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Promoting Cadaver Organ Procurement
Accepted 569
570
PROTECTIVE EFFECT OF DILTIAZEM ON METABOLIC AND FUNCTIONAL IMPAIRMENT, FOLLOWI~G EXPERIM~NTAL RENA~ TRANSPL~NTATION. S. Pamer, W. Hull, K. Dreikorn L. Rohl: Dept. of Urology, Univ. of Heidelberg/FRG. It has been reported, that calcium blockers modify the degree of functional impairment in acute renal injury. The present study examined whether Diltiazem (D) can effectively enhance recovery following renal transplantation. 64 Lewis rats were divided into 4 groups: recipients of Diltiazem (25 mg/kg)-treated kidneys (a. after 30 minutes of warm ischemia and 8 hours of cold storage, b. after cold storage of 8 hours), recipients of untreated kidneys (c. 30 minutes of warm ischemia and 8 hours of cold storage, d. cold storage of 8 hours). The metabolic state of kidneys was evaluated by phosphorus-31 magnetic resonance spectroscopy prior to and after the transplantation and excretory function was measured daily by endogeneous creatinine clearance. Kidneys treated with D exhibited higher NAD/P ratios after both warm and cold ischemia; rats treated with D. had improved creatinine clearance on the third postoperative day, res Group NAO P Creat1n1ne Clearance before TPX in ml/min. a 0,22 78,6 + 39,5 b 0,39 141,2 + 60,2 C 0,18 50,5 + 45,4 d 0,34 84,3 + 45,4 These results show that blocking calcium uptake decreases the severity of ischemia-induced postoperative functional impairment and that this effect correlates well with ameliorating the metabolism of phosphor nucleotides.
ASSESSMENT OF RENAL VIABILITY DURIN:; UNILATERAL URETERAL OBSTRUCTION BY PHOSPHORUS-31 MAGNETIC RESONANCE SPECTROSCOPY: EXPERIMENTAL STUDY IN RATS AND CANINES. P.N. Bretan, Jr.,* D.B. Vigneron,* K.-P. Juenemann,* and T.L. James,* San Francisco, CA. (Presentation by Dr. Bretan) Phosphorus-31 magnetic resonance spectroscopy (3lpMRS) is a nondestructive technique in which intracellular metabolic parameters can be q wntified to assess renal viability, independent of blood flow or tubular function. We used this technique in rats to study obstructive nep hropathy secondary to unilateral ureteral obstruction. In groups of 4 rats each, obstruction was maintained for 1, 3 5, 6 and 7 weeks. Kidneys were removed, and results of immediate ex vivo MRS studies were compared with 4 control rats that underwent sham surgery. In 4 dogs, renal spectra were intermittently obtained in vivo with implanted MRS coils during normal ureteral drainage, acute obstruction (up to 13,5 hr), and post-obstruction recovery, MRS-derived runophosphate/inorganic phosphate (MP/Pi) ratios obtained immediately from cold-stored ex vivo obstructed rat kidneys did not differ significantly from those in nonobstructed controls. However, cumulative data from canine kidneys revealed a triphasic change of both MP/Pi and adenosine triphosphate/Pi ratios over 13.5 hr of obstruction. Although ex vivo 3 1P-MRS does not seem to be useful for assessing renal viability in chronic obstruction, in vivo monitoring in acute obstruction can readily quantify metabolic changes secondary to intrarenal hemodynamic responses. Further in vivo MRS studies during chronic unilateral ureteral obstruction are indicated; however, these preliminary flndings suggest that these methods may allow assessment of renal viability in this setting,
571
572
7.:
PROMOTING CADAVER ORGAN PROCUREMENT. Raja B. Khauli, *Elias Arous, Robert Blute, Jr., Stuart Jaffee and *Holly Franz, Worcester, MA (Presentation to be made by Dr. Khauli) Although renal transplantation is the treatment of choice for patients with end-stage renal disease, there is an expanding discrepancy between the growth rates of the dialysis and transplant populations, with significantly greater yearly additions to the dialysis population. The limiting factor is the availability of cadaveric organs. It has also been demonstrated that the kidneys retrieved in the United States were harvested from only 16% of the potential donors nationwide. In an attempt to promote cadaver organ procurement, we examined the parameters affecting organ donation nationally, and implemented newer strategies at the local level. The major policies adopted were: 1) Defining roles and responsibilities of nurses and physicians and implementing the "required request" policy at the Medical Center. 2) Liberalizing attitudes regarding "ideal donors". 3) Direct interaction with the procurement coordinators of the New England Organ Bank (NEOB). 4) Organization of a surgical team for procurement to cover our affiliated hospitals. From 1983 to 1985 there has been a significant increase in the number of kidney harvests at our center, (4,16,40) and this contributed to a progressively increasing proportion of the total procurements in New England. (We contributed 6% of the activity of NEOB in 1983, 16% in 1984, 25% in 1985.) The increase in procurement was not a function of the total number of trauma patients admitted during this time. (Total trauma= 903 in 1983, 900 in 1984, 950 in 1985.) In conclusion 1) Strategies that helped promote organ procurement included defining roles and responsibilities and implementing a "required request" policy locally. 2) The increase in organ procurement was not attributable to the number of trauma deaths, but to an increased identification of suitable donors. 3) A federal policy of "required request" is now needed to further promote organ donation.
a
THE ROLE OF BLADDER RECONSTRUCTION IN THE RENAL TRANSPLANT RECIPIENT
*J. Vincent Thomalla, *Stephen B. Leapman, *Ronald S. Filo, Micheal E. Mitchell, Indianapolis, Indiana (Presentation to be made by Dr. Tho mall a) Successful renal transplantation relies, in part, on the ability of the urinary bladder to serve as a continent, low pressure reservoir that is easily emptied. In our experience of 732 transplants performed between I 974 and 1986, we have used the patient's native or reconstructed bladder in all instances except one (ilea! loop). Five patients have undergone enterocystoplasty and successful renal transplantation. An additional patient has undergone enterocystoplasty post transplantation. Of these 6 patients, 5 have functioning grafts (BUN 27 ±. 11.5/creatinine 1.6 ±. I.I) 2 months to 3 years post transplantation or augmentation. Bladder augmentation was performed because of urethral valves (2), exstrophy of the bladder (1 ), prune belly syndrome (1 ), sacral agenesis (I), and neurogenic bladder of unknown etiology (1). The sigmoid colon was utilized in 4 patients, ileocecal patches were used in the others. Two patients had cadaveric grafts and 4 had living related donors. The one graft failure was due to rejection in a haplotype parent to child transplant. Intermittent catheterization has been required in 4/6 patients and 5/6 have been maintained on suppressive antibiotics, There have been no cases of transplant pyelonephritis. There has been one technical urological complication (bladder leak). One patient mai.ntains continence with an artificial urinary sphincter device. lmmunosuppression has consisted of triple therapy in 2 patients, CyA and Medrol in 2 and lmuran and Medrol in 2 (including the one graft loss). Use of a reconstructed urinary bladder appears to be a feasible and sound alternative to loop urinary diversion with its attendant morbidity and mortality. The incidence of patients presenting for transplantation with a reconstructed bladder is likely to increase as many more patients are undergoing either primary or secondary reconstruction who ultimately will proceed to renal failure because of inadequate renal reserve.
246A
570
PROTECTIVE EFFECT OF DILTIAZEM ON METABOLIC AND FUNCTIONAL IMPAIRMENT, FOLLOWI~G EXPERIM~NTAL RENA~ TRANSPL~NTATION. S. Pamer, W. Hull, K. Dreikorn L. Rohl: Dept. of Urology, Univ. of Heidelberg/FRG. It has been reported, that calcium blockers modify the degree of functional impairment in acute renal injury. The present study examined whether Diltiazem (D) can effectively enhance recovery following renal transplantation. 64 Lewis rats were divided into 4 groups: recipients of Diltiazem (25 mg/kg)-treated kidneys (a. after 30 minutes of warm ischemia and 8 hours of cold storage, b. after cold storage of 8 hours), recipients of untreated kidneys (c. 30 minutes of warm ischemia and 8 hours of cold storage, d. cold storage of 8 hours). The metabolic state of kidneys was evaluated by phosphorus-31 magnetic resonance spectroscopy prior to and after the transplantation and excretory function was measured daily by endogeneous creatinine clearance. Kidneys treated with D exhibited higher NAD/P ratios after both warm and cold ischemia; rats treated with D. had improved creatinine clearance on the third postoperative day, res Group NAO P Creat1n1ne Clearance before TPX in ml/min. a 0,22 78,6 + 39,5 b 0,39 141,2 + 60,2 C 0,18 50,5 + 45,4 d 0,34 84,3 + 45,4 These results show that blocking calcium uptake decreases the severity of ischemia-induced postoperative functional impairment and that this effect correlates well with ameliorating the metabolism of phosphor nucleotides.
ASSESSMENT OF RENAL VIABILITY DURIN:; UNILATERAL URETERAL OBSTRUCTION BY PHOSPHORUS-31 MAGNETIC RESONANCE SPECTROSCOPY: EXPERIMENTAL STUDY IN RATS AND CANINES. P.N. Bretan, Jr.,* D.B. Vigneron,* K.-P. Juenemann,* and T.L. James,* San Francisco, CA. (Presentation by Dr. Bretan) Phosphorus-31 magnetic resonance spectroscopy (3lpMRS) is a nondestructive technique in which intracellular metabolic parameters can be q wntified to assess renal viability, independent of blood flow or tubular function. We used this technique in rats to study obstructive nep hropathy secondary to unilateral ureteral obstruction. In groups of 4 rats each, obstruction was maintained for 1, 3 5, 6 and 7 weeks. Kidneys were removed, and results of immediate ex vivo MRS studies were compared with 4 control rats that underwent sham surgery. In 4 dogs, renal spectra were intermittently obtained in vivo with implanted MRS coils during normal ureteral drainage, acute obstruction (up to 13,5 hr), and post-obstruction recovery, MRS-derived runophosphate/inorganic phosphate (MP/Pi) ratios obtained immediately from cold-stored ex vivo obstructed rat kidneys did not differ significantly from those in nonobstructed controls. However, cumulative data from canine kidneys revealed a triphasic change of both MP/Pi and adenosine triphosphate/Pi ratios over 13.5 hr of obstruction. Although ex vivo 3 1P-MRS does not seem to be useful for assessing renal viability in chronic obstruction, in vivo monitoring in acute obstruction can readily quantify metabolic changes secondary to intrarenal hemodynamic responses. Further in vivo MRS studies during chronic unilateral ureteral obstruction are indicated; however, these preliminary flndings suggest that these methods may allow assessment of renal viability in this setting,
571
572
7.:
PROMOTING CADAVER ORGAN PROCUREMENT. Raja B. Khauli, *Elias Arous, Robert Blute, Jr., Stuart Jaffee and *Holly Franz, Worcester, MA (Presentation to be made by Dr. Khauli) Although renal transplantation is the treatment of choice for patients with end-stage renal disease, there is an expanding discrepancy between the growth rates of the dialysis and transplant populations, with significantly greater yearly additions to the dialysis population. The limiting factor is the availability of cadaveric organs. It has also been demonstrated that the kidneys retrieved in the United States were harvested from only 16% of the potential donors nationwide. In an attempt to promote cadaver organ procurement, we examined the parameters affecting organ donation nationally, and implemented newer strategies at the local level. The major policies adopted were: 1) Defining roles and responsibilities of nurses and physicians and implementing the "required request" policy at the Medical Center. 2) Liberalizing attitudes regarding "ideal donors". 3) Direct interaction with the procurement coordinators of the New England Organ Bank (NEOB). 4) Organization of a surgical team for procurement to cover our affiliated hospitals. From 1983 to 1985 there has been a significant increase in the number of kidney harvests at our center, (4,16,40) and this contributed to a progressively increasing proportion of the total procurements in New England. (We contributed 6% of the activity of NEOB in 1983, 16% in 1984, 25% in 1985.) The increase in procurement was not a function of the total number of trauma patients admitted during this time. (Total trauma= 903 in 1983, 900 in 1984, 950 in 1985.) In conclusion 1) Strategies that helped promote organ procurement included defining roles and responsibilities and implementing a "required request" policy locally. 2) The increase in organ procurement was not attributable to the number of trauma deaths, but to an increased identification of suitable donors. 3) A federal policy of "required request" is now needed to further promote organ donation.
a
THE ROLE OF BLADDER RECONSTRUCTION IN THE RENAL TRANSPLANT RECIPIENT
*J. Vincent Thomalla, *Stephen B. Leapman, *Ronald S. Filo, Micheal E. Mitchell, Indianapolis, Indiana (Presentation to be made by Dr. Tho mall a) Successful renal transplantation relies, in part, on the ability of the urinary bladder to serve as a continent, low pressure reservoir that is easily emptied. In our experience of 732 transplants performed between I 974 and 1986, we have used the patient's native or reconstructed bladder in all instances except one (ilea! loop). Five patients have undergone enterocystoplasty and successful renal transplantation. An additional patient has undergone enterocystoplasty post transplantation. Of these 6 patients, 5 have functioning grafts (BUN 27 ±. 11.5/creatinine 1.6 ±. I.I) 2 months to 3 years post transplantation or augmentation. Bladder augmentation was performed because of urethral valves (2), exstrophy of the bladder (1 ), prune belly syndrome (1 ), sacral agenesis (I), and neurogenic bladder of unknown etiology (1). The sigmoid colon was utilized in 4 patients, ileocecal patches were used in the others. Two patients had cadaveric grafts and 4 had living related donors. The one graft failure was due to rejection in a haplotype parent to child transplant. Intermittent catheterization has been required in 4/6 patients and 5/6 have been maintained on suppressive antibiotics, There have been no cases of transplant pyelonephritis. There has been one technical urological complication (bladder leak). One patient mai.ntains continence with an artificial urinary sphincter device. lmmunosuppression has consisted of triple therapy in 2 patients, CyA and Medrol in 2 and lmuran and Medrol in 2 (including the one graft loss). Use of a reconstructed urinary bladder appears to be a feasible and sound alternative to loop urinary diversion with its attendant morbidity and mortality. The incidence of patients presenting for transplantation with a reconstructed bladder is likely to increase as many more patients are undergoing either primary or secondary reconstruction who ultimately will proceed to renal failure because of inadequate renal reserve.
246A