Correlation of histopathologic and dynamic tissue perfusion measurement findings in transplanted kidneys

BACKGROUND: Cortical perfusion of the renal transplant can be non-invasively assessed by color Doppler ultrasonography. We performed the Dynamic Tissue Perfusion Measurement (DTPM) of the transplant’s renal cortex using color Doppler ultrasonography (PixelFlux technique), and compared the results with the histopathological findings of transplant biopsies. METHODS: Ninety-six DTPM studies of the renal transplant’s cortex followed by transplant biopsies were performed in 78 patients. The cortical perfusion data were compared with the parameter of peritubular inflammatory cell accumulation (PTC 0 to 3) based on Banff-classification system. RESULTS: A significant decrease of cortical perfusion could be demonstrated as the inflammatory cells accumulation in peritubular capillaries increased. Increasing peritubulitis caused a perfusion loss from central to distal layers of 79% in PTC 0, of 85% in PTC 1, of 94% in PTC 2, and of 94% in PTC 3. Furthermore, the perfusion loss due to peritubular inflammation was more prominent in the distal cortical layer. The extent of perfusion decline with increasing peritubulitis (from PTC 0 to PTC 3) was 64% in proximal 20% cortical layer (p20), 63% in proximal 50% cortical layer (p50), increased to 76% in distal 50% cortical layer (d50), and peaked at 90% in the distal 20% cortical layer (d20). For those without peritubulitis (PTC 0), the increase in the the Interstitial Fibrosis/Tubular Atrophy (IF/TA) score was accompanied by a significantly increased cortical perfusion. A Polyomavirus infection was associated with an increased cortical perfusion. CONCLUSIONS: Our study demonstrated that the perfusion of the renal transplant is associated with certain pathological changes within the graft. DTPM showed a significant reduction of cortical perfusion in the transplant renal cortex related to peritubular capillary inflammation

Percutaneous Transhepatic Cholangiography and Drainage is an Effective Rescue Therapy for Biliary Complications in Liver Transplant Recipients Who Fail Endoscopic Retrograde Cholangiopancreatography

BackgroundWe attempted to evaluate both the factors that predispose a patient to biliary complications after liver transplantation and the results of percutaneous transhepatic cholangiography and drainage (PTCD) for the management of those complications.MethodsThis study retrospectively reviewed the cases of 81 patients who received liver transplants at Taipei Veterans General Hospital between February 2003 and June 2008. Biliary complications were diagnosed on the basis of clinical findings, laboratory data, and the results of imaging studies.ResultsA total of 18 patients (22.2%) developed biliary complications, and living donor liver transplantation (LDLT) was a significant risk factor (p = 0.035), compared to cadaveric liver transplantation. Eight patients with biliary complications received PTCD as the first treatment modality and 6 had successful results. An additional 10 patients received endoscopic retrograde cholangiopancreatography (ERCP) initially, but only 2 patients were effectively managed. One patient received conservative treatment after ERCP failure. One patient died from sepsis after ERCP. The remaining 6 patients with failed ERCP were successfully managed with PTCD. The overall mortality rate in these patients with biliary complications was 16.7%. No significant prognostic predictors were identified, including age, sex, biochemical data, and model for end-stage liver disease scores.ConclusionBiochemical markers cannot predict biliary complications preoperatively. LDLT increases the risk of biliary complications. PTCD is an effective rescue therapy when ERCP fails

Canagliflozin and renal outcomes in type 2 diabetes and nephropathy

BACKGROUND Type 2 diabetes mellitus is the leading cause of kidney failure worldwide, but few effective long-term treatments are available. In cardiovascular trials of inhibitors of sodium–glucose cotransporter 2 (SGLT2), exploratory results have suggested that such drugs may improve renal outcomes in patients with type 2 diabetes. METHODS In this double-blind, randomized trial, we assigned patients with type 2 diabetes and albuminuric chronic kidney disease to receive canagliflozin, an oral SGLT2 inhibitor, at a dose of 100 mg daily or placebo. All the patients had an estimated glomerular filtration rate (GFR) of 30 to <90 ml per minute per 1.73 m2 of body-surface area and albuminuria (ratio of albumin [mg] to creatinine [g], >300 to 5000) and were treated with renin–angiotensin system blockade. The primary outcome was a composite of end-stage kidney disease (dialysis, transplantation, or a sustained estimated GFR of <15 ml per minute per 1.73 m2), a doubling of the serum creatinine level, or death from renal or cardiovascular causes. Prespecified secondary outcomes were tested hierarchically. RESULTS The trial was stopped early after a planned interim analysis on the recommendation of the data and safety monitoring committee. At that time, 4401 patients had undergone randomization, with a median follow-up of 2.62 years. The relative risk of the primary outcome was 30% lower in the canagliflozin group than in the placebo group, with event rates of 43.2 and 61.2 per 1000 patient-years, respectively (hazard ratio, 0.70; 95% confidence interval [CI], 0.59 to 0.82; P=0.00001). The relative risk of the renal-specific composite of end-stage kidney disease, a doubling of the creatinine level, or death from renal causes was lower by 34% (hazard ratio, 0.66; 95% CI, 0.53 to 0.81; P<0.001), and the relative risk of end-stage kidney disease was lower by 32% (hazard ratio, 0.68; 95% CI, 0.54 to 0.86; P=0.002). The canagliflozin group also had a lower risk of cardiovascular death, myocardial infarction, or stroke (hazard ratio, 0.80; 95% CI, 0.67 to 0.95; P=0.01) and hospitalization for heart failure (hazard ratio, 0.61; 95% CI, 0.47 to 0.80; P<0.001). There were no significant differences in rates of amputation or fracture. CONCLUSIONS In patients with type 2 diabetes and kidney disease, the risk of kidney failure and cardiovascular events was lower in the canagliflozin group than in the placebo group at a median follow-up of 2.62 years

Watchful Waiting Versus Interval Appendectomy for Patients Who Recovered from Acute Appendicitis with Tumor Formation: A Cost-effectiveness Analysis

Interval appendectomy after conservative treatment of appendicitis with tumor formation remains controversial. The purpose of this study was to evaluate the efficacy of interval appendectomy based on a cost-effectiveness analysis. Methods: This was a retrospective study including appendicitis patients with tumor formation who received conservative treatment at first admission to Taipei Veterans General Hospital between January 1998 and December 2003. Demographic data, rate of recurrent appendicitis, and medical costs were analyzed. Results: Of the 165 patients, 1 died after an acute myocardial infarction. The rate of recurrence of appendicitis after conservative treatment was 25.5%. The median cost of follow-up after conservative treatment was NT$24,344. The median cost of interval appendectomy was NT$47,746. The median cost of appendectomy after recurrent appendicitis was NT$62,135. Routine interval appendectomy in all 164 patients would have cost NT$7,830,344. The follow-up protocol with appendectomy after recurrence cost NT$5,655,220. An additional NT$2,175,124 (38%) would have been needed for routine interval appendectomy compared with the follow-up policy, an extra NT$13,263 per person. Conclusion: Routine interval appendectomy would increase the cost per patient by 38% compared with follow-up and appendectomy after recurrence. Routine interval appendectomy is not a cost-effective intervention

Liver transplantation for a renal transplantation recipient with secondary sclerosing cholangitis by choledochoduodenal fistula

Choledochoduodenal fistula (CDF) complicated by peptic diseases or following surgical or endoscopic approaches of the common bile duct is not uncommon. However, it usually occurs without significant symptoms and can be well controlled with conservative treatment in normal immunized patients. Here we report a case involving a 58-year-old male patient with diabetic nephropathy, who received a choledocholithotomy for choledocholithiasis in November 2007 and renal transplantation in March 2008. The patient had recurring cholangitis during the 5 months following his renal transplantation. Cholangiography and liver biopsy revealed sclerosing cholangitis. The patient underwent liver transplantation (LT) in May 2009 because radiological and endoscopic procedures failed to control his jaundice. A proximal CDF was found during the LT procedures. We considered that the patients advanced secondary sclerosing cholangitis was induced by this fistula. At the 16 months' follow-up, the patient was surviving well and the graft remained intact. To our knowledge, this is the first report of a renal transplantation recipient receiving LT because of uncontrolled cholangitis caused by a CDF

Liver transplantation for a renal transplantation recipient with secondary sclerosing cholangitis by choledochoduodenal fistula

Choledochoduodenal fistula (CDF) complicated by peptic diseases or following surgical or endoscopic approaches of the common bile duct is not uncommon. However, it usually occurs without significant symptoms and can be well controlled with conservative treatment in normal immunized patients. Here we report a case involving a 58-year-old male patient with diabetic nephropathy, who received a choledocholithotomy for choledocholithiasis in November 2007 and renal transplantation in March 2008. The patient had recurring cholangitis during the 5 months following his renal transplantation. Cholangiography and liver biopsy revealed sclerosing cholangitis. The patient underwent liver transplantation (LT) in May 2009 because radiological and endoscopic procedures failed to control his jaundice. A proximal CDF was found during the LT procedures. We considered that the patient's advanced secondary sclerosing cholangitis was induced by this fistula. At the 16 months' follow-up, the patient was surviving well and the graft remained intact. To our knowledge, this is the first report of a renal transplantation recipient receiving LT because of uncontrolled cholangitis caused by a CDF

High-surgical-volume hospitals associated with better quality and lower cost of kidney transplantation in Taiwan

AbstractBackgroundOnly a small proportion of patients with end-stage renal disease can receive kidney transplants because of insufficiency of kidney donors in Taiwan. Hospitals compete with each other for kidney transplant surgeries. This study examined the association between hospital surgical volume of kidney transplants and patients’ outcomes and utilizations.MethodsClaims data of all kidney transplants between 1996 and 2003 were retrieved from the National Health Insurance Research Database for analysis. Every kidney recipient was followed up for 3 years until the end of 2006. Hospitals were classified as high-surgical-volume hospitals (HSVHs) if their total number of kidney transplants was 72 or more between 1996 and 2003; otherwise, they were grouped into the low-surgical-volume hospitals (LSVHs). The differences in quality (infection rate, graft rejection rate, readmission rate, mortality, and survival rates of patients and transplanted grafts at 1, 2, and 3 years after surgery) and cost (length of stay, total transplant cost, and annual medical cost for 3 years) of kidney transplants were examined between the two groups.ResultsTotally, 1,060 kidney transplants were analyzed, 77% of which were conducted at 6 of 29 qualified hospitals. Compared with those performed at LSVHs, transplant surgeries at HSVHs were associated with lower bacteria (35.1% vs. 48.8%, p<0.001), fungus (0.2% vs. 1.3%, p=0.008), and cytomegalovirus (1.2% vs. 4.6%, p=0.003) infection; lower mortality (1.1% vs. 5.0%, p<0.001); and higher 1-, 2-, and 3-year survival rates for patients (96.3%, 94.1%, 93.5% vs. 91.2%, 87.1%, 85.4%, respectively, p<0.01) and for transplanted grafts (89.5%, 81.0%, 80.5% vs. 85.8%, 74.6%, 73.3%, respectively, p<0.015). The transplant cost was lower for HSVHs than for LSVHs (New Taiwan $221,977 vs. New Taiwan$257,992, p=0.018).ConclusionSeventy-seven percent of kidney transplant surgeries were concentrated at six hospitals in Taiwan. There were significant differences in quality and cost between HSVHs and LSVHs. We suggest adopting volume-based strategies for nonurgent kidney transplants