COVID-19 pandemic: Building organisational flexibility to scale transplant programs

The prevailing coronavirus disease 2019 pandemic has challenged our lives in an unprecedented manner. The pandemic has had a significant impact on transplantation worldwide. The logistics of travel restrictions, stretching of available resources, unclear risk of infection in immunosuppressed transplant recipients, and evolving guidelines on testing and transplantation are some of the factors that have unfavourably influenced transplant activity. We must begin to build organisational flexibility in order to restart transplantation so that we can be mindful stewards of organ donation and sincere advocates for our patients. Building a culture of honesty and transparency (with patients, families, colleagues, societies, and authorities), keeping the channels of communication open, working in collaboration with others (at local, regional, national, and international levels), and not restarting without rethinking and appraising all elements of our practice, are the main underlying principles to increase the flexibilit

Feasibility, safety and efficacy of enhanced recovery after living donor nephrectomy: systematic review and meta-analysis of randomized controlled trials.

This meta-analysis aims to compare enhanced recovery after surgery (ERAS) vs. standard perioperative practice in the management of living kidney donors. Primary endpoints included mortality, complications, length of stay (LOS) and quality of life after living donor nephrectomy. Medline, Embase, Scopus, Cochrane and Web of Science databases were searched. In total, 3029 records were identified. We then screened 114 full texts. Finally, 11 studies were included in the systematic review corresponding to 813 living donors. Of these, four randomized controlled trials were included in the meta-analysis. ERAS resulted in shorter LOS (95CI: -1.144, -0.078, I2 = 87.622%) and lower incidence of post-operative complications (95CI: 0.158, 0.582, I2 = 0%). This referred to Clavien-Dindo I-II complications (95CI: 0.158, 0.582, I2 = 0%). There was no difference in Clavien-Dindo III-V complications (95CI: 0.061,16.173, I2 = 0%). ERAS donors consumed decreased amounts of narcotics during their hospital stay (95CI: -27.694, -8.605, I2 = 0%). They had less bodily pain (95CI:6.735, 17.07, I2 = 0%) and improved emotional status (95CI: 6.593,13.319, I2 = 75.682%) one month postoperatively. ERAS protocols incorporating multimodal pain control interventions resulted in a mean reduction of 1 day in donors' LOS (95CI: -1.374, -0.763, I2 = 0%). Our results suggest that ERAS protocols result in reduced perioperative morbidity, shorter length of hospital stay and improved quality of life after living donor nephrectomy

Clinical negligence cases in the English NHS: uncertainty in evidence as a driver of settlement costs and societal outcomes

The cost of clinical negligence claims continues to rise, despite efforts to reduce this now ageing burden to the National Health Service (NHS) in England. From a welfarist perspective, reforms are needed to reduce avoidable harm to patients and to settle claims fairly for both claimants and society. Uncertainty in the estimation of quanta of damages, better known as financial settlements, is an important yet poorly characterised driver of societal outcomes. This reflects wider limitations to evidence informing clinical negligence policy, which has been discussed in recent literature. There is an acute need for practicable, evidence-based solutions that address clinical negligence issues, and these should complement long-standing efforts to improve patient safety. Using 15 claim cases from one NHS Trust between 2004 and 2016, the quality of evidence informing claims was appraised using methods from evidence-based medicine. Most of the evidence informing clinical negligence claims was found to be the lowest quality possible (expert opinion). The extent to which the quality of evidence represents a normative deviance from scientific standards is discussed. To address concerns about the level of uncertainty involved in deriving quanta, we provide five recommendations for medico-legal stakeholders that are designed to reduce avoidable bias and correct potential market failures

The effect of erythropoietin on ?-glutamyltransferase during ischemia reperfusion injury in rats

The aim of this experimental study was to examine the effect of erythropoietin on rat model and particularly in an ischemia reperfusion (IR) protocol. The effect of that molecule was studied biochemically using blood mean ?-glutamyltransferase (?GT) levels. Materials and methods: 40 rats of mean weight 247.7 g were used in the study. ?GT levels were measured at 60 min (groups A and C) and at 120 min (groups B and D) of reperfusion. Erythropoietin was administered only in groups C and D. Results were that Epo administration non-significantly decreased the ?GT levels by 12.70% +13.11% results of paired t-test (p= 0.3541). Reperfusion time kept non-significantly increased the ?GT levels by 6.35%+13.24% (P=0.6264). However, erythropoietin administration and reperfusion time together produced a non-significant combined effect in keeping decreased the ?GT levels by 4.62%+7.97% (P= 0.5534). Conclusions are that erythropoietin administration interacted or not with reperfusion time have non significant short term decreasing effects on ?GT levels

Akutan učinak antioksidantnog lijeka U-74389G kod srednjih razina crvenih krvnih tjelešaca za vrijeme hipoksije i ponovljene oksigenacije kod štakora

Aim: The aim of this experimental study was to examine the effect of the antioxidant drug “U-74389G”, on rat model and particularly in a hypoxia – reoxygenation protocol. The beneficial effect or non-effectiveness of that molecule was studied hematologically using blood mean corpuscular hemoglobin (MCH) levels. Methods: 40 rats of mean weight 231.875 gr were used in the study. MCH levels were measured 60 min after reperfusion (groups A and C) and 120 min after reperfusion (groups B and D) with the administration of drug U-74389G in groups C and D. Results: The results were that U-74389G administration significantly increased the MCH levels by 2.40% ± 0.57% (p = 0.0001). Reoxygenation time non-significantly decreased the MCH levels by 0.48% ± 0.69 (p = 0.4103). However, U-74389G administration and reoxygenation time together significantly increased the MCH levels by 1.33% ± 0.36% (p = 0.0005). Conclusion: The results of this study indicate that U-74389G administration either alone or interacted with reoxygenation time has significant increasing short – term effects on the pathophysiology recovery of MCH values.Cilj: Cilj ove eksperimentalne studije je ispitatiučinakantioksidantnog lijeka “U-74389G”, na model štakora, a posebno u protokolu hipoksije i ponovljene oksigenacije. Blagotvoran učinak ili neučinkovitost navedene molekule ispitani su hematološki korištenjem srednjih razina crvenih krvnih tjelešaca (MCH). Metode: U studiji je korišteno 40 štakora srednje težine od 231,875 g. MCH razine izmjerene su 60 min nakon reperfuzije (skupine A i C) i 120 min nakon reperfuzije (skupine B i D) davanjem lijeka U-74389G skupinama C i D. Rezultati: Davanje lijeka U-74389G značajno je povećalo razine MCH za 2,40% ± 0,57% (p = 0,0001). Ponovljena oksigenacija smanjila je beznačajno razine MCH za 0,48% ± 0,69 (p = 0,4103). Davanje U-74389G tijekom ponovljene oksigenacije međutim, značajno je povećalo MCH razine za 1,33% ± 0,36% (p = 0,0005). Zaključak: Rezultati ove studije pokazuju da zasebno davanje U-74389G ili u interakciji s ponovljenom oksigenacijom, značajno povećava kratkotrajne učinke na oporavak patofiziološke razine MCH

The impact of recipient demographics on outcomes from living donor kidneys: systematic review and meta-analysis.

Background and Aims: Recipient demographics affect outcomes after kidney transplantation. The aim of this study was to assess, for kidneys retrieved from living donors, the effect of recipient sex, ethnicity, and body mass index (BMI) on delayed graft function (DGF) and one-year graft function, incidence of acute rejection (AR), and recipient and graft survivals. Methods: A systematic review and meta-analysis was performed. EMBASE and MEDLINE databases were searched using algorithms through Ovid. Web of Science collection, BIOSIS, CABI, Korean Journal database, Russian Science Citation Index, and SciELO were searched through Web of Science. Cochrane database was also searched. Risk of bias was assessed using the NHBLI tools. Data analysis was performed using Revman 5.4. Mean difference (MD) and risk ratio (RR) were used in analysis. Results: A total of 5129 studies were identified; 24 studies met the inclusion criteria and were analysed. Female recipients were found to have a significantly lower serum creatinine 1-year-post renal transplantation (MD: -0.24 mg/dL 95%CI: -0.18 to -0.29 p 30) was found to have no effect on 1-year recipient (p = 0.28) and graft survival (p = 0.93) compared to non-obese recipients although non-obese recipients had a lower rate of DGF (RR = 0.65 p < 0.01) and AR (RR = 0.81 p < 0.01) compared to obese recipients. Conclusions: Gender mismatch between male recipients and female donors has negative impact on graft survival. African ethnicity and obesity do not to influence recipient and graft survival but negatively affect DGF and AR rates

Machine perfusion for abdominal organ preservation: a systematic review of kidney and liver human grafts

Introduction: To match the current organ demand with organ availability from the donor pool, there has been a shift towards acceptance of extended criteria donors (ECD), often associated with longer ischemic times. Novel dynamic preservation techniques as hypothermic or normothermic machine perfusion (MP) are increasingly adopted, particularly for organs from ECDs. In this study, we compared the viability and incidence of reperfusion injury in kidneys and livers preserved with MP versus Static Cold Storage (SCS). Methods: Systematic review and meta-analysis with a search performed between February and March 2019. MEDLINE, EMBASE and Transplant Library were searched via OvidSP. The Cochrane Library and The Cochrane Central Register of Controlled Trials (CENTRAL) were also searched. English language filter was applied. Results: the systematic search generated 10,585 studies, finally leading to a total of 30 papers for meta-analysis of kidneys and livers. Hypothermic MP (HMP) statistically significantly lowered the incidence of primary nonfunction (PMN, p = 0.003) and delayed graft function (DGF, p < 0.00001) in kidneys compared to SCS, but not its duration. No difference was also noted for serum creatinine or eGFR post-transplantation, but overall kidneys preserved with HMP had a significantly longer one-year graft survival (OR: 1.61 95% CI: 1.02 to 2.53, p = 0.04). Differently from kidneys where the graft survival was affected, there was no significant difference in primary non function (PNF) for livers stored using SCS for those preserved by HMP and NMP. Machine perfusion demonstrated superior outcomes in early allograft dysfunction and post transplantation AST levels compared to SCS, but however, only HMP was able to significantly decrease serum bilirubin and biliary stricture incidence compared to SCS. Conclusions: MP improves DGF and one-year graft survival in kidney transplantation; it appears to mitigate early allograft dysfunction in livers, but more studies are needed to prove its potential superiority in relation to PNF in livers