Purpose The logistics of cadaveric renal transplantation are largely driven by Cold Ischemic Time (CIT). However, to achieve successful outcomes in increasingly complex donor-recipient combinations, recipient and operative issues demand equal consideration. Extending CIT without detriment to graft function would therefore be of value. We have investigated the role of Hypothermic Machine Perfusion (HMP) as a tool by which such an extension might be obtained. Methods Cadaveric kidneys were allocated to a storage method depending on predicted time to theatre. Kidneys to be transplanted between 8am-8pm in the dedicated transplant theatre remained in Static Cold Storage (SCS). If predicted operating time was out-of-hours, the kidney was transferred to HMP and transplanted at the earliest opportunity on the elective transplant list. Data were collected prospectively including donor and recipient demographics, CIT, operative factors and post-transplant outcomes. Results During the study period (Jan 2012-Dec 2013 inclusive) 74 kidneys were transplanted from HMP and 101 from SCS. Median CIT was 23.85 hours in the HMP group compared to 13 hours in the SCS group (p=<0.0001). 20 HMP kidneys suffered from DGF (27%) compared to 47 (47%) in the SCS group (p=0.012). For DBD kidneys only, 15 of the 65 (23%) HMP kidneys developed DGF compared to 30 of the 75 (40%) SCS kidneys (p=0.046). DGF rates were equivalent for the small number of DCD kidneys in the study. There were no other significant differences in graft or post-operative complications. Conclusions This study demonstrates that improved early graft outcomes can be achieved following longer CITs by utilising HMP storage rather than traditional SCS. This effect is likely to be multi-factorial; including improved recipient preparation, better peri-operative conditions and the inherent effects of HMP itself. Preferences§1234567890-=Backspace Tabqwertyuiop[] Return capslockasdfghjkl;' shift'zxcvbnm,./shift English Deutsch Español Français Italiano Português PyCCKNN alt alt Preferences DISCLOSURES:Guy, A.: Grant/Research Support, Organ Recovery Systems. Inston, N.: Grant/Research Support, Organ Recovery Systems. Ready, A.: Grant/Research Support, Organ Recovery Systems.

BACKGROUND:Guidelines suggest tuberculosis (TB) prophylaxis in renal transplant recipients originating in endemic areas or in those at risk from non-endemic countries. Concern remains that these guidelines may fail to provide adequate prophylaxis for a cohort of patients who remain at potential risk. We aimed to determine variation patterns among different transplant units within the United Kingdom (UK) with regard to TB prophylaxis policy.METHODS:The renal pharmacist at each of the 25 UK renal transplant centers was contacted. Specific information was obtained relating to drug prophylaxis given, duration of treatment, as well as which transplant recipients were eligible for treatment.RESULTS:A 96% response rate (24/25 centers) was achieved. Prophylaxis regimens varied from no prophylaxis to isoniazid 300 mg given life-long. The most common duration of treatment was 6 months post transplantation (at 7 centers). Variations existed in the concurrent use of pyridoxine. A wide discrepancy was seen in the determination of who should receive prophylaxis, with no clear association with frequency of TB incidence in the region.CONCLUSIONS:A marked discrepancy exists among national renal transplant units in pharmacologic prophylaxis for TB, as well in the selection of individuals for this treatment.

Background: Renal transplantation provides the optimal renal replacement therapy albeit in the context of an associated immunocompromised state. This places recipients at increased risk of infective complications with Tuberculosis 20 - 70 times more common in renal transplant recipients. Recent guidelines regarding routine Tuberculosis prophylaxis have been published in the United Kingdom by the British Thoracic Society (mandating Isoniazid 300mg for six months). However, concerns have been raised about drug interactions with immunosuppressnts as well as the risk of hepatic dysfunction. We aimed to investigate prophylactic regimens in use amongst Renal Transplant units nationally. This is an area of particular relevance given the increasing prevalence of the disease nationally combined with the documented deleterious effects on both patient and graft outcome. Methods: All renal transplantation centres across Great Britain and Ireland were approached for tuberculosis prophylaxis protocols post-transplantation. This was achieved via the designated renal transplant pharmacist for each centre who was approached by e-mail and telephonically sequentially with a standardised questionnaire. This enquired as to medication used for prophylaxis, including dosage and duration of treatment as well as patient demographics warranting inclusion for treatment. Results: 24/25 (96%) transplant centres in Great Britain and Ireland responded. All centres giving prophylaxis did so in the form of Isoniazid with variable dosages given across the majority of centres although a propensity for either 200mg or 300mg was noted. (no prophylaxis: 4 centres; Isoniazid 200mg: 5 centres; Isoniazid 300mg: 8 centres; others: 6 centres) In addition, duration of prophylaxis offered also varied, with many centres offering no prophylaxis and 6 months prophylaxis having the highest incidence (no prophylaxis: 4 centres; 6 months:7 centres; 1year:4 centres; lifelong:3 centres; others: 5 centres.) There appears to be no patient demographic standard for prophylaxis in the United Kingdom with great variance amongst individual units. Discussion: Tuberculosis remains an important pathogen in the immunocompromised host particularly in areas with high prevalence of the disease. Prophylaxis therefore has a potentially crucial role in the post-transplant population to prevent possible graft dysfunction and patient morbidity. There appears to be no national consensus or adherence to recently published guidelines to ensure standardised ‘best practice’. This is occurring despite that the fact that within certain urban communities nationally, tuberculosis has reached endemic levels. It is important that a rigorous approach to TB prophylaxis is undertaken to prevent unnecessary morbidity and mortality in the transplant population. Guidelines should be adhered to thereby ensuring optimal outcomes, particularly in light of the great variability in prophylactic regimens nationally.

Background: Renal transplantation, either synchronously with or subsequent to another solid organ, remains unusual. The number of transplant units with the multidisciplinary infrastructure to provide this service coupled with patients with adequate cardio-respiratory reserve and suitable indications for this procedure remain rare. The paucity of suitable donor organs for transplantation with lengthening waiting times has heightened interest in the suitability of transplanting this valuable resource into complex patients as the perception remains that outcomes in this cohort of patients may be suboptimal compared to the general recipient population. We aimed to assess outcomes of kidney grafts as part of multiorgan transplant combinations either synchronously or at a later juncture. Methods: A retrospective analysis was made of a renal transplant database maintained at a single institution offering multiorgan transplantation over 7 years (2005- 2011). This included patient undergoing kidney in combination with other solid organs (liver, heart or lung transplantation (but excluding pancreas) either at the time or as a result of end stage renal failure (ESRF) subsequent to previous solid organ transplantation. Patient and graft survival were assessed as primary endpoints with biopsy proven acute rejection (BPAR) and glomerular filtration rate (eGFR) at 3 and 6 months to as a reliable measure of graft function assessed as secondary endpoints. Results: 19 renal transplants were performed during the study period (13 synchronously with another organ; 7 following previous transplant; median age 51 (range 25-65); 10M, 9F) This comprised: 15 liver/kidney, 3 heart/kidney, 2 lung/heart/kidney and 1 lung/kidney. The aetiology of ESRF included: Calcinuerin toxicity: 8, polycystic disease: 8, Diabetes mellitus: 1, reflux nephropathy: 1, IgA nephropathy 1. 1 year or latest graft and patient survival was 100% (compared to total figures of 93.4% and 97.7% respectively for the entire renal transplant programme; p< 001 and p=0.12 respectively, Fisher's exact test.) Transplant median eGFR at 3 and 6 months was 57.2ml/min (range 25.1-133.7) and 60.7ml/min (range 26.7-77.4) respectively. The BPAR rate in the combined group was 21 % (4/19) compared to 13% (85/658; p=0.14, Fisher's exact test) for the total group. Conclusion: Multiorgan transplantation appears to offer a valuable opportunity for normalisation of renal function with excellent patient and graft survival and renal function outcomes in our cohort of patients. This study is limited slightly by the heterogeneous nature of the kidney graft timings used (synchronous and delayed transplants) as well as the differences in associated organs transplanted, but the infrequent nature of this type of transplantation ensures that meaningful independent series are very difficult to collate to provide meaningful results. It is of interest that the BPAR appears higher in this group compared to the entire programme, although not statistically significant, in the combined transplant group. This doesn't correlate with previous reports of the potential immunoprotective effects of combination transplantation. In carefully selected cases with adequate physiological reserve, it appears as though either synchronous or sequential multiorgan transplantation can be associated with excellent patient and graft outcomes and function. This ensures equitable use of the scarce resource of deceased donor grafts.