IMPORTANCE Despite the potential for altruistic nondirected donors (NDDs) to trigger multiple transplants through nonsimultaneous transplant chains, concerns exist that these chains siphon NDDs from the deceased donor wait list and that donors within chains might not donate after their partner receives a transplant. OBJECTIVE To determine the number of transplantations NDDs trigger through chains. DESIGN Retrospective review of large, multicenter living donor-recipient database. SETTING Fifty-seven US transplant centers contributing donor-recipient pairs to the database. PARTICIPANTS The NDDs initiating chain transplantation. MAIN OUTCOMES MEASURE Number of transplants per NDD. RESULTS Seventy-seven NDDs enabled 373 transplantations during 46 months starting February 2008. Mean chain length initiated by NDDs was 4.8 transplants (median, 3; range, 1-30). The 40 blood type O NDDs triggered a mean chain length of 6.0 (median, 4; range, 2-30). During the interval, 66 of 77 chains were closed to the wait list, 4 of 77 were ongoing, and 7 of 77 were broken because bridge donors became unavailable. No chains were broken in the last 15 months, and every recipient whose incompatible donor donated received a kidney. One hundred thirty-three blood type O recipients were transplanted. CONCLUSION AND RELEVANCE This large series demonstrates that NDDs trigger almost 5 transplants on average, more if the NDD is blood type O. There were more blood type O recipients than blood type O NDDs participating. The benefits of transplanting 373 patients and enabling others without living donors to advance outweigh the risk of broken chains that is decreasing with experience. Even 66 patients on the wait list without living donors underwent transplantation with living-donor grafts at the end of these chains.

This is the case of a 69-year-old woman with a history of right iliac fossa living-related kidney transplant that developed acute renal failure due to an obstructing stone in the proximal transplant ureter. She was successfully treated with mini-percutaneous nephrolithotomy wherein a 14-Fr tract was created with serial dilation and a 14-Fr ureteral access sheath was used for access. A flexible ureteroscope with holmium laser and a helical wire basket were used to fragment and extract the stone, respectively. A 10-Fr nephrostomy tube was left for postoperative drainage. There are only a few published reports of mini-percutaneous nephrolithotomy in transplant kidneys, but those reports suggest that the procedure is safe and effective.

Objective To evaluate our multi-institutional outcome with robot-assisted radical prostatectomy (RARP) in renal transplant recipients and describe technical modifications of the procedure. Materials and Methods We retrospectively reviewed 1677 patients, 1422 from Mayo Clinic Arizona and 255 from Loyola University Medical Center, undergoing RARP from March 2004 to October 2010, of which 7 were renal transplant recipients. Baseline demographic features, perioperative data, and oncologic outcomes were reviewed. Results At diagnosis, mean patient age was 63.3 years and serum prostate specific antigen was 6.17 ng/mL. The mean total operative time was 186 minutes (range, 80-210 minutes). No intraoperative complications were noted. The mean hospital length of stay was 1.8 days (range, 1-3 days). Clavien grade II postoperative complications occurred in 3 of the 7 patients (42.9%), consisting of urosepsis, atrial fibrillation, and gross hematuria, all resolving with appropriate medical management. No significant changes were observed in graft function. Two patients (28.6%) had positive surgical margins. During a mean follow-up of 16 months, 1 patient with pathologic T3a, Gleason 9 cancer experienced a biochemical recurrence, which was treated with salvage external-beam radiation and androgen-deprivation therapy. Conclusion Our series suggests that RARP is a safe and feasible form of therapy for localized prostate cancer in a select group of renal transplant recipients.

PURPOSE:Dual kidney transplantation is a technique that some transplant centers have adopted to increase organ use. We investigated whether kidneys that were recovered and discarded were similar to those kidneys used for dual kidney transplantation.MATERIALS AND METHODS:We reviewed all kidneys recovered, biopsied and placed on machine perfusion in the state of Illinois from January 2002 to October 2009. We selected those kidneys used in dual kidney transplant, and compared their characteristics to those of kidneys that were recovered and biopsied but ultimately discarded. The immediate and 1-year outcomes of the dual kidney transplant recipients were analyzed.RESULTS:During the study period 60 dual transplants were performed while 94 kidney pairs were discarded. Overall donors from the used group had a lower mean creatinine clearance, older mean patient age, lower percentage of glomerulosclerosis, higher final flow rate and lower resistance. However, the comparison between those kidneys used successfully with 1-year graft survival and those discarded demonstrated only 3 less favorable parameters among the discarded group, namely a higher percentage of glomerulosclerosis (18.5% vs 13.9%, p=0.024), a higher degree of interstitial fibrosis and a higher final resistance (0.39 vs 0.31, p<0.001).CONCLUSIONS:The considerable overlap in demographics, histology and perfusion parameters between used and discarded kidneys suggests that many kidneys that were recovered and discarded could have been used in dual kidney transplantation with acceptable outcomes. This highlights the need for further study of how kidneys are selected and used.

Introduction: While the ethical aspects of transplant tourism have received much attention recently, less has been written about the medical safety of this practice. We retrospectively evaluated the outcomes of patients who purchased organs internationally and presented to our center for follow-up care.Methods: Baseline demographic characteristics were recorded. Post-operative outcomes including patient survival, graft survival, five-yr graft function, and complications were assessed.Results: Eight patients who purchased international organs for transplant were identified. The country of transplant was China (n = 3), Pakistan (n = 3), India (n = 1), and the Philippines (n = 1). All patients were born in either Asia or the Middle East and traveled to the region of their ethnicity for transplantation. The mean time to presentation was 49 d post-operatively. The overall one-and two-yr patient survival rates were 87% and 75%, respectively. One patient died of miliary tuberculosis and another of Acinetobacter baumanii sepsis. There was one case of newly acquired hepatitis B infection. At last follow-up, all six surviving patients had functioning grafts with a mean creatinine level of 1.26 mg/dL at five yr.Conclusion: Although intermediate-term graft function is acceptable, the early morbidity and mortality among transplant tourists is high. These results suggest that the associated risks may not justify the trip.

PURPOSE:With the now routine use of computerized tomography angiography with 3-dimensional reconstruction in the donor evaluation, renal volume can be easily determined using volume calculating software. We evaluated whether donor renal volume could predict recipient renal function.MATERIALS AND METHODS:Clinical data of all donor and recipient pairs undergoing live donor kidney transplantation at our institution between January 2006 and October 2009 were reviewed. The volume of the kidney selected for transplant was determined using volume calculating software, and correlated to transplant recipient nadir and 1-year serum creatinine. Multivariate regression analysis was performed to adjust for demographic and clinical variables.RESULTS:During the study period 114 patients underwent live donor renal transplantation. Recipient nadir and 1-year serum creatinine levels were significantly correlated with the volume of donated kidney even after adjusting for age, body mass index, body surface area and donor creatinine clearance. Kidney volume also retained significance after excluding recipients from analysis who experienced acute rejection episodes.CONCLUSIONS:Larger kidney volumes calculated using 3-dimensional computerized tomography with volume calculating software are correlated with lower recipient nadir and 1-year serum creatinine levels.

While the widespread use of imaging has resulted in an increasing number of incidentally detected renal cancers, up to one third of patients present with metastatic disease and a significant number of those with clinically localized disease subsequently develop metastasis. The prognosis for patients with metastatic disease has traditionally been poor, with a 2-year survival of only 10 to 20%. However, over the past decade a number of developments have enhanced the treatment of these patients. Phase III trials have demonstrated a significant improvement in overall survival for well-selected patients undergoing cytoreductive nephrectomy prior to immunotherapy. Meanwhile, the recent introduction of molecular targeted agents has resulted in improved response rates and tolerability compared with immunotherapy, and has prompted a re-evaluation of the role and timing of surgery in patients with advanced disease. This review examines the role of surgical therapy for patients with metastatic disease in the new era of molecular targeted therapy.

You have accessJournal of Urology1 Apr 2009DEVELOPMENT OF END-STAGE RENAL DISEASE IN KIDNEY DONORS: A SINGLE-INSTITUTION EXPERIENCE Kristin A. Greco, Ahmer V Farooq, David Holt, Susan Hou, and John E. Milner Kristin A. GrecoKristin A. Greco More articles by this author , Ahmer V FarooqAhmer V Farooq More articles by this author , David HoltDavid Holt More articles by this author , Susan HouSusan Hou More articles by this author , and John E. MilnerJohn E. Milner More articles by this author View All Author Informationhttps://doi.org/10.1016/S0022-5347(09)62065-6AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "DEVELOPMENT OF END-STAGE RENAL DISEASE IN KIDNEY DONORS: A SINGLE-INSTITUTION EXPERIENCE." The Journal of Urology, 181(4S), p. 739 © 2009 by American Urological AssociationFiguresReferencesRelatedDetails Volume 181Issue 4SApril 2009Page: 739 Advertisement Copyright & Permissions© 2009 by American Urological AssociationMetricsAuthor Information Kristin A. Greco More articles by this author Ahmer V Farooq More articles by this author David Holt More articles by this author Susan Hou More articles by this author John E. Milner More articles by this author Expand All Advertisement PDF downloadLoading ...

A 27-year-old woman with end-stage renal disease secondary to type I diabetes received a living-related renal transplant in December 2000. The kidney function immediately improved and serum creatinine during the first month was between 106 and 124 μmol/l. In September 2001, her serum creatinine increased to 292 μmol/l. In November 2001, she underwent a renal biopsy, which showed no evidence of acute cellular rejection. One week later, she presented to the emergency room with confusion and falls. The patient's husband stated that she had tremors over the previous 4 months, but they had worsened over the past week. The patient also reported visual hallucinations beginning 1 day before admission. Her home medications were acyclovir, amantadine, aspirin, bupropion, cyclosporine, fluconazole, insulin, isosorbide dinitrate, metoclopramide, metoprolol, mycophenolate mofetil, pantoprazole, prednisone, sulfamethoxazole/trimethoprim, and warfarin. Additional symptoms of ataxia, agitation, and aggressive behavior were also present. On examination, the patient was alert, oriented, and in no apparent distress, but extremely tremulous. Her blood pressure was 164/90 mm Hg; however, the remaining physical exam was unremarkable. On admission, blood urea nitrogen and serum creatinine were 17.1 and 327 μmol/l (estimated creatinine clearance of 0.33 ml/s), respectively. Laboratory results that were remarkable were the following: serum sodium 125 μmol/l, chloride 90 μmol/l, glucose 15.9 μmol/l, and hemoglobin 102 g/l. Cyclosporine level was 195 nmol/l. A computed tomography scan of the head, magnetic resonance imaging of the brain (Figure 1), electroencephalogram, and electrocardiogram were performed. What is the cause of this patient's altered mental status? As the patient's amantadine dosage was increased 5 days before admission, amantadine toxicity was suspected and the drug was discontinued. The patient's computed tomography and electrocardiogram were unremarkable. Magnetic resonance imaging of the brain demonstrated chronic ischemic changes. Electroencephalogram did not show diffuse slowing. Both serotonin syndrome and neuroleptic malignant syndrome were ruled out. Bupropion, sulfamethoxazole/trimethoprim, acyclovir, and metoclopramide were also discontinued. High-dose benzodiazepines were used to control the patient's agitation and hallucinations over the next 7 days. Serial amantadine levels were obtained (Figure 2). Clinical evidence of amantadine toxicity was resolved on day 5 of hospitalization. She was restarted on bupropion, sulfamethoxazole/trimethoprim, and metoclopramide at the same doses without recurrent symptoms. Methylphenidate was added for the treatment of her depression and cognitive deficit. She was discharged 7 days after admission with an improved serum creatinine of 221 μmol/l (estimated creatinine clearance of 0.48 ml/s). Amantadine serum concentrations of greater than 1000 ng/ml have been associated with toxicity.1.Strong D.K. Eisenstat D.D. Bryson S.M. et al.Amantadine neurotoxicity in a pediatric patient with renal insufficiency.DICP. 1991; 25: 1175-1177PubMed Google Scholar Amantadine toxicity is associated with central nervous system findings more commonly in chronic toxicity and with cardiovascular effects more commonly in acute toxicity.2.Snoey E.R. Bessen H.A. Acute psychosis after amantadine overdose.Ann Emerg Med. 1990; 19: 668-670Abstract Full Text PDF PubMed Scopus (24) Google Scholar Cardiovascular effects that have been reported with acute amantadine toxicity are bradycardia, congestive heart failure, hypotension, torsades de pointes, and ventricular arrhythmias.2.Snoey E.R. Bessen H.A. Acute psychosis after amantadine overdose.Ann Emerg Med. 1990; 19: 668-670Abstract Full Text PDF PubMed Scopus (24) Google Scholar In addition, coma, seizures, and death have been reported with acute toxicity.2.Snoey E.R. Bessen H.A. Acute psychosis after amantadine overdose.Ann Emerg Med. 1990; 19: 668-670Abstract Full Text PDF PubMed Scopus (24) Google Scholar Central nervous system effects such as agitation, altered mental status, ataxia, delirium, hallucinations (auditory and visual), hypersomnia, impaired concentration, insomnia, nightmares, psychosis, and tremor have been more evident with chronic toxicity; however, they can occur with acute toxicity.1.Strong D.K. Eisenstat D.D. Bryson S.M. et al.Amantadine neurotoxicity in a pediatric patient with renal insufficiency.DICP. 1991; 25: 1175-1177PubMed Google Scholar, 2.Snoey E.R. Bessen H.A. Acute psychosis after amantadine overdose.Ann Emerg Med. 1990; 19: 668-670Abstract Full Text PDF PubMed Scopus (24) Google Scholar, 3.Armbruster K.F.W. Rahn A.C. Ing T.S. et al.Amantadine toxicity in a patient with renal insufficiency.Nephron. 1974; 13: 183-186Crossref PubMed Scopus (15) Google Scholar Risk factors for chronic amantadine toxicity are concurrent anticholinergic medications, renal impairment, and advanced age.1.Strong D.K. Eisenstat D.D. Bryson S.M. et al.Amantadine neurotoxicity in a pediatric patient with renal insufficiency.DICP. 1991; 25: 1175-1177PubMed Google Scholar, 2.Snoey E.R. Bessen H.A. Acute psychosis after amantadine overdose.Ann Emerg Med. 1990; 19: 668-670Abstract Full Text PDF PubMed Scopus (24) Google Scholar, 3.Armbruster K.F.W. Rahn A.C. Ing T.S. et al.Amantadine toxicity in a patient with renal insufficiency.Nephron. 1974; 13: 183-186Crossref PubMed Scopus (15) Google Scholar The care of renal transplant recipients requires the use of many drugs with potential interactions, and renal function in such patients frequently changes. Because 90% of amantadine is excreted in the urine, it is important to adjust the dose for renal function in patients with renal impairment to avoid the accumulation of amantadine and drug toxicity.3.Armbruster K.F.W. Rahn A.C. Ing T.S. et al.Amantadine toxicity in a patient with renal insufficiency.Nephron. 1974; 13: 183-186Crossref PubMed Scopus (15) Google Scholar The reason for this patient's acute renal insufficiency was not clear. Her renal biopsy was normal and her cyclosporine concentrations were not elevated. The increase in her serum creatinine level began while she was being treated with intravenous acyclovir, and this is the presumed etiology of her renal insufficiency. There is no known nephrotoxicity from amantadine, although it might aggravate renal insufficiency by causing urinary retention. This case highlights the importance of adjusting amantadine dose when renal function changes and monitoring for potential medication interaction in renal transplant recipients.

PURPOSE:To review our experience with renal-sparing approaches for upper-tract transitional-cell carcinoma (UT-TCC) associated with solitary kidneys.PATIENTS AND METHODS:Ten patients with UT-TCC associated with solitary kidneys who were managed with renal-sparing approaches from 2000 to 2004 were identified. Patient data were gathered retrospectively, and a patient interview was conducted. A literature review was performed, and our results were compared with those from selected other authors. The mean follow-up was 33 months.RESULTS:Eight patients (80%) developed recurrence after initial treatment necessitating further intervention. The average number of procedures was nine per patient, and an average of two cycles of topical therapy was given. At the end of the follow-up period, 6 patients (60%) were disease free. Of these 6 patients, 2 (33%) required interval nephroureterectomy because of disease progression in one and renal insufficiency leading to dialysis in the other. Metastatic disease occurred in four patients during the surveillance interval, including one patient with a nephrostomy-site recurrence. Three patients died from their disease during the follow-up period, and one patient remained alive after chemotherapy. The overall survival rate was 70% at 33 months. Of the living patients, 6 (86%) could be reached for comment, and all were very satisfied with their renal-sparing management.CONCLUSIONS:Renal-sparing approaches remain an option in motivated patients with solitary kidneys and UT-TCC. Patients should realize that management tends to involve multiple procedures that are associated with potential morbidity, entails lifetime follow-up, and often requires long-term nephrostomy access for topical treatment or relief of obstruction. Long-term patient quality-of-life and cancer-specific outcomes for renal- sparing management compared with quality-of-life and survival on dialysis are unknown.

Phlyctenular keratoconjunctivitis is a rare manifestation of tuberculosis. If the disease is acute, local corticosteroid therapy coupled with systemic antituberculous drugs commonly results in a speedy cure. However, in chronic or recurrent disease, therapy is less effective. In such cases, antituberculous drugs alone are usually ineffectual, and supplementation with topical corticosteroids may have only a temporary suppressive effect. It is generally believed that the phlyctenules of phlyctenular keratoconjunctivitis represent mainly an allergic response to tuberculoprotein.1Desensitization treatment with tuberculin has been used successfully for adjunctive therapy in certain carefully selected cases in which the usual agents, such as topical steroids and systemic antibiotics, were ineffective.2,3Pines3has reported that systemic corticosteroid therapy facilitates rapid desensitization with tuberculin. Since no experimental evidence has been gained in animals or in man that tuberculin treatment sufficient to effectively abolish skin reactivity will at the same time abolish corneal reactivity, the