Right Ventricular Dysfunction and Adverse Outcomes after Renal Transplantation

INTRODUCTION: Pulmonary hypertension is common among patients with end-stage renal disease, although data regarding the impact of right ventricular (RV) failure on postoperative outcomes remain limited. We hypothesized that echocardiographic findings of RV dilation and dysfunction are associated with adverse clinical outcomes after renal transplant. METHODS: A retrospective review of adult renal transplant recipients at a single institution from January 2008 to June 2010 was conducted. Patients with transthoracic echocardiograms (TTEs) within 1 year leading up to transplant were included. The primary end point was a composite of delayed graft function, graft failure, and all-cause mortality. RESULTS: Eighty patients were included. Mean follow-up time was 9.4 ± 0.8 years. Eight patients (100%) with qualitative RV dysfunction met the primary end point, while 39/65 patients (60.0%) without RV dysfunction met the end point (p = 0.026). Qualitative RV dilation was associated with a significantly shorter time to all-cause graft failure (p = 0.03) and death (p = 0.048). RV systolic pressure was not measurable in 45/80 patients (56%) and was not associated with outcomes in the remaining patients. CONCLUSION: RV dilation and dysfunction are associated with adverse outcomes after renal transplant. TTE assessment of RV size and function should be a standard part of the pre-kidney transplant cardiovascular risk assessment

Robotic-Assisted Versus Open Techniques for Living Donor Kidney Transplant Recipients: A Comparison Using Propensity Score Analysis

Background: Following the rapid advancements in minimally invasive urology, living donor robotic-assisted kidney transplantation (RAKT) has developed into a feasible alternative to open kidney transplantation (OKT). The procedure has been performed in multiple international programs, but a relative dearth of experience exists in the US. In this investigation, we compare RAKT to OKT using a propensity score analysis, to elucidate the safety and feasibility of RAKT as a suitable alternative to OKT. Methods: A retrospective review of 101 living kidney transplants (36 RAKT, 65 OKT), which occurred between January 2016 and June 2018, was conducted. Selection for RAKT was based on Robot availability. Recipient and donor demographic variable were collected, in addition to perioperative parameters. A propensity score analysis was conducted, matching for recipient age, gender, body mass index, race, pre-operative dialysis, preoperative serum creatinine, panel reactive antibody, and donor age. Primary outcomes assessed included perioperative factors such as estimated blood loss (EBL), cold ischemic time (CIT), warm ischemic time (WIT), operative time, as well as several patient outcomes including, length of stay, narcotics consumed on postoperative days one and two, and change in serum creatinine (SCr) at five time points (day 3, day 7, day 14, 6 months, and 1 year). Final analysis included 35 patients in each group. Results: Recipients’ (N=101) mean age was 49 years (range 19-74), with RAKT recipients slightly younger than OKT recipients (46 vs 51 years). 61 recipients were male and 62 white (29 Black, 10 other). Average recipient BMI was 29 (range 20-40), with equivalent BMIs in RAKT and OKT subsets. Following propensity score analysis, RAKT recipients demonstrated significantly greater WIT (49 vs 38 minutes, p\u3c0.001) and less EBL (62.5 vs 150 mL, p\u3c0.001). However, total operative time and overall length of stay were not significantly different in the groups. Postoperative narcotics consumed on postoperative days one and two were similar between the groups (31.8 vs 32.3 morphine equivalents). Additionally, SCr was evaluated at days 3, 7, and 14 as well as 6 months and 1 year, without significant differences between the groups. Conclusion: RAKT offers an important minimally invasive alternative to OKT, with a short learning curve, and similar graft and patient outcomes. Notably, this study compares RAKT to OKT with a heterogeneous study population, using propensity scoring. The largest limitation of this study is a small sample size. Interestingly, despite the significantly longer WIT in RAKT, we found an equivalence of SCr between groups in the early and intermediate postoperative period. Although the small sample size limits our ability to detect differences in graft and patient outcomes, trends demonstrate shorter lengths of stay, shorter operative times, and smaller amounts of blood loss for RAKT recipients. Additionally, trends demonstrate fewer narcotics administered by the second postoperative day. Similar to the advent of laparoscopic technology in living donor nephrectomy, early findings in RAKT demonstrate a safe and reasonable alternative for living donor kidney transplantation in various populations.https://scholarlycommons.henryford.com/merf2019clinres/1052/thumbnail.jp

Robotic-assisted Versus Open Technique for Living Donor Kidney Transplantation: A Comparison Using Propensity Score Matching for Intention to Treat

Living donor robotic-assisted kidney transplantation (RAKT) is an alternative to open kidney transplantation (OKT), but experience with this technique is limited in the United States. METHODS: A retrospective review of living donor kidney transplants performed between 2016 and 2018 compared RAKT with OKT with regard to recipient, donor, and perioperative parameters. A 1:1 propensity score matching was performed on recipient/donor age, sex, body mass index, race, preoperative dialysis, and calculated panel reactive antibodies. RESULTS: Outcomes of patient survival, graft survival, and postoperative complications were assessed for 139 transplants (47 RAKT and 92 OKT). Propensity score analysis (47:47) showed that RAKT recipients had longer warm ischemic times (49 versus 40 min; P \u3c 0.001) and less blood loss (100 versus 150 mL; P = 0.005). Operative time and length of stay were similar between groups. Postoperative serum creatinine was similar during a 2-y follow-up. Post hoc analysis excluding 4 open conversions showed lower operative time with RAKT (297 versus 320 min; P = 0.04) and lower 30-d (4.7% versus 23.4%; P = 0.02) and 90-d (7% versus 27.7%; P = 0.01) Clavien-Dindo grade ≥3 complications. CONCLUSIONS: Our findings suggest that RAKT is a safe alternative to OKT

Buffering Social Influence: Neural Correlates of Response Inhibition Predict Driving Safety in the Presence of a Peer

Adolescence is a period characterized by increased sensitivity to social cues, as well as increased risk-taking in the presence of peers. For example, automobile crashes are the leading cause of death for adolescents, and driving with peers increases the risk of a fatal crash. Growing evidence points to an interaction between neural systems implicated in cognitive control and social and emotional context in predicting adolescent risk. We tested such a relationship in recently licensed teen drivers. Participants completed an fMRI session in which neural activity was measured during a response inhibition task, followed by a separate driving simulator session 1 week later. Participants drove alone and with a peer who was randomly assigned to express risk-promoting or risk-averse social norms. The experimentally manipulated social context during the simulated drive moderated the relationship between individual differences in neural activity in the hypothesized cognitive control network (right inferior frontal gyrus, BG) and risk-taking in the driving context a week later. Increased activity in the response inhibition network was not associated with risk-taking in the presence of a risky peer but was significantly predictive of safer driving in the presence of a cautious peer, above and beyond self-reported susceptibility to peer pressure. Individual differences in recruitment of the response inhibition network may allow those with stronger inhibitory control to override risky tendencies when in the presence of cautious peers. This relationship between social context and individual differences in brain function expands our understanding of neural systems involved in top–down cognitive control during adolescent development

Neural Responses to Exclusion Predict Susceptibility to Social Influence

Purpose Social influence is prominent across the lifespan, but sensitivity to influence is especially high during adolescence and is often associated with increased risk taking. Such risk taking can have dire consequences. For example, in American adolescents, traffic-related crashes are leading causes of nonfatal injury and death. Neural measures may be especially useful in understanding the basic mechanisms of adolescents\u27 vulnerability to peer influence. Methods We examined neural responses to social exclusion as potential predictors of risk taking in the presence of peers in recently licensed adolescent drivers. Risk taking was assessed in a driving simulator session occurring approximately 1 week after the neuroimaging session. Results Increased activity in neural systems associated with the distress of social exclusion and mentalizing during an exclusion episode predicted increased risk taking in the presence of a peer (controlling for solo risk behavior) during a driving simulator session outside the neuroimaging laboratory 1 week later. These neural measures predicted risky driving behavior above and beyond self-reports of susceptibility to peer pressure and distress during exclusion. Conclusions These results address the neural bases of social influence and risk taking; contribute to our understanding of social and emotional function in the adolescent brain; and link neural activity in specific, hypothesized, regions to risk-relevant outcomes beyond the neuroimaging laboratory. Results of this investigation are discussed in terms of the mechanisms underlying risk taking in adolescents and the public health implications for adolescent driving

Recovery of bowel function after liver transplant surgery

Background: Prolonged postoperative ileus (PPOI) is a common complication after major abdominal surgery. In liver transplant surgery, the portal vein is clamped which leads to bowel congestion. Additionally, factors such as perioperative medications often affect postoperative bowel function recovery. However, factors contributing to PPOI in liver transplant patients has not been fully elucidated. Methods: This is a retrospective study of patients who received liver transplantation at a single institutional between 2016 and 2017. A total of 101 patients were evaluated. Anhepatic time was defined as the time from portal vein clamp to liver graft reperfusion. One patient required veno-venous bypass, and was excluded. This allowed for anhepatic time to be considered as the bowel congestion time. PPOI was determined clinically either by symptomatology, or with radiographic assistance in the form of an abdominal x-ray or computed tomography of the abdomen. Intraoperative variables such as anhepatic time (=bowel congestion time), cold ischemia time (CIT), warm ischemia time (WIT), transfusion requirements, and pressor requirements were analyzed. Postoperative variables such as time to first bowel movement, duration intravenous (IV) or enteral (PO) narcotic usage, and length of hospital stay were analyzed. Graft survival and patient survival was also analyzed. Results: Median time to first bowel movement was 4 days. Patients on 0-2 pressors by the end of the case had bowel movements earlier, when compared to patients on 3-4 pressors (3±3.4 days vs. 3.8±1.6 days, P=0.007). Longer anhepatic times did not correlate to longer times to first bowel movement postoperatively (3±2.5 days for \u3c80min vs. 4.0±1.7 days for \u3e=80min, P=0.502). Of the 100 patients, 22 patients (22%) were diagnosed as having a PPOI. Median (IQR) anhepatic time was significantly shorter in the PPOI group (67 [55.5-78] min vs. 79 [66-98] min, P =0.004). There was no difference in other intraoperative factors. Median (IQR) duration of postoperative intravenous narcotics (IV) and oral narcotics (PO) were significantly longer in the PPOI group (IV, 6 [2-8.5] days vs. 3 [2-6] days, P=0.034; PO, 9.5 [6.3-15] days vs. 6 [4-8] days, P=0.001). To predict PPOI, the cut-off duration of IV and PO narcotics was 6.5 days (AUC 0.648) and 7.5 days (AUC 0.724), respectively. Based on a logistic multivariable regression model, usage of PO narcotics 8 days or longer was considered an independent risk factor for PPOI (odds ratio=3.747, 95%CI=1.108-12.673, P=0.034) (Table 1). Length of hospital stay was significantly longer in the PPOI group (12.5 [8.75-23.5] days vs. 8 [6-12] days, P \u3c0.001). Graft or patient survival was not affected by PPOI (P=0.519 and 0.189, respectively). Conclusion: Although possible association was expected, longer anhepatic times did not adversely affect postoperative recovery of bowel function. Shortening the duration of PO narcotics may shorten patient hospital stay

Epithelioid Hemangioendothelioma Presenting as Inferior Vena Cava Obstruction Diagnosed Using an Endovascular Thrombectomy Device.

Epithelioid hemangioendothelioma is a rare vascular sarcoma that arises from the lining (intima) of blood vessels. We report a case of a 43-year-old male patient, who presented with inferior vena cava (IVC) obstruction and acute bilateral lower extremity deep vein thrombosis. Mechanical thrombectomy was performed with an endovascular thrombectomy device, followed by stent placement in the IVC. The initial pathology on the retrieved specimen obtained from the thrombectomy device revealed an undifferentiated neoplasm, and definitive surgical resection of the retroperitoneal soft tissue tumor of the IVC documented a rare case of epithelioid hemangioendothelioma

Thlaspi montanum L. (BR0000010535691)

Belgium Herbarium image of Meise Botanic Garden

The implications of impaired glucose tolerance after kidney transplantation

Background: Post-transplantation diabetes mellitus (PTDM) is highly prevalent after kidney transplantation and associated with significant morbidity. Routine utilization of screening oral glucose tolerance tests (OGTT) after kidney transplant has been scarcely utilized. Given the increased risk of mortality, graft failure, and CV complications associated with PTDM, we sought to describe the prevalence of impaired glucose tolerance (IGT) in a large, single-center cohort of adult nondiabetic kidney transplant patients and to elucidate risk factors and associated long-term outcomes. Methods: A retrospective review of adult living (49.5%) and deceased (50.5%) donor kidney transplant recipients from 2008-2017 was conducted. Individuals with a pretransplant diagnosis of diabetes were excluded. OGTT\u27s were completed within 6 mo post-transplant, at a mean interval of 78 ± 24 days. IGT was defined by 2-hr glucose of 140-199 mg/dL, and PTDM \u3e200 mg/dL. Odds ratio of 95% confidence intervals are reported for risk factors for development of IGT and PTDM. Results: Of 668 recipients, 62% were male, 75% white, 18% black, and 3% Hispanic. 14% underwent prior kidney transplant. Based on screening OGTT, 23.7% of patients developed IGT, with 12% PTDM. Age \u3e50 years was a risk factor for dysglycemia (IGT OR=2.8 (1.9-4.1); PTDM OR=3.1 (1.9-5.1)). BMI \u3e30 kg/m2 at transplant was predictive of IGT (OR=1.7 (1.2-2.5)). Living donation was protective for the development of IGT (OR=0.67 (0.46-0.96)). Race, gender, prior transplant, type of insurance (medicare vs private), cPRA and year of transplant were not predictive for the development of IGT or PTDM. There was no difference in patient or graft survival between recipients with normoglycemia, IGT, or PTDM over a mean follow-up period of 4.2 ± 2.3 years. Conclusions: Over one third of non-diabetic kidney transplant recipients had developed IGT or PTDM within 6 mo post-transplantation. Age \u3e50 and BMI \u3e30 at transplant were associated with increased odds of developing IGT. Recent data from protocol biopsies demonstrates evidence of diabetic nephropathy in prediabetic transplant recipients. Addressing the high incidence of prediabetic states posttransplantation could translate into improved long-term patient and graft outcomes