Lessons Learned from the Amputation of a Bilateral Hand Grafted Patient due to Psychiatric Disorders

The importance of psychosocial aspects in upper extremity transplantation (UET) has been emphasized since the beginning of the vascularized composite allotransplantation era. Herein a long-term UET failure mainly due to psychiatric disorders is reported. A young woman amputated in 2004 (electrocution) underwent bilateral UET in 2007. At the time of transplantation the patient underwent a psychological evaluation, which did not completely consider some traits of her personality. Indeed, she had an anxious personality and a tendency to idealize. The trauma of amputation, the injuries associated with the accident, and the short delay between the accident and the transplantation elicited vindictiveness, entitlement, and impulsivity. Following transplantation, she had a high anxiety level, panic attacks, depression, and hypomanic episodes. She was poorly compliant to the rehabilitation program and the immunosuppressive treatment. She developed 13 acute rejection episodes (reversed by appropriate treatment) but neither clinical signs of chronic rejection nor donor specific antibiodies. She developed many severe complications due to the treatment and the psychiatric disorders. At her request, after many interviews, the allografts were removed in 2018. Pathological examination and an angiography performed post-amputation revealed signs of graft vasculopathy of varying severity, in the absence of clinically overt chronic rejection. This case highlights the need to detect during the initial patients’ assessment even mild traits of personality disorders, which could herald psychiatric complications after the transplantation, compromising UET outcomes. It further confirms that skin and vessels are the main targets of the alloimmune response in the UET setting

Stress urinary incontinence after holmium laser enucleation of prostate: incidence and risk factors

Background and objective: To evaluate the incidence and the risk factors of stress urinary incontinence (SUI) during the first year following Holmium Laser Enucleation of the Prostate (HoLEP). Materials and methods: Our monocentric and retrospective study includes 155 patients who underwent HoLEP for benign prostatic hyperplasia. Surgeries were performed by 2 expert surgeons. The continence was evaluated before and after surgery at 1, 3, 6 and 12 months. The predictive factors of SUI were analysed using logistic regression. Results: The SUI rate at 1, 3, 6 and 12 months was respectively 7.3%, 8.1%, 3.4% and 2.7%. SUI remained present in 4 patients (2.6%) at 12 months. The mean International Consultation Incontinence Questionnaire Urinary Incontinence Short Form (ICIQ-SF) score for patients with SUI was respectively 11.69 ± 5.28, 8.70 ± 4.24, 1.81 ± 3.53 and 8 ± 4.24 at 1, 3, 6 and 12 months (p 30 (Odds Ratio (OR), 4.69; 95% Confidence Interval (CI), 1.51–14.52; p = 0.007) and patients over 70 years old (OR, 16.23; 95% CI, 1.96–134.09; p = 0.010) were respectively identified as independent risk factors for SUI at 1 and 3 months. Conclusions: SUI after HoLEP is transitory in most cases. It is favoured by a high BMI and an age over 70. These criteria should be considered before choosing the operative technique and preventive measures must be taken in high-risk patients

First World Consensus Conference on pancreas transplantation: Part II - recommendations.

Funder: Fondazione Pisa, Pisa, Italy; Id: http://dx.doi.org/10.13039/100007368Funder: Tuscany Region, Italy; Id: http://dx.doi.org/10.13039/501100009888Funder: Pisa University Hospital, Pisa, ItalyFunder: University of Pisa, Pisa, Italy; Id: http://dx.doi.org/10.13039/501100007514The First World Consensus Conference on Pancreas Transplantation provided 49 jury deliberations regarding the impact of pancreas transplantation on the treatment of diabetic patients, and 110 experts' recommendations for the practice of pancreas transplantation. The main message from this consensus conference is that both simultaneous pancreas-kidney transplantation (SPK) and pancreas transplantation alone can improve long-term patient survival, and all types of pancreas transplantation dramatically improve the quality of life of recipients. Pancreas transplantation may also improve the course of chronic complications of diabetes, depending on their severity. Therefore, the advantages of pancreas transplantation appear to clearly surpass potential disadvantages. Pancreas after kidney transplantation increases the risk of mortality only in the early period after transplantation, but is associated with improved life expectancy thereafter. Additionally, preemptive SPK, when compared to SPK performed in patients undergoing dialysis, appears to be associated with improved outcomes. Time on dialysis has negative prognostic implications in SPK recipients. Increased long-term survival, improvement in the course of diabetic complications, and amelioration of quality of life justify preferential allocation of kidney grafts to SPK recipients. Audience discussions and live voting are available online at the following URL address: http://mediaeventi.unipi.it/category/1st-world-consensus-conference-of-pancreas-transplantation/246

Néphrectomie partielle versus élargie en cas d'envahissement de la graisse péri rénale (résultats oncologiques et fonctionnels)

LYON1-BU Santé (693882101) / SudocSudocFranceF

Complications urologiques après greffe de reins issus de donneurs à critères étendus (anastomoses urétéro-vésicales versus anastomoses pyélo-urétérales)

La pénurie de greffons pousse de plus en plus à réaliser des greffes de reins marginaux, issus de donneurs à critères étendus. L'utilisation de ce type de greffons entraîne une augmentation du nombre de complications urologiques post-opératoires à type de fistules et de sténoses principalement. Deux techniques différentes d'anastomose utilisées afin de rétablir la continuité urinaire sont comparées dans cette étude. Nous avons conduit une étude rétrospective, bi-centrique sur une période de 5 ans. 176 patients opérés aux Hospices Civils de Lyon ont bénéficié d'une anastomose urétéro-vésicale selon Lich-Gregoir (Groupe 1) et 167 patients opérés à l'hôpital Necker à Paris ont eu une anastomose pyélourétérale (Groupe 2). Les différentes complications urologiques (fistules, sténoses, lymphocèles, hématomes et reflux vésico-urétéraux) ainsi que leurs prises en charge ont été comparées. Nous avons ensuite recherché les facteurs de risque de complications dans ces deux populations en analyse univariée et réalisé une régression logistique à la recherche de facteurs pronostics indépendants. Les délais d'attente avant la greffe étaient plus longs dans le groupe 2 que dans le groupe 1 (51 et 33,84 mois) ainsi que le pourcentage de patients anuriques (52,9% contre 32,9%) (p<0,001). Le temps d'ischémie froide était plus court dans le groupe 1 (939,3 min en moyenne contre 1325,3 min pour le groupe 2) (p<0,001). Une sonde double J était mise en place dans 97,6% des cas pour le groupe 2 contre 84,2% pour le groupe 1 (p<0,001). On ne retrouvait pas de différence significative dans la survenue de fistules et des sténoses (complications majeures) entre les 2 groupes. Il existait plus de complications mineures (hématomes, lymphocèles et reflux vésico-urétéral) dans le groupe 1 (p=0,033). Il y avait une différence dans la prise en charge de ces complications, en particulier des sténoses (p=0,024) avec une approche significativement plus conservatrice dans le groupe 2. L'analyse multivariée retrouvait l'anurie, le sexe des receveurs et l'âge des donneurs comme facteurs de risque indépendants dans la survenue de complications et la sonde double J comme facteur protecteur. Cette étude ne permet pas de mettre en évidence la supériorité d'une technique d'anastomose urinaire par rapport à l'autre lors de greffes de reins issus de donneurs à critères étendus. Cependant, l'analyse des facteurs de risque permet de proposer un arbre décisionnel afin de guider la stratégie en particulier dans la des receveurs anuriquesLYON1-BU Santé (693882101) / SudocSudocFranceF

Obituary: Jean-Michel "Max" Dubernard (1941-2021)

Jean Michel Dubernard (Max to his friends) passed away on 11 July 2021. He was on vacation with his wife Camille and some of his grandchildren. His death was sudden and unexpected

Greffes de main et de visage : quels sont les enjeux éthiques?

International audienc

Immunopathology of rejection: do the rules of solid organ apply to vascularized composite allotransplantation?

International audiencePURPOSE OF REVIEW: As both the number of vascularized composite allotransplants (VCAs) recipients and the duration of their follow-up are limited, immunopathology of VCA rejection remains incompletely understood. VCAs have several immunological peculiarities, which make inaccurate a direct extrapolation of all rules established for solid organs. RECENT FINDINGS: Despite their bone marrow content, VCA do not induce chimerism in recipient and are therefore not spontaneously tolerated. Skin compartment of VCA contains a high density of antigen-presenting cells (APCs), some with self-renewal capacity. Donor APCs are responsible for continuous direct allosensitization of recipient's T cells that explains the high incidence of skin T-cell-mediated rejection and their occurrence beyond 1 year.Regenerative capability of the skin prevents the development of chronic rejection of this compartment as long as immunosuppression is maintained. In contrast, VCA can develop graft arteriosclerosis, which could be because of T cell and/or chronic antibody-mediated rejection (AMR). VCA recipients can indeed develop donor-specific antibodies (DSA). Whether DSA can also trigger acute AMR of VCA remains to be clarified. SUMMARY: A better understanding of the specificities of the immunopathology of VCA rejection should pave the way for the rationalization of immunosuppressive strategies aiming at optimizing long-term outcome