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Surgical management of vascular access related complications in hemodialysis patients
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Abstracts / Indian Journal of Transplantation 10 (2016) 81–117
post-transplant month; infections were due to UTI (30%); percutaneous drain fluid (24%); central venous catheters (17%); bacteremia (11%) and lower respiratory tract infection (LRTI) in 12%. In 1–6 months period UTI (45%) was the commonest cause of infection followed by bacteremia (21%), and LRTI (16%). 65 (40%) episodes of infection occurred in 1st post-transplant month; majority were caused by Pseudomonas sps. (26%), Coagulase negative staphylococcus (CoNS) [23%], Escherichia coli (14%) and Klebsiella (8%). In post transplant 1–6 month period, 51 episodes (31%) occurred mainly due to Pseudomonas (23%), E. coli (19%), Klebsiella (8%), CoNS (10%) and CMV (10%). During 6–12 month period, only 30 episodes (18%) of infection occurred primarily with, E. coli (20%) and pseudomonas (17%). Conclusions: 58% renal allograft recipients had at least one episode of infection within one year post-transplant period. UTI was the commonest infection in all quarters of the time table. Most of the infections were caused by Pseudomonas, E coli, CoNS and Klebsiella. They still follow the traditional timeline. Conflicts of interest The authors have none to declare. http://dx.doi.org/10.1016/j.ijt.2016.09.063 Screening for tuberculosis prior renal transplantation K. Supraja ∗ , Georgi Abraham, Rajeevalochana Madras Medical Mission, Chennai, India Background: Where TB remains to be dreaded infection in India. Prevalence of TB in CKD and RTx recipients is higher than in general population. Identification of both latent/active infection is diagnostic challenge due to impaired immune response in these states. Pre operative screening with TST and imaging (chest X ray/CT chest) helps identify patients with active/latent TB and treatment of such patients is mandatory to improve outcome. Aim of the study: To look at the prevalence of TB in the pre renal transplant period of recipients in a tertiary care centre. Methods: To look into screening tools adapted in pre transplant evaluation and its effectiveness in identification of active or latent tuberculosis, treatment strategies used and outcome. Medical records of 124 renal transplant recipients from 2010 to 2016 were reviewed in this retrospective observational cohort study. Exclusion criteria were treatment for tuberculosis >6 months before renal transplantation. Microbiological examination of respiratory secretions, biological liquids, molecular studies and biochemistry analysis noted. Patient demographics, co-morbid disease, riskfactors for TB, creatinine, complete blood count, chest radiograph patterns, CT chest, organ involvement, diagnostic methods, administration of anti-TB therapy were recorded. Results: 8 patients (6.45%) were started on ATT <6 months prior to renal transplantation, 4 (50%) based on mantoux/imaging and 5(62.5%) based on imaging/interventional studies. 3(37.5%) treated presumptively. Median time to transplant was 4(2–6) months. 2(25%) was pulmonary, 3(37.5%) were extra pulmonary tuberculosis. The ATT regimen used was HRZ + Quinolone for a period of 6–9 months. 1(12.5%) developed drug induced hepatitis. None developed active TB in post transplant period. Conclusions: Active pre renal transplant screening with tuberculin skin testing and imaging services (chest X ray and CT chest when applicable) followed by microbiological/biochemical/molecular analysis helps to identify latent tuberculosis and prevent development of active infection in the post transplant period.
Conflicts of interest The authors have none to declare. http://dx.doi.org/10.1016/j.ijt.2016.09.064 Transplant nephrectomy: Our experience over the last 15 years Arun Wesley S. David 1,2,∗ , S. Sudhakar 1 , Sanjay Pai 2 , S. Sundar 1 , Ajit K. Huilgol 1 1
Karnataka Nephrology and Transplant Institute (KANTI), Columbia Asia Hospitals, Bangalore, India 2 Department of Pathology, Columbia Asia Hospitals, Bangalore, India Background: Transplant nephrectomy (TN) is a technically challenging, high risk procedure with high morbidity and mortality. This study looks at indications and outcomes of patients who underwent TN at our center over the last 15 years. Aim of the study: To review our experience with renal allograft nephrectomy over the last 15 years. Methods: Review of our transplant surgery database over the last 15 years looking at indications and outcomes of TN. Results: Over the last 15 years; 1040 renal transplants and 38 TN were carried out at our center. Of these 38 TN; 5 patients were from other centers. The average time to TN was 1.6 years. Chronic allograft nephropathy (CAN) was the indication for TN in 13 patients (34%); at an average 3.45 years (range 1–8.5 years) after transplant. Acute rejection (both cellular and antibody mediated) occurred in 11(30%) at about 17 days post transplant and hyperacute rejection in 2 (5.3%) on day 0. Infection was the indication in 7 patients (21%) of which 2 were BK nephropathy; 2 fungal infections; 1 CMV and 2 urinary tract infections with graft pyelonephritis. There were 3(7.9%) cases of renal vein thrombosis and 1(2.6%) case of thrombotic microangiopathy. Of 38 TN patients; 3(8%) were successfully re-transplanted; 13(34.2%) died at an average of 60 days (3–365 days) after TN; and the remaining 22(57.8%) went back on dialysis. Four patients (10%) were re-explored for either bleeding or TN site infection. Conclusions: The commonest indications for TN in the early post transplant period (<3 months) were rejection; infections or thrombosis; and in the late post transplant period CAN. TN carried a high morbidity rate and 34% patients died within months of the operation. Conflicts of interest The authors have none to declare. http://dx.doi.org/10.1016/j.ijt.2016.09.065 Surgical management of vascular access related complications in hemodialysis patients Srivastava Devarshi ∗ , Dharamvir Singh, S.K. Sureka, U.P. Singh, A. Srivastava Department of Urology and Renal Transplantation, SGPGIMS, Lucknow, India Background: The arteriovenous fistulae (AVF) remain the ideal vascular access for patients on maintenance hemodialysis. Many of these complications are potentially dangerous and need aggressive surgical management.
Abstracts / Indian Journal of Transplantation 10 (2016) 81–117
Aim of the study: Here we aimed to study the clinical presentation and surgical management of the complications associated with surgically created AVF in patients on maintenance hemodialysis. Methods: This retrospective study was conducted on patients who underwent surgical intervention for various complications related to AVF created at our centre or referred to our centre for management of complications. Results: A total of 2260 AVF were created and a total of 176 complications were encountered during period of 2001–2016 requiring surgical intervention. Seventy two patients had primary fistula made at other centre. Preoperatively complications were evaluated with USG Doppler or angiography (CT/MR) in selected cases. Most Common complication was pseudoanerysm (PA) (n = 120–68.2%), followed by Venous hypertension (16%), steal phenomenon (11%), Pulmonary hypertension (3.2%) and Cardiac failure (1.6%). PA was most commonly encountered at anastomosis site followed by vein puncture site and accidental arterial puncture site. Fistula could be salvaged only in 13.8%. Radial artery was ligated in radial AVF for any of the above complications. Brachiocephalic (BCF) or Brachiobasilic fistula (BBF) complications required repair of artery when PA involved anastomotic site. Venous hypertension involving BCF were managed with ligation of outflow vein or angiographic balloon dilatation of proximal venous stenotic segment. Success rate of Angiographic management were 50% in our cases with 85% of them had recurrence of symptoms with median follow up of 9.5 months. Conclusions: Pseudoaneurysm is the commonest complication of AVF. MR angiography helps in preoperative vascular mapping and surgical planning. Aggressive management of expanding pseudoaneurysm must be done to minimize the risk of life threatening bleeding. Conflicts of interest The authors have none to declare. http://dx.doi.org/10.1016/j.ijt.2016.09.066 Role of C1Q SAB assay in prediction of kidney transplantation outcome in highly sensitized patients Arpita Ghosh-Mitra ∗ , Sudip Roy, Nasifa Hasan, Soma Choudhury, Saheli Podder, Dilip Pahari HLA & Molecular Lab, Medica Superspecialty Hospital, Kolkata, India Background: A large number of patients are now coming for second transplant for the wide spread availability of kidney transplant. Patients after long years of dialysis are also coming for transplant. Such prospective recipients often become cross match (CDC with AHG augmentation) positive with their recipients. We perform SAB donor specific antibody testing to find who have truly anti HLA antibody. We have also preformed C1q binding SAB assay to find out which of the SAB antibodies complement fixing. Aim of the study: We want to present our data with CDC and C1q SAB Positive with or without DSA. Only in selected cases; transplantation performed with desensitization protocol with positive SAB cross match. Methods: Complement dependent cytotoxicity (CDC) crossmatch had been performed with anti-human globulin (AHG) augmentation and DTT treatment. Single Antigen assay with C1q
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had been performed using Labscreen assay kit from One Lamda; USA. Results: Among 15 highly sensitized patients after confirming with C1q SAB, 6 patients were detected with complement fixing Donor specific anti-HLA antibodies against either Class I or Class II. 9 patients among 15 were detected with no Donor specific but positive complement fixing anti-HLA antibodies. Among the 6 patients with positive DSA 4 patients exhibit Class I positive and 2 were Class II positive. Among the 9 patients with no DSA 1 patient was Class I positive and 8 patients were Class II positive. Patients with positive complement fixing anti-HLA Class I and Class II antibodies underwent desensitization and allograft loss occurred ¼ patients (25%) of the Class I C1q positive group. Patients with negative complement fixing anti-HLA antibodies did not require any desensitization and appeared with stable graft function without any rejection symptom. Conclusions: Successful kidney transplant can be possible even in highly sensitized patients after prescreening with C1q SAB assay and desensitization protocol. C1q positive Class I antibodies are highly associated with AMR and should be considered as high risk for transplant rejection. Conflicts of interest The authors have none to declare. http://dx.doi.org/10.1016/j.ijt.2016.09.067 Operating room challenges for the scrub nurse during renal transplantation Shilpi Srivastava ∗ , Neetu Verma All India Institute of Medical Sciences (AIIMS), New Delhi, India Background: Renal Transplantation is a complex procedure involving two major operations: Donor nephrectomy and recipient surgery. There are challenges for the scrub-nurse including maintenance of asepsis; preparation of bench; provision of special instruments and handling of fine needles and sutures during special situations like those involving multiple vessels. Experience in handling these situations is required to avoid any mishaps. Aim of the study: To analyze the challenges faced by the operating room nurse during renal transplantation at a tertiary care academic hospital. Methods: Records of 150 live related renal transplants were analyzed for special situations like multiple vessels requiring multiple anastomosis and need for reperfusion during recipient operation. Results: Of the 150 cases, multiple arteries were found in 18 cases. There were two arteries in 16 cases and three arteries in 2 cases. An average of twenty 6-0 and 7-0 sutures were required in the recipient procedure in these cases. In two cases, the needle got misplaced and it took substantial time to find them. The needle was found in a sponge in one case and on the floor in another. In 4 cases the kidney had to be taken off after the anastomosis and declamping of vessels as there was a doubt about the perfusion. Reperfusion on bench and reanastomosis was required posing fresh challenge in a panic situation. Conclusions: The challenges faced by the scrub nurse during renal transplantation do not receive attention. Assistance by nursing staff experienced in handling these situations helps a great deal in achieving optimal results and puts surgeons at ease during such stressful situations.
Abstracts / Indian Journal of Transplantation 10 (2016) 81–117
post-transplant month; infections were due to UTI (30%); percutaneous drain fluid (24%); central venous catheters (17%); bacteremia (11%) and lower respiratory tract infection (LRTI) in 12%. In 1–6 months period UTI (45%) was the commonest cause of infection followed by bacteremia (21%), and LRTI (16%). 65 (40%) episodes of infection occurred in 1st post-transplant month; majority were caused by Pseudomonas sps. (26%), Coagulase negative staphylococcus (CoNS) [23%], Escherichia coli (14%) and Klebsiella (8%). In post transplant 1–6 month period, 51 episodes (31%) occurred mainly due to Pseudomonas (23%), E. coli (19%), Klebsiella (8%), CoNS (10%) and CMV (10%). During 6–12 month period, only 30 episodes (18%) of infection occurred primarily with, E. coli (20%) and pseudomonas (17%). Conclusions: 58% renal allograft recipients had at least one episode of infection within one year post-transplant period. UTI was the commonest infection in all quarters of the time table. Most of the infections were caused by Pseudomonas, E coli, CoNS and Klebsiella. They still follow the traditional timeline. Conflicts of interest The authors have none to declare. http://dx.doi.org/10.1016/j.ijt.2016.09.063 Screening for tuberculosis prior renal transplantation K. Supraja ∗ , Georgi Abraham, Rajeevalochana Madras Medical Mission, Chennai, India Background: Where TB remains to be dreaded infection in India. Prevalence of TB in CKD and RTx recipients is higher than in general population. Identification of both latent/active infection is diagnostic challenge due to impaired immune response in these states. Pre operative screening with TST and imaging (chest X ray/CT chest) helps identify patients with active/latent TB and treatment of such patients is mandatory to improve outcome. Aim of the study: To look at the prevalence of TB in the pre renal transplant period of recipients in a tertiary care centre. Methods: To look into screening tools adapted in pre transplant evaluation and its effectiveness in identification of active or latent tuberculosis, treatment strategies used and outcome. Medical records of 124 renal transplant recipients from 2010 to 2016 were reviewed in this retrospective observational cohort study. Exclusion criteria were treatment for tuberculosis >6 months before renal transplantation. Microbiological examination of respiratory secretions, biological liquids, molecular studies and biochemistry analysis noted. Patient demographics, co-morbid disease, riskfactors for TB, creatinine, complete blood count, chest radiograph patterns, CT chest, organ involvement, diagnostic methods, administration of anti-TB therapy were recorded. Results: 8 patients (6.45%) were started on ATT <6 months prior to renal transplantation, 4 (50%) based on mantoux/imaging and 5(62.5%) based on imaging/interventional studies. 3(37.5%) treated presumptively. Median time to transplant was 4(2–6) months. 2(25%) was pulmonary, 3(37.5%) were extra pulmonary tuberculosis. The ATT regimen used was HRZ + Quinolone for a period of 6–9 months. 1(12.5%) developed drug induced hepatitis. None developed active TB in post transplant period. Conclusions: Active pre renal transplant screening with tuberculin skin testing and imaging services (chest X ray and CT chest when applicable) followed by microbiological/biochemical/molecular analysis helps to identify latent tuberculosis and prevent development of active infection in the post transplant period.
Conflicts of interest The authors have none to declare. http://dx.doi.org/10.1016/j.ijt.2016.09.064 Transplant nephrectomy: Our experience over the last 15 years Arun Wesley S. David 1,2,∗ , S. Sudhakar 1 , Sanjay Pai 2 , S. Sundar 1 , Ajit K. Huilgol 1 1
Karnataka Nephrology and Transplant Institute (KANTI), Columbia Asia Hospitals, Bangalore, India 2 Department of Pathology, Columbia Asia Hospitals, Bangalore, India Background: Transplant nephrectomy (TN) is a technically challenging, high risk procedure with high morbidity and mortality. This study looks at indications and outcomes of patients who underwent TN at our center over the last 15 years. Aim of the study: To review our experience with renal allograft nephrectomy over the last 15 years. Methods: Review of our transplant surgery database over the last 15 years looking at indications and outcomes of TN. Results: Over the last 15 years; 1040 renal transplants and 38 TN were carried out at our center. Of these 38 TN; 5 patients were from other centers. The average time to TN was 1.6 years. Chronic allograft nephropathy (CAN) was the indication for TN in 13 patients (34%); at an average 3.45 years (range 1–8.5 years) after transplant. Acute rejection (both cellular and antibody mediated) occurred in 11(30%) at about 17 days post transplant and hyperacute rejection in 2 (5.3%) on day 0. Infection was the indication in 7 patients (21%) of which 2 were BK nephropathy; 2 fungal infections; 1 CMV and 2 urinary tract infections with graft pyelonephritis. There were 3(7.9%) cases of renal vein thrombosis and 1(2.6%) case of thrombotic microangiopathy. Of 38 TN patients; 3(8%) were successfully re-transplanted; 13(34.2%) died at an average of 60 days (3–365 days) after TN; and the remaining 22(57.8%) went back on dialysis. Four patients (10%) were re-explored for either bleeding or TN site infection. Conclusions: The commonest indications for TN in the early post transplant period (<3 months) were rejection; infections or thrombosis; and in the late post transplant period CAN. TN carried a high morbidity rate and 34% patients died within months of the operation. Conflicts of interest The authors have none to declare. http://dx.doi.org/10.1016/j.ijt.2016.09.065 Surgical management of vascular access related complications in hemodialysis patients Srivastava Devarshi ∗ , Dharamvir Singh, S.K. Sureka, U.P. Singh, A. Srivastava Department of Urology and Renal Transplantation, SGPGIMS, Lucknow, India Background: The arteriovenous fistulae (AVF) remain the ideal vascular access for patients on maintenance hemodialysis. Many of these complications are potentially dangerous and need aggressive surgical management.
Abstracts / Indian Journal of Transplantation 10 (2016) 81–117
Aim of the study: Here we aimed to study the clinical presentation and surgical management of the complications associated with surgically created AVF in patients on maintenance hemodialysis. Methods: This retrospective study was conducted on patients who underwent surgical intervention for various complications related to AVF created at our centre or referred to our centre for management of complications. Results: A total of 2260 AVF were created and a total of 176 complications were encountered during period of 2001–2016 requiring surgical intervention. Seventy two patients had primary fistula made at other centre. Preoperatively complications were evaluated with USG Doppler or angiography (CT/MR) in selected cases. Most Common complication was pseudoanerysm (PA) (n = 120–68.2%), followed by Venous hypertension (16%), steal phenomenon (11%), Pulmonary hypertension (3.2%) and Cardiac failure (1.6%). PA was most commonly encountered at anastomosis site followed by vein puncture site and accidental arterial puncture site. Fistula could be salvaged only in 13.8%. Radial artery was ligated in radial AVF for any of the above complications. Brachiocephalic (BCF) or Brachiobasilic fistula (BBF) complications required repair of artery when PA involved anastomotic site. Venous hypertension involving BCF were managed with ligation of outflow vein or angiographic balloon dilatation of proximal venous stenotic segment. Success rate of Angiographic management were 50% in our cases with 85% of them had recurrence of symptoms with median follow up of 9.5 months. Conclusions: Pseudoaneurysm is the commonest complication of AVF. MR angiography helps in preoperative vascular mapping and surgical planning. Aggressive management of expanding pseudoaneurysm must be done to minimize the risk of life threatening bleeding. Conflicts of interest The authors have none to declare. http://dx.doi.org/10.1016/j.ijt.2016.09.066 Role of C1Q SAB assay in prediction of kidney transplantation outcome in highly sensitized patients Arpita Ghosh-Mitra ∗ , Sudip Roy, Nasifa Hasan, Soma Choudhury, Saheli Podder, Dilip Pahari HLA & Molecular Lab, Medica Superspecialty Hospital, Kolkata, India Background: A large number of patients are now coming for second transplant for the wide spread availability of kidney transplant. Patients after long years of dialysis are also coming for transplant. Such prospective recipients often become cross match (CDC with AHG augmentation) positive with their recipients. We perform SAB donor specific antibody testing to find who have truly anti HLA antibody. We have also preformed C1q binding SAB assay to find out which of the SAB antibodies complement fixing. Aim of the study: We want to present our data with CDC and C1q SAB Positive with or without DSA. Only in selected cases; transplantation performed with desensitization protocol with positive SAB cross match. Methods: Complement dependent cytotoxicity (CDC) crossmatch had been performed with anti-human globulin (AHG) augmentation and DTT treatment. Single Antigen assay with C1q
107
had been performed using Labscreen assay kit from One Lamda; USA. Results: Among 15 highly sensitized patients after confirming with C1q SAB, 6 patients were detected with complement fixing Donor specific anti-HLA antibodies against either Class I or Class II. 9 patients among 15 were detected with no Donor specific but positive complement fixing anti-HLA antibodies. Among the 6 patients with positive DSA 4 patients exhibit Class I positive and 2 were Class II positive. Among the 9 patients with no DSA 1 patient was Class I positive and 8 patients were Class II positive. Patients with positive complement fixing anti-HLA Class I and Class II antibodies underwent desensitization and allograft loss occurred ¼ patients (25%) of the Class I C1q positive group. Patients with negative complement fixing anti-HLA antibodies did not require any desensitization and appeared with stable graft function without any rejection symptom. Conclusions: Successful kidney transplant can be possible even in highly sensitized patients after prescreening with C1q SAB assay and desensitization protocol. C1q positive Class I antibodies are highly associated with AMR and should be considered as high risk for transplant rejection. Conflicts of interest The authors have none to declare. http://dx.doi.org/10.1016/j.ijt.2016.09.067 Operating room challenges for the scrub nurse during renal transplantation Shilpi Srivastava ∗ , Neetu Verma All India Institute of Medical Sciences (AIIMS), New Delhi, India Background: Renal Transplantation is a complex procedure involving two major operations: Donor nephrectomy and recipient surgery. There are challenges for the scrub-nurse including maintenance of asepsis; preparation of bench; provision of special instruments and handling of fine needles and sutures during special situations like those involving multiple vessels. Experience in handling these situations is required to avoid any mishaps. Aim of the study: To analyze the challenges faced by the operating room nurse during renal transplantation at a tertiary care academic hospital. Methods: Records of 150 live related renal transplants were analyzed for special situations like multiple vessels requiring multiple anastomosis and need for reperfusion during recipient operation. Results: Of the 150 cases, multiple arteries were found in 18 cases. There were two arteries in 16 cases and three arteries in 2 cases. An average of twenty 6-0 and 7-0 sutures were required in the recipient procedure in these cases. In two cases, the needle got misplaced and it took substantial time to find them. The needle was found in a sponge in one case and on the floor in another. In 4 cases the kidney had to be taken off after the anastomosis and declamping of vessels as there was a doubt about the perfusion. Reperfusion on bench and reanastomosis was required posing fresh challenge in a panic situation. Conclusions: The challenges faced by the scrub nurse during renal transplantation do not receive attention. Assistance by nursing staff experienced in handling these situations helps a great deal in achieving optimal results and puts surgeons at ease during such stressful situations.