Uro | Special Issue : Current Concepts in Transplantation

Research

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12 pages, 743 KiB

Open AccessArticle

The Deceased Transplant Recipients: A Forgotten Source of Organ Donors

by Dai D. Nghiem

Uro 2023, 3(3), 187-198; https://doi.org/10.3390/uro3030020 - 3 Jul 2023

Viewed by 1221

Abstract

Background: Organ transplantation is the most successful therapy for end-stage organ disease since it increases the quality of life and life expectancy. For these reasons, over 107,000 patients were on the waitlist in the United States for a transplant in 2022. Unfortunately, only [...] Read more.

Background: Organ transplantation is the most successful therapy for end-stage organ disease since it increases the quality of life and life expectancy. For these reasons, over 107,000 patients were on the waitlist in the United States for a transplant in 2022. Unfortunately, only 42,887 transplants were performed, and annually, over 7000 patients on the kidney list die or are too sick to transplant. To solve this severe organ shortage, the use of the deceased transplant recipients with functioning organs, whether transplanted or native, is explored as a new source of organ donors. Methods: To assess the feasibility of this option, first, we will review the rate of kidney transplant recipients dying with functioning grafts (DWGF), their re-use, the organ allocation system, the technical aspects of the organ procurement, and the transplantation of the DWGF kidneys. Then, we will consider the larger group of all deceased transplant recipients as potential donors for all functioning, native, or transplanted organs. Conclusions: (1). All functioning kidney transplants explanted from the deceased transplant recipients have excellent long-term function after re-transplantation. (2). The other functioning organs constitute a large unrecognized pool of transplantable organs. (3). The intensivists and the transplant community should be educated about these new options to improve the organ shortage. Full article

(This article belongs to the Special Issue Current Concepts in Transplantation)

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19 pages, 6057 KiB

Open AccessArticle

A Decade of Pancreas Transplantation—A Registry Report

by Angelika C. Gruessner

Uro 2023, 3(2), 132-150; https://doi.org/10.3390/uro3020015 - 25 May 2023

Cited by 4 | Viewed by 2797

Abstract

Since the first pancreas transplant in 1966, over 67,000 pancreas transplants have been performed worldwide and the number is growing. While the number of transplants in the US has changed only slightly over the past decade, many countries outside the US have shown [...] Read more.

Since the first pancreas transplant in 1966, over 67,000 pancreas transplants have been performed worldwide and the number is growing. While the number of transplants in the US has changed only slightly over the past decade, many countries outside the US have shown strong growth in transplant numbers. The worldwide growth in numbers is due to the increasing number of patients with type 2 diabetes mellitus receiving a pancreas transplant. Only during the COVID-19 pandemic in 2020 and 2021 did transplant numbers decline, but they started to recover in 2022. The decline was especially noted for solitary transplants. This development over time was due to excellent patient and graft survival after simultaneous pancreas and kidney transplant (SPK). Patient survival at three years was >90% in SPK as well as in solitary transplants. At 3 years post-transplant, SPK pancreas graft survival was over 86% and SPK kidney graft survival over 90%. In pancreas transplants alone (PTA) and in pancreas after kidney transplants, the 3-year graft function reached 75%. The main reasons for advancement in outcome were reductions in technical failures and immunological graft losses. These improvements were due to better patient and donor selection, standardization of surgical techniques, and superior immunosuppressive protocols. Full article

(This article belongs to the Special Issue Current Concepts in Transplantation)

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9 pages, 263 KiB

Open AccessFeature PaperArticle

Use of Kidneys from Anencephalic Donors to Offset Organ Shortage

by Dai D. Nghiem

Uro 2023, 3(1), 10-18; https://doi.org/10.3390/uro3010002 - 5 Jan 2023

Viewed by 1903

Abstract

Background: It is well recognized that patient survival and quality of life are superior with renal transplantation than with dialysis. Organ availability is far outweighed by the large number of wait-listed patients. Additional stratagems are sought to expand the donor pool, and [...] Read more.

Background: It is well recognized that patient survival and quality of life are superior with renal transplantation than with dialysis. Organ availability is far outweighed by the large number of wait-listed patients. Additional stratagems are sought to expand the donor pool, and kidneys from anencephalic infants can be considered a source of organs, until now unexplored. We plan to assess the feasibility of using the kidneys from anencephalic infants for transplantation. Material and Methods: Information about anencephaly, the characteristics of the infant kidneys, the ethical, social and medico-legal aspects raised by the use of these kidneys, their procurement and their transplantation are reviewed. Conclusions: En bloc kidney transplants from infants can provide long-term normal renal function after an accelerated catch up growth. They are not subjected to hyperfiltration since they have a full complement of nephrons. They can be transplanted using the techniques currently available. Full article

(This article belongs to the Special Issue Current Concepts in Transplantation)

9 pages, 590 KiB

Open AccessArticle

Transplantation of the Horseshoe Kidneys: A Model for Dual Adult Kidney Transplantation

by Dai D. Nghiem

Uro 2022, 2(3), 157-165; https://doi.org/10.3390/uro2030019 - 5 Jul 2022

Cited by 1 | Viewed by 3883

Abstract

Background: The shortage of organs has called for the use of two marginal adult kidneys (MAKs) with a low nephron mass as dual adult kidneys transplanted to a single recipient. The operative techniques of the transplantation of these kidneys are still debated. Since [...] Read more.

Background: The shortage of organs has called for the use of two marginal adult kidneys (MAKs) with a low nephron mass as dual adult kidneys transplanted to a single recipient. The operative techniques of the transplantation of these kidneys are still debated. Since the horseshoe kidneys have been transplanted as early as 1975, it is theorized that the technique of the en bloc transplantation of the horseshoe kidney may be applied to the MAKs. Material and Methods: The world literature search during the period 1975–2021 on the use of deceased-donor horseshoe kidneys was reviewed. The selection of the donors, the anatomy of the kidneys, the principles of organ recovery, the transplantation procedure, and the results were discussed. Finally, this technique of en bloc transplantation was applied successfully to seven pairs of MAKs and is described herein. The dual adult kidneys were simultaneously vascularized by the donor aorta and vena cava, which were anastomosed, respectively, to the recipient iliac artery and vein. Results: A total of 131 case reports of deceased horseshoe kidney donors were reviewed, of which 53 en bloc kidneys were transplanted successfully to a single recipient, and the remaining 78 were divided and transplanted as single units to 131 recipients. Twenty-five single kidneys were discarded. At the time of publication, all horseshoe kidneys had a good renal function. In the series of seven pairs of MAKs transplanted en bloc, the operative time was 3 h. There were no primary nonfunctions, no vascular thromboses, no urinary leakages, and no wound infections. Only two patients required temporary dialysis despite an average of 28.4 h of cold ischemia time. No hydronephrosis and lymphocele was experienced. Both patient and graft survival were 100%. At the time of follow-up at 36 months, serum creatinine levels averaged 1.8 mg/dL (range 1.4–1.9). Conclusions: This technique of en bloc renal transplantation using the donor aorta and vena cava for revascularization can be applied to both the horseshoe kidneys and the MAK, and improve organ utilization. Full article

(This article belongs to the Special Issue Current Concepts in Transplantation)

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7 pages, 2313 KiB

Open AccessArticle

Pull-Through Ureteroneocystostomy for Very Small En Bloc Kidney Transplants from Donors Weighing ≤ 5 kg

by Dai D. Nghiem

Uro 2022, 2(2), 102-108; https://doi.org/10.3390/uro2020013 - 13 May 2022

Cited by 3 | Viewed by 3520

Abstract

Background: Urologic complications are the most dreaded complications of renal transplantation, particularly when pediatric en bloc kidneys (EBKs) are used. Current techniques of ureteroneocystostomy (UNC) are not applicable to the very small ureters of very small en bloc kidneys. We reviewed our experience [...] Read more.

Background: Urologic complications are the most dreaded complications of renal transplantation, particularly when pediatric en bloc kidneys (EBKs) are used. Current techniques of ureteroneocystostomy (UNC) are not applicable to the very small ureters of very small en bloc kidneys. We reviewed our experience with the pull-through ureteroneocystostomy in kidney transplantation from donors under or equal to 5 kg weight. Material and Methods: The technique was used in 32 EBKs. Complications and 4-year graft survival are discussed. Results: One single graft thrombosed and required nephrectomy. The remaining kidneys provided good renal function. Hematuria was transient in five patients and did not require fulguration. No leakage was experienced. Delayed graft function occurred in 16% of cases. No primary nonfunction was noted. During the follow-up period, hydronephrosis and/or pyelonephritis were not observed. The 4-year graft survival was 95% with serum creatinine levels averaging 0.9 mg/dl. Conclusions: The procedure proved to be safe and reproducible. It can be applied to the ureteral re-implantation of very small EBKs. Full article

(This article belongs to the Special Issue Current Concepts in Transplantation)

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7 pages, 4022 KiB

Open AccessArticle

En-Bloc Transplantation of Dual Adult Kidneys with Multiple Vessels

by Dai D. Nghiem

Uro 2021, 1(4), 274-280; https://doi.org/10.3390/uro1040030 - 17 Dec 2021

Cited by 1 | Viewed by 2833

Abstract

Background. To provide optimal nephron mass, two adult kidneys with suboptimal function can be transplanted into one single recipient. All techniques described to date are based on the lengthy sequential transplantation of one allograft after the other, in each iliac fossa, or [...] Read more.

Background. To provide optimal nephron mass, two adult kidneys with suboptimal function can be transplanted into one single recipient. All techniques described to date are based on the lengthy sequential transplantation of one allograft after the other, in each iliac fossa, or through one long incision in the right iliac quadrant. Material and Methods. We report on a novel shorter and simpler operative technique allowing the en-bloc transplantation of seven dual adult kidneys with multiple vessels into a single iliac fossa, with revascularization through the donor aorta and vena cava. A proposal for the identification, allocation, procurement, and placement of the dual adult kidneys is presented. Results. There was no primary non-function, no thrombosis, and no urinary leakage. No urosepsis and hydronephrosis were noted during the follow-up. The operative time was 180 min. At 36 months, serum creatinine levels averaged 1.8 mg/dL (range 1.4–1.9 mg/dL). Conclusions. The procedure described permits converting two complex vascular kidneys into one en-bloc graft, which then can be transplanted into a single iliac incision, using only one arterial and one venous anastomoses. It avoids extensive dissection, shortens the operative time, and reduces the complications rate for the elderly recipients. It is applicable to the transplantation of dual kidneys with single or multiple arteries. Full article

(This article belongs to the Special Issue Current Concepts in Transplantation)

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Review

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9 pages, 244 KiB

Open AccessFeature PaperReview

From the Triangulation Technique to the Use of the Donor Aorta and Vena Cava for Kidney Transplantation: Lessons from the Past and Path to the Future of Xenotransplantation

by Dai D. Nghiem

Uro 2023, 3(2), 151-159; https://doi.org/10.3390/uro3020016 - 26 May 2023

Viewed by 1327

Abstract

Revascularization of the kidney transplant is classically performed by anastomosing the renal vessels to the recipient iliac vessels. This technique is not applicable when the renal vessels are very small, numerous or anomalous and aberrant. In these instances, the donor aorta and the [...] Read more.

Revascularization of the kidney transplant is classically performed by anastomosing the renal vessels to the recipient iliac vessels. This technique is not applicable when the renal vessels are very small, numerous or anomalous and aberrant. In these instances, the donor aorta and the vena cava have to be used for vascular anastomosis. It would be useful to briefly review the development and the use of the donor aorta and cava in renal transplantation during the last century and discuss the potential clinical application of this technique in xenotransplantation of the porcine kidneys in humans at the dawn of the 21st century. Full article

(This article belongs to the Special Issue Current Concepts in Transplantation)

32 pages, 5589 KiB

Open AccessFeature PaperReview

Pancreas Transplantation in Minorities including Patients with a Type 2 Diabetes Phenotype

by Robert J. Stratta and Angelika Gruessner

Uro 2022, 2(4), 213-244; https://doi.org/10.3390/uro2040026 - 19 Oct 2022

Viewed by 2453

Abstract

Background: Prior to year 2000, the majority of pancreas transplants (PTx) were performed as simultaneous pancreas-kidney transplants (SPKTs) in Caucasian adults with end stage renal failure secondary to type 1 diabetes mellitus (T1DM) who were middle-aged. In the new millennium, improving outcomes have [...] Read more.

Background: Prior to year 2000, the majority of pancreas transplants (PTx) were performed as simultaneous pancreas-kidney transplants (SPKTs) in Caucasian adults with end stage renal failure secondary to type 1 diabetes mellitus (T1DM) who were middle-aged. In the new millennium, improving outcomes have led to expanded recipient selection that includes patients with a type 2 diabetes mellitus (T2DM) phenotype, which excessively affects minority populations. Methods: Using PubMed^® to identify appropriate citations, we performed a literature review of PTx in minorities and in patients with a T2DM phenotype. Results: Mid-term outcomes with SPKT in patients with uremia and circulating C-peptide levels (T2DMphenotype) are comparable to those patients with T1DM although there may exist a selection bias in the former group. Excellent outcomes with SPKT suggests that the pathophysiology of T2DM is heterogeneous with elements consisting of both insulin deficiency and resistance related to beta-cell failure. As a result, increasing endogenous insulin (Cp) production following PTx may lead to freedom checking blood sugars or taking insulin, better metabolic counter-regulation, and improvements in quality of life and life expectancy compared to other available treatment options. Experience with solitary PTx for T2DM or in minorities is limited but largely mirrors the trends reported in SPKT. Conclusions: PTx is a viable treatment option in patients with pancreas endocrine failure who are selected appropriately regardless of diabetes type or recipient race. This review will summarize data that unconventional patient populations with insulin-requiring diabetes may gain value from PTx with an emphasis on contemporary experiences and appropriate selection in minorities in the new millennium. Full article

(This article belongs to the Special Issue Current Concepts in Transplantation)

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Other

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6 pages, 192 KiB

Open AccessCase Report

Tacrolimus Induced Organ Failure: Reversal by Activation of the Cytochrome P450-3a System

by Dai D. Nghiem

Uro 2021, 1(4), 222-227; https://doi.org/10.3390/uro1040024 - 11 Nov 2021

Cited by 1 | Viewed by 3850

Abstract

Tacrolimus is the cornerstone component of all immunosuppressive regimens. Despite its long record of use, very little is known about its acute toxicity syndrome. We describe five patients with acute organ failure, involving both native and transplanted organs, which was reversed by inducing [...] Read more.

Tacrolimus is the cornerstone component of all immunosuppressive regimens. Despite its long record of use, very little is known about its acute toxicity syndrome. We describe five patients with acute organ failure, involving both native and transplanted organs, which was reversed by inducing the cytochrome P450-3A system. In all patients, the causative drug was stopped and phenytoin was given intravenously to accelerate tacrolimus metabolism. Within 24 h, tacrolimus trough levels fell daily at a significant level (p < 0.05) and all failed organs recovered their normal function within 48–72 h. Therefore, phenytoin metabolic induction appears to be a safe therapeutic option for patients with acute tacrolimus toxicity. Full article

(This article belongs to the Special Issue Current Concepts in Transplantation)

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