Vein graft surveillance: Is graft revision without angiography justified and what criteria should be used?

AbstractPurpose: The objective of this study was to assess the accuracy of color-flow duplex surveillance parameters to detect infrainguinal vein graft stenoses and to investigate whether graft revision without angiography is justified. Methods: In a prospective study in which three centers participated, the data of graft surveillance in 300 patients were analyzed. For the evaluation of surveillance criteria all patients underwent a digital subtraction angiography if a graft stenosis was suspected. To create a control group, in patients with normal grafts a consented digital subtraction angiography was performed also. From these data the accuracy of seven duplex and three ankle blood pressure-derived variables was assessed. The relation between various surveillance criteria and continued graft patency was determined with life table analysis with the transient state method. Results: The mean follow-up period was 20 months (range, 1 to 40 months). At univariate and multivariate analysis the peak systolic velocity (PSV) ratio provided the best correlation with angiographic stenoses ≥70% (PSV ratio cutoff 3.0: sensitivity 80%, specificity 84%). This finding did not differ between the participating centers. With life table methods it was demonstrated that the best combination of efficacy (limitation of the number of unnecessary revisions), safety (minimal number of correctable lesions missed), and reduction of angiograms was obtained by a two-parameter surveillance algorithm. This algorithm included a PSV ratio <2.5 to delineate patients in whom a conservative approach without angiography or revision was appropriate, a PSV ratio ≥4.0 to indicate patients in whom vein graft revision without angiography could be scheduled, and a group with PSV ratios between 2.5 and 4.0 in whom angiography was to be performed to determine clinical management on the basis of the stenosis severity. This algorithm had a positive predictive value of 93% and a negative predictive value of 89%. In addition, it resulted in a reduction of the number of angiograms of 49% compared with a policy of angiographies in all patients with a PSV ratio ≥2.5. Conclusions: The best criterion to identify a failing graft is the PSV ratio. With a two-parameter algorithm for vein graft surveillance, the incidence of unnecessary revisions and of missed high-grade lesions was acceptably low, whereas the number of angiograms was reduced by one half. (J Vasc Surg 1998;27:399-413.

Towards a standardised informed consent procedure for live donor nephrectomy:the PRINCE (Process of Informed Consent Evaluation) project-study protocol for a nationwide prospective cohort study

Introduction: Informed consent is mandatory for all (surgical) procedures, but it is even more important when it comes to living kidney donors undergoing surgery for the benefit of others. Donor education, leading to informed consent, needs to be carried out according to certain standards. Informed consent procedures for live donor nephrectomy vary per centre, and even per individual healthcare professional. The basis for a standardised, uniform surgical informed consent procedure for live donor nephrectomy can be created by assessing what information donors need to hear to prepare them for the operation and convalescence. Methods and analysis: The PRINCE (Process of Informed Consent Evaluation) project is a prospective, multicentre cohort study, to be carried out in all eight Dutch kidney transplant centres. Donor knowledge of the procedure and postoperative course will be evaluated by means of pop quizzes. A baseline cohort (prior to receiving any information from a member of the transplant team in one of the transplant centres) will be compared with a control group, the members of which receive the pop quiz on the day of admission for donor nephrectomy. Donor satisfaction will be evaluated for all donors who completed the admission pop-quiz. The primary end point is donor knowledge. In addition, those elements that have to be included in the standardised format informed consent procedure will be identified. Secondary end points are donor satisfaction, current informed consent practices in the different centres (eg, how many visits, which personnel, what kind of information is disclosed, in which format, etc) and correlation of donor knowledge with surgeons' estimation thereof. Ethics and dissemination: Approval for this study was obtained from the medical ethical committee of the Erasmus MC, University Medical Center, Rotterdam, on 18 February 2015. Secondary approval has been obtained from the local ethics committees in six participating centres. Approval in the last centre has been sought. Results: Outcome will be published in a scientific journal

Early Steroid Withdrawal Compared With Standard Immunosuppression in Kidney Transplantation - Interim Analysis of the Amsterdam-Leiden-Groningen Randomized Controlled Trial

BACKGROUND: The optimal immunosuppressive regimen in kidney transplant recipients, delivering maximum efficacy with minimal toxicity, is unknown. METHODS: The Amsterdam, LEiden, GROningen trial is a randomized, multicenter, investigator-driven, noninferiority, open-label trial in 305 kidney transplant recipients, in which 2 immunosuppression minimization strategies-one consisting of early steroid withdrawal, the other of tacrolimus minimization 6 months after transplantation-were compared with standard immunosuppression with basiliximab, corticosteroids, tacrolimus, and mycophenolic acid. The primary endpoint was kidney function. Secondary endpoints included death, primary nonfunction, graft failure, rejection, discontinuation of study medication, and a combined endpoint of treatment failure. An interim analysis was scheduled at 6 months, that is, just before tacrolimus minimization. RESULTS: This interim analysis revealed no significant differences in Modification of Diet in Renal Disease between the early steroid withdrawal group and the standard immunosuppression groups (43.2 mL/min per 1.73 m2 vs 45.0 mL/min per 1.73 m2, P = 0.408). There were also no significant differences in the secondary endpoints of death (1.0% vs 1.5%; P = 0.737), primary nonfunction (4.1% vs 1.5%, P = 0.159), graft failure (3.1% vs 1.5%, P = 0.370), rejection (18.6% vs 13.6%, P = 0.289), and discontinuation of study medication (19.6% vs 12.6%, P = 0.348). Treatment failure, defined as a composite endpoint of these individual secondary endpoints, was more common in the early steroid withdrawal group (P = 0.027), but this group had fewer serious adverse events and a more favorable cardiovascular risk profile. CONCLUSIONS: Based on these interim results, early steroid withdrawal is a safe short-term immunosuppressive strategy. Long-term outcomes, including a comparison with tacrolimus minimization after 6 months, will be reported in the final 2-year analysis

Vesicoureteral Reflux in Kidney Transplantation

Vesicoureteral reflux (VUR) is frequently found after transplantation, but its impact on graft function, urine tract infection, and graft loss remains uncertain. Therefore our objective was to evaluate the effects of VUR on the outcome of renal transplantation. We included 1008 adult renal transplant recipients of whom a 1-week posttransplant voiding cystourethrogram was available. Study end points included occurrence of bacteriuria, renal function, and graft survival. In total, 106 (10.5%) of 1008 graft recipients had a diagnosis of VUR on voiding cystography. The incidence of bacteriuria was comparable in the reflux and nonreflux group (17% vs 17.4%, P = .91). There was no significant difference in renal function at 3 months and 1 year in patients with and without VUR. One- and 5-year graft survival in patients with VUR was 85.8% and 82.1% compared to 87.3% and 83.0% in patients without VUR ( P = .68 and P = .80). Posttransplant VUR has no correlations with early bacteriuria, renal function, and graft surviva

Robot-assisted donor nephrectomy: Initial results and comparison with the hand-assisted laparoscopic technique. A retrospective study

Background: The aim of this study is to evaluate feasibility and safety of robotic-assisted donor nephrectomy (RADN) as compared with the hand-assisted laparoscopic technique (HALDN). Patient and methods: This is a retrospective study of the first 83 consecutive RADN procedures which were compared with a group of 103 consecutive HALDN procedures. Results: The median operating time in the RADN group and the HALDN group were respectively 173 (SD = 37) and 137 (SD = 29) min (p = 0.000). The mean first warm ischemia time (min, SD) in the RADN and HALDN group were respectively 2.60 (0.78) and 2.15 (0.38) (p = 0.000). The median blood loss (ml, SD) in the RADN and HALDN group were respectively 33 (87) and 64 (146) ml (p = 0.000). There were no statistically significant differences in post-operative pain-score, post-operative length of stay and complications between the two groups. There were also no statistically significant differences in recipient serum creatinine at 1 week and 1 month after transplantation. The median recipients eGFR (CKD-EPI) at 1 week in the RADN and HALDN group were respectively 50 (SD = 20) and 38 (SD = 19) (p = 0.018) and at 1 month respectively 52 (SD = 16) and 47 (SD = 15) ml/min/1.73m2 (p = 0.090). Conclusion: Robotic-assisted donor nephrectomy is an evolving technique which is safe for the donor and for the graft

Microsurgery for "wrist" arteriovenous fistula creation in children: a retrospective cohort study

INTRODUCTION: Creating functional arteriovenous fistulae (AVF) at the wrist is challenging in paediatric patients because of the small calibre of the blood vessels. METHODS: We report our experience with AVF surgery in children younger than 15 years of age using microsurgical techniques. Twenty-five patients underwent AVF surgery between 2003 and 2015 (20 for haemodialysis, 4 for plasmapheresis and 1 for parenteral nutrition). Median (range) age was 9 (2-15) years and median weight was 24 (8-61) kg. RESULTS: The one-month occlusion rate was 8%. The primary and secondary patency rates at 1, 2, 3 years were: 60%, 49%, 42%, and 82%, 72%, 54%, respectively. The median (range) maturation time was 4.53 (0.5-11.2) months. We found no statistically significant effect of patient age, body weight, type of AVF and indication for AVF creation on the primary and secondary patency rates. CONCLUSIONS: Microsurgical AVF creation at the wrist can be performed with satisfactory results and should be the preferred technique in the paediatric population

Ureterovesical anastomotic techniques for kidney transplantation: a systematic review and meta-analysis

No consensus exists about which ureterovesical anastomosis technique to use for kidney transplantation. The aim of this systematic review was to compare the existing techniques in relation to the risk of urological complications. All studies that compared ureterovesical anastomotic techniques in kidney transplantation were included. Study endpoints were urinary leakage, ureteral stricture, vesicoureteral reflux and hematuria. Subanalyses of stented and nonstented techniques were performed. Two randomized clinical trials and 24 observational studies were included. Meta-analyses were performed on the Lich-Gregoir (LG) versus Politano-Leadbetter (PL) techniques and LG versus U-stitch (U) techniques. Compared with the PL technique, the LG technique had a significantly lower prevalence of urinary leakage (risk ratio (RR): 0.47, 95% confidence interval (CI): 0.30 to 0.75) and a significantly lower prevalence of hematuria when compared with both PL and U techniques (RR: 0.28, 95% CI: 0.16 to 0.49 and RR: 0.23, 95% CI: 0.11 to 0.50, respectively), regardless of ureteral stenting. There was no difference in the prevalence of ureteral strictures or vesicoureteral reflux between the various techniques. Of the three most frequently used ureterovesical anastomotic techniques, the LG technique results in fewer urological complications than the PL and U technique