a period of dialysis, particularly within the live donor cohort.