Rhabdomyolysis, the release of myoglobin and other cellular breakdown products from necrotic muscle tissue, is seen in patients with crush injuries, drug overdose, malignant hyperthermia, muscular dystrophy, and with increasing frequency in obese patients undergoing routine procedures. For the perioperative clinician, managing the resultant shock, hyperkalemia, acidosis, and myoglobinuric acute kidney injury can present a significant challenge. Prompt recognition, hydration, and correction of metabolic disturbances may reduce or eliminate the need for long-term renal replacement therapy. This article reviews the pathophysiology and discusses key issues in the perioperative diagnosis, risk stratification, and management of rhabdomyolysis.

BACKGROUND: Continuous blood pressure monitoring may facilitate early detection and prompt treatment of hypotension. We tested the hypothesis that area under the curve (AUC) mean arterial pressure (MAP) <65 mm Hg is reduced by continuous invasive arterial pressure monitoring. METHODS: Adults having noncardiac surgery were randomly assigned to continuous invasive arterial pressure or intermittent oscillometric blood pressure monitoring. Arterial catheter pressures were recorded at 1-minute intervals; oscillometric pressures were typically recorded at 5-minute intervals. We estimated the arterial catheter effect on AUC-MAP <65 mm Hg using a multivariable proportional odds model adjusting for imbalanced baseline variables and duration of surgery. Pressures <65 mm Hg were categorized as 0, 1–17, 18–91, and >91 mm Hg × minutes of AUC-MAP <65 mm Hg (ie, no hypotension and 3 equally sized groups of increasing hypotension). RESULTS: One hundred fifty-two patients were randomly assigned to arterial catheter use and 154 to oscillometric monitoring. For various clinical reasons, 143 patients received an arterial catheter, while 163 were monitored oscillometrically. There were a median [Q1, Q3] of 246 [187, 308] pressure measurements in patients with arterial catheters versus 55 (46, 75) measurements in patients monitored oscillometrically. In the primary intent-to-treat analysis, catheter-based monitoring increased detection of AUC-MAP <65 mm Hg, with an estimated proportional odds ratio (ie, odds of being in a worse hypotension category) of 1.78 (95% confidence interval [CI], 1.18–2.70; P = .006). The result was robust over an as-treated analysis and for sensitivity analyses with thresholds of 60 and 70 mm Hg. CONCLUSIONS: Intraoperative blood pressure monitoring with arterial catheters detected nearly twice as much hypotension as oscillometric measurements.

OBJECTIVES Cervical cytology screening has been successful in reducing deaths from cervical cancer. We sought to determine risk factors for abnormal Pap test results in women undergoing kidney transplant evaluation. MATERILAS AND METHODS We retrospectively examined women undergoing kidney transplant evaluations from 2008 to 2011. Patients were stratified based on normal cytology and atypical/malignant cytology. RESULTS Of 404 patients, 293 patients (72.5%) had normal cytologic findings, whereas 111 (27.5%) had abnormal findings. On univariate logistic regression analyses, patients who had chronic kidney disease with an autoimmune cause (odds ratio = 2.71 [95% confidence interval, 1.41-5.19]; P = .003), previous renal transplants (odds ratio = 2.64 [95% confidence interval, 1.20-5.82], P = .016), or age ≤ 50 years (odds ratio = 1.68 [95% confidence interval, 1.08-2.61], P = .022) were more likely to have abnormal findings. Patients with normal and abnormal findings had similar rates of dialysis use. On multivariate logistic regression, patients who had chronic kidney disease with autoimmune causes (odds ratio = 2.48 [95% confidence interval, 1.26-4.88]; P = .008) and who had previous renal transplants (odds ratio = 2.67 [95% confidence interval, 1.20-5.95]; P = .017) were more likely to have abnormal findings. CONCLUSIONS Previous kidney transplant, autoimmune disease, and age ≤ 50 years were associated with abnormalities on cervical cancer screening in our female group of patients. Patients with these characteristics may benefit more from routine cervical cancer screening than other patients evaluated for kidney transplant.

BackgroundBetter risk assessment tools are needed to predict post-transplantation diabetes mellitus (PTDM). Using analytic morphomic measurements from computed tomography (CT) scans, we aimed to identify specific measures of body composition associated with PTDM.MethodsWe retrospectively reviewed 99 non-diabetic kidney transplant recipients who received pre-transplant CT scans at a single institution between 1/2005 and 5/2014. Analytic morphomic techniques were used to measure abdominal adiposity, abdominal size, and psoas muscle area and density, standardized by gender. We measured the associations of these morphomic factors with PTDM.ResultsOne-year incidence of PTDM was 18%. The morphomic factors significantly associated with PTDM included visceral fat area (OR=1.84 per standard deviation increase, P=.020), body depth (OR=1.79, P=.035), and total body area (OR=1.67, P=.049). Clinical factors significantly associated with PTDM included African American race (OR=3.01, P=.044), hypertension (OR=2.97, P=.041), and dialysis vintage (OR=1.24 per year on dialysis, P=.048). Body mass index was not associated with PTDM (OR=1.05, P=.188). On multivariate modeling, visceral fat area was an independent predictor of PTDM (OR=1.91, P=.035).ConclusionsAnalytic morphomics can identify pre-transplant measurements of body composition that are predictive of PTDM in kidney transplant recipients. Pre-transplant imaging contains a wealth of underutilized data that may inform PTDM prevention strategies.

BACKGROUND:Smoking is a modifiable risk factor for cardiovascular disease, malignancy, and surgical complications. Transplant center practices toward smokers vary widely and evoke the classic tension between the ethical principles of justice and utility. We sought to assess current smoking policy variation in U.S. kidney, liver, and pancreas transplant centers.METHODS:An online survey was sent to program directors of all United Network for Organ Sharing-approved solid abdominal organ transplant programs regarding their policies toward prior and current tobacco use.RESULTS:Responses were received from 26% of kidney, 31% of liver, and 37% of pancreas transplant centers. Across organ programs, virtually all centers (97% to 100%) reported transplantations for former smokers, whereas 59% of kidney, 62% of liver, and 33% of pancreas programs reported transplantations for current smokers. Organ programs reported similar rates of having smoking cessation programs (74% to 77%) and performing serum cotinine testing (31% to 38%). Smoking was an absolute contraindication to transplantation at 38% of kidney, 15% of liver, and 50% of pancreas programs. Programs with absolute contraindication policies were less likely to perform transplantations in current smokers and more likely to check serum cotinine levels, but no more likely to have smoking cessation programs.CONCLUSIONS:There is variation in tobacco use policies among abdominal organ transplant programs and centers. Balancing equity and justice when deciding which patients to waitlist requires an individualized approach to the tobacco-using patient, consideration of organ-specific factors, tobacco-related disease burden, and overall patient health. Such multifaceted assessments might be favorable to inflexible tobacco use policies.

Transplant centers typically require screening mammography (MMG) for women 40 during evaluation. American Cancer Society recommends starting annual MMG at 40, while USPSTF recommends biennial MMG at 50. We sought to determine the effect of age and other breast malignancy risk factors on screening MMG in the pre-transplant renal failure population undergoing transplant evaluation.MethodsWe retrospectively examined women 40 undergoing kidney transplant evaluation from 2006 to 2012 (n = 541).ResultsPatients aged 40.0-49.9 and 50 had similar rates of breast biopsy and breast malignancy. African Americans underwent a higher rate of biopsies (OR 2.391, 95%CI 1.111-5.019, p = 0.026), with a lower rate of biopsy in those already on dialysis at presentation (OR 0.434, 95%CI 0.212-0.888, p = 0.022). Higher breast density (>50% fibroglandular tissue) increased both rate of biopsy (OR 2.876, 95%CI 1.377-6.010, p = 0.005) and malignancy (OR 5.061, 95%CI 1.012-25.315, p = 0.048).ConclusionsAs we found no independent differences in biopsy or malignancy between age groups, it is reasonable for transplant centers to use the same evaluation MMG screening policy for all women 40. However, as malignancy risk increased with higher breast density, a lower threshold for additional workup may be warranted in patients with dense breasts or an indeterminate lesion on MMG.

Background/Purpose: Although graft loss remains the biggest challenge for all pediatric kidney transplant (KT) recipients, unique challenges exist within different age groups. We aim to evaluate the different characteristics and graft survival outcomes of young children and adolescents undergoing KT.Methods: Children who underwent isolated KT between 2000 and 2013 at our institution were included in this retrospective analysis. Patient characteristics and outcomes were compared using student's t-test, chi-square test, Kaplan-Meier curve and Cox proportional hazards model.Results: Of 73 children who underwent KT, 31 were <12 (young children), and 42 were >= 12 years old (adolescents). Overall patient survival was 100%. The younger group had superior 5-year (100% vs. 75.5%) and 10-year (94.4% vs. 43.8%) graft survival (p = 0.008). Factors predictive of poor graft survival on multivariate analysis were older age at transplantation (HR 1.2, CI 1-1.4, p = 0.047), female gender (HR 9.0, CI 1.9-43, p = 0.006), and acute rejection episodes (HR 13, CI 2-90, p = 0.008). The most common causes of graft loss were acute and chronic rejection episodes and immunosuppression nonadherence.Conclusion: Adolescents undergoing KT have inferior graft survival compared to younger children. In adjusted modeling, children with older age, female gender, and acute rejection episodes have inferior graft survival. (C) 2015 Elsevier Inc. All rights reserved.

Background: General health preventive screenings, including colonoscopy, can delay listing for kidney transplant. Unfortunately, length of time on dialysis has been correlated with allograft failure in transplant recipients. Many patients are reluctant to complete colonoscopy, despite its effectiveness in prevention of colon cancer by removal of adenomatous polyps. Methods: With IRB approval, we performed a retrospective analysis of 205 ESRD patients undergoing kidney transplant evaluation at University Hospitals Case Medical Center between 2010 and 2011. Patients age<48, with no colonoscopy on record, or with a personal history of colorectal cancer were excluded. Patients were stratified based on normal pathology at colonoscopy (no finding or hyperplastic polyp) or abnormal pathology at colonoscopy (adenomatous polyp or carcinoma). Results: 128 (62.4%) patients had normal colonoscopies and 77 (37.6%) patients had abnormal colonoscopies, with a median age of 59 (49-76) and 62 (50-73), respectively. Colonoscopic findings included 133 polyps total, 1 of which displayed high-grade dysplasia. A t-test returned seven variables with p≤0.20, on which a logistic regression analysis was performed. Significant findings included age>60 (OR=1.991, 95% CI: 1.077 to 3.678, p=0.028), as well as a higher BMI (OR=1.069, 95% CI: 1.011 to 1.131, p=0.020).Table: No Caption available.Conclusion: A large proportion of patients (38%) had polyps requiring removal. Quality colonoscopies should be obtained prior to transplant, especially for patients age>60 and for patients with higher BMIs.

Introduction: Patients who are immune to hepatitis B virus (HBV) can receive kidneys from HBcAb+ donors, which could shorten their wait time. We sought to determine which subsets of patients are more likely to seroconvert, either through vaccination or prior exposure. Methods: After IRB approval, demographics, serologies, and eventual listing statuses were collected from 292 dialysis patients who had undergone evaluation for adult kidney transplants between 2010 and 2011. Patients were compared based on whether they were immune (n=152) or not immune (n=145), and whether they seroconverted during the study period (n=29) or never converted (n=145). Immunity was defined as having protective levels of hepatitis B surface antibody (HBsAb+). We also compared a subset of the patients who had confirmed vaccination dates using the same groupings: immune (n=21) vs. not immune (n=32) and converters (n=8) vs. non-converters (n=32). Results: Within the larger group of dialysis patients, non-diabetics were more likely to be immune against hepatitis B (Table 1). This association persisted after controlling for BMI, age and successful transplantation (Odds ratio in diabetics=0.59 (95% CI: 0.36 to 0.98, p=0.042)). Within the smaller subset, immunity was more likely in those with a lower BMI and without diabetes (Table 2). The dialysis patients in the larger group who seroconverted during the study period were more likely to be listed than those who remained seronegative (86.2% vs 56.4%, p=0.005) (Table 3), while the patients in the smaller subset whose seroconversion was captured tended to have lower BMIs (p=0.030) (Table 4).Table: No Caption available.Table: No Caption available.Table: No Caption available.Table: No Caption available.Conclusion: Diabetics with ESRD are less likely to have HBV immunity. Those who remain HBV seronegative are less likely to get listed.