Ultrasound-guided supraclavicular brachial plexus anaesthesia improves arteriovenous fistula flow characteristics in end-stage renal disease patients

Background: Surgical construction of an arteriovenous fistula is preferred for end-stage renal failure patients requiring long-term haemodialysis.Methods: Patients were randomised into two groups: brachial plexus group (n = 30) or local infiltration group (n = 30). In all patients, a radiocephalic arteriovenous fistula was created by an experienced surgeon using a standard surgical technique. In both groups 20 ml of 0.375% ropivacaine was used. Doppler assessment of vessels was performed at fixed time intervals.Results: Primary patency rate was 100% in the brachial plexus block group whereas there was 10% fistula failure rate in the local infiltration group (p-value = 0.237). Diameter of the vessels, peak systolic velocity, mean diastolic velocity, and blood flow at 30 minutes, 48 hours, 2 weeks, and 6 weeks after the fistula creation was significantly greater than the preoperative diameter in all patients (p-value < 0.05). Intergroup comparison revealed that vascular parameters were significantly better in the brachial plexus analgesia group versus local infiltration group at all observation points up to and including six weeks post fistula creation (p-value < 0.05).Conclusion: Brachial plexus anaesthesia significantly dilates the vessel diameter and increases blood flow whereas local infiltration has a negligible effect on vessel diameter and blood flow.Keywords: arteriovenous fistula, end-stage renal disease, ultrasound guided supraclavicular bloc

Use of autogenous internal iliac artery for bridging the external iliac artery after excision of Aspergillus mycotic aneurysm in renal transplant recipients

Repair of vascular defects in the presence of infection remains a challenging task in immunocompromised patients. We report two patients with postrenal transplant Aspergillus mycotic aneurysms of the allograft renal artery involving the external iliac artery which were excised along with the allograft. The defect in the external iliac artery was repaired successfully with interposition of autogenous internal iliac artery graft. Use of an internal iliac artery graft in such settings has been rarely reported in English literature. Autogenous internal iliac artery grafts provide a useful method to bridge the vascular defects created by radical debridement in the presence of fungal infections

Serum Neopterin Levels among Hepatitis C-Positive Living-Donor Renal Transplant Recipients

Background The role of neopterin as a marker of cell-mediated immunity for immunological monitoring after transplantation is of great potential interest. Neopterin levels among hepatitis C virus (HCV)-positive recipients of living-donor renal transplantation (LDRT) have not been previously described. Methods Twenty-two HCV-positive (group I) and 10 HCV-negative (group II) recipients of LDRT were serially monitored for serum neopterin levels by enzyme-linked immunosorbent assay (ELISA). Group I patients were monitored thrice, ie, before transplantation, day 10, and 6 months post transplantation, while group II patients were monitored twice (day 10 and 6 months post transplantation). Peripheral blood T-lymphocyte subsets (CD3, CD4, CD8, CD4 + CD25 + , CD 16+56 ) and Thl/Th2 cytokines were monitored concomitantly by flow cytometry. Results Ten days post transplantation, there was a significant increase in neopterin and neopterin/creatnine levels among group I patients. There was a positive correlation between activated T-lymphocyte (CD4 + CD25 + ) and neopterin early post transplantation (day 10). Th2 cytokines IL-10 and IL-5 showed a positive correlation with neopterin levels on day 10 and 6 months post transplantation, respectively. Neopterin levels did not show association with either HCV viral load or allograft rejection among our study cohort. Conclusion Increased monocyte/macrophage activation with elevated serum neopterin was detected among group I patients on day 10 post transplantation, but it could not predict rejection. It appears that IL-10 either from a regulatory or nonregulatory source helps in the maintenance of stable graft early post transplantation. Further, it would be of interest to assess the role of neopterin in chronic allograft nephropathy and long-term graft outcome

Renal autotransplantation in a child following renal artery stent fracture

We report an 8-year-old child who underwent percutaneous transluminal renal angioplasty (PTRA) and stenting for renal artery stenosis (RAS) and later presented with stent fracture. Ex vivo renal artery repair and renal autotransplantation were successfully done

Preinduction hemodynamic fluctuations in renal transplant recipients-Comparison of two combined anesthesia regimens

An ideal anesthetic technique for a renal allograft recipient must ensure hemodynamic stability, enhance graft reperfusion, and provide good postoperative pain relief. Hence, a combined general and epidural anesthesia is preferred. In our clinical practice, it has been observed that in chronically ill end-stage renal disease (ESRD) patients, a bolus injection of epidural local anesthetics invariably necessitated the use of vasopressor agents. Such hemodynamic fluctuations may not be favorable for the graft. A prospective, randomized, double-blind study was conducted on 50 ESRD adults, 18-55 years, scheduled for elective live related kidney transplantation. The patients randomly received either epidural fentanyl (50 μg) and normal saline (10 mL) or epidural fentanyl (50 μg) and bupivacaine (0.5%; 10 mL) followed by standardized general anesthesia. Perioperative hemodynamics and vasopressor requirements were compared with both regimens. Early graft function was assessed by the onset of diuresis after declamping, serial creatinine values, glomerular filtration rate, and 24-hour urine output estimation. In the preoperative period, statistically significant reduction in the mean arterial pressure and the cardiac index occurred in 60% of the patients receiving epidural bupivacaine boluses. These hypotensive episodes required a therapeutic intervention prior to general anesthesia, that is, intravenous mephenteramine (3-6 mg; 9.60 ± 2.32 mg) and crystalloid infusion (189.28 ± 21.29 mL). Intraoperative hemodynamic parameters, surgical blood loss, and transplanted kidney function were comparable between the groups. We concluded that the use of regional anesthetics needed to administered cautiously in renal transplant recipients to maintain hemodynamic parameters

Salvage of renal allograft in mycotic pseudoaneurysm of the transplant renal artery

Mycotic pseudoaneurysm of transplant renal artery is a rare complication and warrants allograft nephrectomy. We report a 54-year-old renal allograft recipient who presented with 9.2 cm × 5.9 cm × 5.7 cm sized pseudoaneurysm of transplant renal artery. Blood culture grew Pseudomonas aeruginosa. The allograft was explanted, aneurysm was excised, and the allograft was reimplanted to right internal iliac artery with interposition of autogenous arterial graft. Microbiological examination of the aneurysm wall did not reveal active infection. The patient did well and at four years maintains normal renal function. Salvage of renal allograft is possible in selected patients with mycotic pseudoaneurysm of transplant renal artery