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ABSTRACT: Regarding transplant surgery, the minimally invasive revolution was started in 1995 by laparoscopic living donor nephrectomy (L-LDN). In 2006, we made the first report on a minimally invasive technique for kidney transplantation; restricted to a 7-9 cm transverse incision targeted on the anastomotic area of the iliac vessels, and with the meticulously prepared kidney placed in a fitting, retroperitoneal pouch lateral to the skin incision.
By combining "hand-assisted laparoscopic nephrectomy" and "minimally invasive kidney transplantation" - using the same incision (7-8 cm) for hand-assistance, kidney harvesting, and transplantation - we have during 2009 conducted "minimally invasive renal auto-transplantation" in two patients.
In both cases, the postoperative course was uneventful. When examined 3 mo postoperatively, both auto-transplants were shown to have excellent function by renal scintigraphy.
Renal auto-transplantation, a traditionally major surgical procedure, can be made minimally invasive by a similar incision as that used for L-LDN. Taking into regard the highly traumatic conventional incisions, we expect the generally proven minimally invasive benefits to be considerable.
Journal of Surgical Research 11/2010; 164(1):e181-4. · 2.25 Impact Factor
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ABSTRACT: Conventional open living donor nephrectomy (LDN) technique is perceived as a barrier for expanding living donor programmes. Thus, minimal invasive surgery techniques have been advocated to overcome this hurdle. The aim of this study was to evaluate our experience on minimally invasive LDN. During the last decade we have gradually expanded the use of minimally invasive LDN with various techniques; strictly laparoscopic versus hand-assisted, and laparoscopic versus retroperitoneoscopic. This study is based on 305 consecutive minimally invasive LDN's, from 1998 to 2009. By multiple regression analysis, minimally invasive hand-assisted technique was shown to be associated with a significantly lower risk of major complications and intraoperative incidents, as well as reduced warm ischemia and operative time. In our opinion, the introduction of hand-assisted technique is probably the most significant single factor for improved results, although accumulated experience and developments in equipment will contribute. Our experience indicates that learning curves are facilitated by the use of hand-assisted technique. Improvements in surgical outcomes following donor nephrectomy may enhance living donor programmes.
Transplant International 04/2010; 23(10):1008-14. · 2.92 Impact Factor
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ABSTRACT: Serum osteocalcin and C-terminal telopeptides of type-1 collagen (CTX-1) are known markers of bone turnover, whereas the role of fibroblast growth factor 23 (FGF-23) is yet unknown. We investigated early changes in bone mass and the association of these biochemical markers and FGF-23 with bone loss following renal transplantation (RTx).
In 44 first-kidney allograft patients, BMD was measured by dual-energy X-ray absorptiometry in the lumbar spine (LS), total femur (TF) and total body (TB) at baseline and 10 weeks post-transplant. Serum osteocalcin, CTX-1, intact FGF-23, intact parathormone (iPTH) and 25-hydroxyvitamin D (25-OHD) levels were measured. Associations were tested by correlation and multiple linear regression.
We found a significant (p<0.05) decrease in bone mass in LS (2.6 %), TF (2.1 %) and TB (1.4 %). Osteocalcin (0.95 versus 1.56 nmol/L) and CTX-1 (1.05 versus 1.47 ng/mL) levels increased significantly, while serum FGF-23 and iPTH decreased. Serum osteocalcin and CTX-1 were significantly associated at both baseline and follow-up. Baseline osteocalcin and CTX-1 were independently associated with bone loss in TB and TF, respectively. Neither iPTH nor 25-OHD showed consistent association with bone loss. FGF-23 was not related to change in bone mass or to biochemical markers of bone turnover.
Our results confirm an early decrease in bone mass with high bone resorption rate after RTx. Osteocalcin and CTX-1 are associated with bone loss in the early post-transplant period; thus, these markers may be a reasonable choice for routine assessment of bone turnover in this setting. The role of FGF-23 remains to be further elucidated.
Scandinavian journal of clinical and laboratory investigation 11/2008; 69(2):161-7. · 1.38 Impact Factor
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ABSTRACT: Changes in body composition after renal transplantation (RTx) are of clinical significance, since increments in fat mass may contribute to glucose intolerance and cardiovascular morbidity. The aim of this study was to quantify the early changes in body composition after transplantation and identify predictors of these changes.
Total and regional body composition of 102 first kidney allograft recipients were measured at transplantation and after 10 weeks using dual-energy X-ray absorptiometry. The population comprised a high proportion of pre-emptive and well-nourished kidney recipients. Multiple linear regression was used to identify predictors of change.
Mean fat mass was 27.1+/-8.7% of body weight at baseline. The fat mass percentage increased by 2.2% corresponding to a 1.3 kg increase in fat mass at 10 weeks (p< 0.001). Fat-free mass declined by 2.5 kg (p<0.001), with no significant loss of body weight (0.9 kg, p=0.11). Age, low-tertile fat mass, plasma C-reactive protein, time on dialysis and cumulative prednisolone dose were independent predictors (p<0.05) of the increase in fat mass. Cumulative prednisolone dose was the only significant predictor of decrease in fat-free mass. Essentially the same results were found for both genders.
A significant increase in fat mass occurred rapidly after RTx along with a reduction in fat-free mass despite stable body weight. Early fat mass accumulation may predispose to comorbidity, but the long-term clinical significance of these early changes remains to be explored in prospective studies.
Scandinavian Journal of Urology and Nephrology 09/2008; 43(1):76-83. · 0.99 Impact Factor
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ABSTRACT: Patients with chronic renal failure (CRF) are at high risk of renal osteodystrophy. Our study aimed to identify predictors of bone mass and cumulative fracture rate at the time of renal transplantation (RTx). This is important since the patients experience further substantial bone loss the first month post-transplant.
Altogether 133 renal transplant patients were examined for bone mineral density (BMD) using dual-energy X-ray absorptiometry shortly after RTx.
The patients'Z-scores were significantly lower at the time of RTx compared to the reference population (p < 0.05), 32% were osteopenic and 11% had osteoporosis. Independent predictors of low bone mass were age (p < 0.001), female sex (p < 0.001), intact parathyroid hormone (iPTH) level (p < 0.001), former transplantation (p = 0.001) and time on hemodialysis (HD) (p = 0.005). Body mass index (BMI) (p < 0.001) and physical activity (p = 0.027) were associated with high BMD. Cumulative fracture rate (29%) was associated with physical inactivity (p = 0.003), BMI (p = 0.036) and osteopenia (p < 0.001) at the time of RTx.
In a representative CRF population, BMD was reduced. Independent predictors of BMD were as for the general population, and uremia associated predictors were time on HD, previous transplantation and serum iPTH level. Fracture rate was high, and physical inactivity had the strongest association with fractures.
Clinical Transplantation 04/2008; 22(4):462-8. · 1.67 Impact Factor
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ABSTRACT: We investigated cyclosporine A (CsA) concentrations at the site of action, inside T-lymphocytes, to evaluate its applicability as a new supplementary therapeutic drug monitoring method after renal transplantation.
In this prospective single-center study, 20 kidney transplant recipients, mean age 54 (range 21-74) years, on CsA-based immunosuppression were included within 2 weeks posttransplant and followed for 3 months. Nine patients also had one full 12-hour pharmacokinetic profile performed. T-lymphocytes were isolated from 7 ml whole blood using Prepacyte and intracellular CsA concentrations were determined using a validated liquid chromatography double mass spectrometry method.
Seven patients (35%) experienced acute rejections (all biopsy verified) during the first three months posttransplantation. Intracellular CsA concentrations tended to decline 1 week prior to acute rejection and the decrease was significant (-27.1+/-14.6%, P=0.014) three days before the rejection episodes were recognized clinically. In addition, the intracellular CsA area under the curve 0-12 measured during stable phase was 182% higher in the rejection-free patients (P=0.004). There was no difference between patients experiencing rejection and the rejection-free patients with respect to CsA C2-levels, dose (mg/kg), human leukocyte antigen mismatch, donor age, recipient age, or ABCB1 genotyping.
Intracellular CsA T-lymphocyte concentrations declined significantly 3 days prior to a rejection episode and there was a general lower intracellular exposure of CsA in recipients experiencing rejection. Intracellular measurement of CsA therefore seems to have a potential to further improve individualization of therapeutic drug monitoring. Larger studies are needed to elucidate the role for intracellular T-lymphocyte measurements in ordinary clinical care, for both CsA and other immunosuppressive drugs.
Transplantation 02/2008; 85(2):179-84. · 4.00 Impact Factor
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ABSTRACT: In living donor (LD) kidney transplantation, a predominance of female-to-male donations has been observed. Gender demographics of living donors and outcomes of LD kidney transplantations in Norway were assessed, as this has not been explored previously.
Data from the Norwegian Renal Registry of first LD kidney transplantations (n = 1319) in the period 1985-2002 were used.
The majority of all LD was female (57.8%; P<0.001), while 62.7% of the recipients were men (P<0.001). Females dominated as donors in the spousal group and the parental group (P<0.0001). However, no gender difference was observed in the parental group when the recipients were <30 years old (P = 0.65). In opposite-sex pairs, female-to-male donations were as expected based on the incidence of end-stage renal disease. Donor sex affected neither the incidence of acute rejections nor graft survival. Serum creatinine was higher in renal allografts from female donors to male recipients in the first 4 years after transplantation. Donor age also had significant impact on graft function measured as serum creatinine.
Gender disparities in LD transplantation result from a higher proportion of female-to-female and a lower proportion of male-to-male donations than expected. Both donor age and donor sex influence graft function during the first years. Graft survival and acute rejection episodes appear not to be affected by donor sex in LD kidney transplantation.
Nephrology Dialysis Transplantation 05/2005; 20(4):783-9. · 3.40 Impact Factor
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Eric Thervet, Per Pfeffer,
Maria Piera Scolari,
Lorenzo Toselli,
Luis M Pallardó,
Steven Chadban,
Helen Pilmore,
John Connolly,
Matthias Buchler,
Francesco Paolo Schena,
César Agost Carreño,
Raymond Dandavino,
Edward Cole
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ABSTRACT: MO2ART (monitoring of 2-hr absorption in renal transplantation) is the first prospective, multicenter trial of cyclosporine (CsA) blood level 2 hr postdose (C2) monitoring in de novo kidney recipients receiving CsA microemulsion (ME) (Neoral; Novartis, Basel, Switzerland). Efficacy and safety results from the first 3 months are presented here.
MO2ART is a 12-month, open-label, randomized study involving 296 patients. In all patients, the dose of CsA-ME was adjusted to achieve protocol-defined C2 targets of 1.6 to 2.0 microg/mL for the first month, with subsequent tapering. Randomization into two target groups occurred at 3 months. All patients received steroids and mycophenolate mofetil (89%) or azathioprine. For patients with delayed graft function, the protocol permitted reduced C2 targets and prophylactic administration of antibodies.
At 3 months, overall incidence of biopsy-proven acute rejection was 11.5%. Median serum creatinine was 132 micromol/L. Patient and graft survival were 96.6% and 91.2%, respectively. C2 levels greater than 1.6 microg/mL were achieved within 5 days by 60.6% of patients with immediate graft function and 19.5% of patients with delayed graft function. Prophylactic antibodies were used in 15% of the total population. Twenty-four patients (8.1%) experienced serious adverse events with a suspected relation to CsA, and 26 patients (8.8%) discontinued the study because of adverse events (n=15) or after a switch in immunosuppression after rejection episodes (n=11).
Patient management by C2 monitoring resulted in a low incidence of biopsy-proven acute rejection in standard risk de novo kidney recipients, 85% of whom did not receive prophylactic antibodies. CsA-ME with C2 monitoring provides excellent short-term efficacy and safety among de novo renal transplant patients.
Transplantation 10/2003; 76(6):903-8. · 4.00 Impact Factor
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ABSTRACT: A number of institutions have reported favorable results in renal transplant patients after conversion from cyclosporine (CsA) to tacrolimus at the time of acute rejection, but no prospective, controlled study has been performed to date. Here, we report the first randomized study comparing patients whose therapy was changed at a first episode of acute rejection to tacrolimus with those who were maintained on CsA microemulsion (ME).
This 3-month, prospective, open, multicenter, parallel-group study was conducted at 15 centers in seven European countries. In total, 119 renal graft recipients experiencing a first biopsy-proven acute rejection episode while receiving CsA-ME were randomized (1:1) to start tacrolimus-based therapy (n=61) or to continue CsA-ME-based therapy (n=58).
Baseline characteristics were comparable for both groups. The initial rejection episode responded to steroid treatment in 93.4% (tacrolimus) and 63.8% (CsA-ME) (P=0.001), respectively. In patients at risk, the incidence of recurrent rejection events within 3 months was significantly lower with tacrolimus therapy (5/57, 8.8%) compared with CsA-ME therapy (15/44, 34.1%) (P=0.002). Patient and graft survival were similar in both study groups 3 months after randomization. The most frequently reported adverse events were increased serum creatinine (29.5% vs. 22.4%), hypertension (24.6% vs. 22.4%), and urinary tract infection (18.0% vs. 20.7%) for tacrolimus versus CsA-ME. Tremor was more common in tacrolimus treated-patients (17.4% vs. 2.1%, P=0.011).
Early conversion to tacrolimus therapy benefited the resolution of acute rejection episodes and significantly reduced the risk of recurrent rejection compared with continuation of CsA-ME.
Transplantation 07/2003; 75(12):2058-63. · 4.00 Impact Factor
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ABSTRACT: Post-transplant lymphoceles are a common problem after renal transplantation, often inflicting the graft or adjacent iliac veins. Since 1991, there have been many reports on laparoscopic fenestration as the treatment of choice, but no larger series has been presented. At our department, 63 laparoscopic procedures were performed between 1993 and 2001 among 1502 renal graft recipients. The laparoscopic operation time, conversion rate, hospital stay, and complications have all decreased progessively. Duration of hospital stay and convalescence was markedly longer in patients treated with conventional open surgery (27 patients). Rejections, CMV disease, and post-transplant reoperations seem to have an increased incidence in the lymphocele population. According to our experience, laparoscopic fenestration is the superior treatment for symptomatic lymphoceles, allowing minimal trauma and fast recovery. Our series suggests that the rate of complications/graft injury decreases progressively with experience. Laparoscopic ultrasound seems useful in difficult cases. Prophylactic measures should be emphasised at the time of transplantation and reoperations.
Transplant International 10/2002; 15(8):406-10. · 2.92 Impact Factor
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ABSTRACT: Abstract
Backround
Laparoscopic adrenalectomy is a promising alternative to open surgery although concerns exist in regard to laparoscopic treatment of pheocromocytoma. This report compares the outcome of laparoscopic and conventional (open) resection for pheocromocytoma particular in regard to intraoperative hemodynamic stability and postoperative patient comfort.
Methods
Seven patients laparoscopically treated (1997–2000) and nine patients treated by open resection (1990–1996) at the National Hospital (Rikshospitalet), Oslo. Peroperative hemodynamic stability including need of vasoactive drugs was studied. Postoperative analgesic medication, complications and hospital stay were recorded.
Results
No laparoscopic resections were converted to open procedure. Patients laparoscopically treated had fewer hypertensive episodes (median 1 vs. 2) and less need of vasoactive drugs peroperatively than patients conventionally operated. There was no difference in operative time between the two groups (median 110 min vs. 125 min for adrenal pheochromocytoma and 235 vs. 210 min for paraganglioma). Postoperative need of analgesic medication (1 vs. 9 patients) and hospital stay (median 3 vs. 6 days) were significantly reduced in patients laparoscopically operated compared to patients treated by the open technique.
Conclusion
Surgery for pheochromocytoma can be performed laparoscopically with a safety comparable to open resection. However, improved hemodynamic stability peroperatively and less need of postoperative analgesics favour the laparoscopic approach. In experienced hands the laparoscopic technique is concluded to be the method of choice also for pheocromocytoma.
BMC Surgery. 01/2001;
