Biopsy Induced Arteriovenous Fistula and Venous Stenosis in a Renal Transplant

Renal transplant vein stenosis is a rare cause of allograft dysfunction. Percutaneous stenting appears to be safe and effective treatment for this condition. A 56-year-old Caucasian female with end stage renal disease received a deceased donor renal transplant. After transplant, her serum creatinine improved to a nadir of 1.2 mg/dL. During the third posttransplant month, her serum creatinine increased to 2.2 mg/dL. Renal transplant biopsy showed BK nephropathy. Mycophenolate was discontinued. Over the next 2 months, her serum creatinine crept up to 6.2 mg/dL. BK viremia improved from 36464 copies/mL to 15398 copies/mL. A renal transplant ultrasound showed lower pole arteriovenous fistula and abnormal waveforms in the renal vein. Carbon dioxide (CO2) angiography demonstrated severe stenosis of the transplant renal vein. Successful coil occlusion of fistula was performed along with angioplasty and deployment of stent in the renal transplant vein. Serum creatinine improved to 1.5 mg/dL after

Is Sociodemographic Status Associated with Empathic Communication and Decision Quality in Diabetes Care?

Abstract Objective To assess the relationship between empathic communication, shared decision-making, and patient sociodemographic factors of income, education, and ethnicity in patients with diabetes. Research Design and Methods This was a cross-sectional study from five primary care practices in the Greater Toronto Area, Ontario, Canada, participating in a randomized controlled trial of a diabetes goal setting and shared decision-making plan. Participants included 30 patients with diabetes and 23 clinicians (physicians, nurses, dietitians, and pharmacists), with a sample size of 48 clinical encounters. Clinical encounter audiotapes were coded using the Empathic Communication Coding System (ECCS) and Decision Support Analysis Tool (DSAT-10). Results The most frequent empathic responses among encounters were “acknowledgement with pursuit” (28.9%) and “confirmation” (30.0%). The most frequently assessed DSAT components were “stage” (86%) and knowledge of options (82.0%). ECCS varied by education (p=0.030) and ethnicity (p=0.03), but not income. Patients with only a college degree received more empathic communication than patients with bachelor’s degrees or more, and South Asian patients received less empathic communication than Asian patients. DSAT varied with ethnicity (p=0.07) but not education or income. White patients experienced more shared decision-making than those in the “other” category. Conclusions We identified a new relationship between ECCS, education and ethnicity, as well as DSAT and ethnicity. Limitations include sample size, heterogeneity of encounters, and predominant white ethnicity. These associations may be evidence of systemic biases in healthcare, with hidden roots in medical education. </jats:sec

Single center observation of the role of pre-existing HLA-DP antibodies in humoral rejection following renal transplantation.

HLA antigens, including HLA-A, B, C, DR and DQ have long been known to have an effect on transplant outcome. Presence of antibodies to these antigens is detrimental to transplant outcome as it ends up to either acute or chronic humoral rejection depending on the titer of the antibodies to these antigens. However, the role of HLA-DP is not fully clear, predominantly due to lack of adequate publications and the fact that DP antigen and antibody detection became possible with the advent of new beads technology. As a results, allocation system has not yet included HA-DP antibodies in virtual crossmatching. This report presents two novel cases with strong HLA-DP antibodies which resulted in acute humoral rejection (AMR)

Atypical Hemolytic Uremic Syndrome After Kidney Transplantation: Lessons Learned From the Good, the Bad, and the Ugly. A Case Series With Literature Review.

Atypical hemolytic uremic syndrome (aHUS) after kidney transplantation is rare and carries a grave outcome. We present a single-center experience of all aHUS cases since the program\u27s inception. Six patients were diagnosed with aHUS, all after kidney transplants, except for 1 patient. All had nonreactive crossmatches. Delayed graft function (DGF) occurred in 2 patients. Five patients developed aHUS after transplant; 4 (80%) of these patients manifested aHUS ≤ 14 days. All were confirmed by allograft biopsy. Genetic testing was abnormal in all patients except for 1 patient. Actual patient and graft survival during the first year was 100% and 83.3%, respectively. A single graft was lost early in the study secondary to aHUS (eculizumab was not used in the treatment process). Prophylactic and therapeutic use of eculizumab salvaged all other cases. At 1 year, mean creatinine level was 1.9 mg/dL (range, 1.3-2.5). After 6 months of eculizumab treatment (halted in 2 cases) 1 patient had recurrence 2 months later and eculizumab was restarted. However, graft function continued to worsen, and the graft was ultimately lost at 20 months after kidney transplantation. High index of suspicion, prompt diagnosis, and utilization of eculizumab are key to successful salvage of allografts in cases of aHUS after kidney transplantation. aHUS can be prevented by prophylactic use of eculizumab. It still needs to be determined when and if eculizumab therapy can be safely discontinued

Successful Transplantation of Pediatric Kidneys Despite Vascular Injuries.

The gap between the kidney transplant recipient list and the number of organs available for transplantation continues to grow. Pediatric donors help fill a small and valuable portion of that gap. Normally these organs are transplanted en-bloc by closing the proximal vascular caps and using the distal aorta and distal inferior vena cava (IVC) for inflow. They are however commonly injured during the donor operation making the standard operation for pediatric en-bloc transplantation not possible. This case report presents two cases in which injured small pediatric kidneys were transplanted successfully in adult patients. We are presenting two examples of common vascular injuries to small pediatric kidneys, one venous and one arterial. In both scenarios, the kidneys were transplanted using a modification to the standard technique. The two kidneys were separated and the technique of implantation was modified to allow safe transplantation. This way we were able to transplant both kidneys successfully and using a reproducible methodology. Both recipients were young adults. There were no surgical complications

Expanding the Envelope: Favorable Outcomes Utilizing Kidneys From Small Pediatric Donors (≤ 15 kg).

BACKGROUND: Utilization of kidneys from small pediatric donors (SPDs ≤ 15 kg) is limited. Decisions to split and use the kidneys for 2 recipients remain controversial. METHODS: Retrospective single-center study aimed primarily at evaluating graft loss within 30 days after transplant using SPD kidneys. Recipients were divided into group A (donor weight \u3c 10 kg, n = 24) and group B (≥ 10  kg, n = 16). RESULTS: Forty transplants were performed with 100% patient survival. Mean follow-up was 402 days, overall graft survival was 95%, with 91.7% and 100% in groups A and B, respectively (P = .24). Mean recipient-to-donor weight ratio (RTDWR) was higher in group A (10.5 vs 6.3, P \u3c .001). Surgical complications were similar between the groups. These were more common with en bloc compared to single implantation (P = .05), and RTDWR was the main predictor (P = .005). Graft function was similar between the groups; mean 12-month creatinine was 1.2 mg % and eGFR was 58.2 mL/min/1.73 m CONCLUSION: Utilization and early splitting of SPD kidneys yields favorable graft survival and function irrespective of donor weight and age. Early splitting should be considered