Safety of simultaneous aortic reconstruction and renal transplantation

Article Abstract:

Patients with chronic kidney failure who are undergoing dialysis (a procedure which removes toxins and other wastes normally excreted by the kidney) often also have aortoiliac atherosclerosis (cholesterol plaque formation on the inner layer of the walls of the major blood vessels of the lower trunk of the body). Traditionally the presence of both conditions has been a reason not to perform either kidney transplant or aortic reconstruction. This hesitancy to perform surgery is due both to the technical demands of the procedure and the physiological impact on these already very sick patients. The authors report their experience treating eight patients with both aortic disease and end-stage kidney failure who underwent both aortic reconstruction and kidney transplant. Seven patients had abdominal aneurysms (localized thinning of the wall of the abdominal aorta) and one patient had aortoiliac occlusive disease. Five patients had sequential development of disease and underwent two separate operations, with an average of four years between operations. Three patients had simultaneous disease and underwent a single operation during which both procedures were carried out. Patients were followed for an average of 4.5 years. The five-year kidney transplant survival was 100 percent; the percentage of primary aortic vascular grafts that remained open and viable (patent) was 82 percent, and secondary aortic graft patency rate was 100 percent. There was one death due to overwhelming cytomegalovirus infection; this occurred 11 years following aortic reconstruction and four months after kidney transplant. There was no significant difference in death rate, complication rate, transplanted kidney function or vascular graft patency between patients operated on simultaneously or in staged procedures. It is concluded that patients with kidney failure and aortic disease can safely undergo surgery for both conditions. Staged procedures should be reserved for patients with sequential disease, otherwise if both conditions are present simultaneously, both procedures should be performed at the same time. Regardless of the time of operation both the 30-day and five-year results are excellent. (Consumer Summary produced by Reliance Medical Information, Inc.)

Surgery, Atherosclerosis, Chronic kidney failure, Aortic aneurysms, Aortic aneurysm

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The "all-autogenous" tissue policy for infrainguinal reconstruction questioned

Article Abstract:

Although vascular reconstruction of the vessels in the leg results in the highest patency (flow) rate when the saphenous vein is used as the bypass-graft conduit, this vein is not always available. It has been suggested that other autogenous tissue (tissue from the patient's own body) such as the lesser saphenous vein can be used, or other procedures may be performed. One alternative is the use of prosthetic bypass grafts (polytetrafluoroethylene, or PTFE), which have been reported to produce a low patency rate (35 percent over five years). The results of using the PTFE bypass procedure are reported. Over a three-year period, 86 patients (93 legs) were referred for treatment for limb-threatening ischemia (decreased blood supply causing pain and tissue death). Surgery was performed only if the loss of the leg was likely. For 30 cases (33 percent) in which no suitable autogenous reconstruction was possible, PTFE reconstruction was performed. Results obtained from autogenous reconstruction and PTFE reconstruction were compared at one and three years following surgery. At one year, the patency rate for autogenous reconstruction was 85 percent, and was 67 percent for PTFE. Cumulative patency rates at three years were 80 percent for autogenous, and 57 percent for PTFE. Rate of leg salvage was 90 percent for autogenous bypass, and 70 percent for the PTFE method. Most of the failures in both groups occurred after the first month. Graft function was monitored closely by duplex scanning and ankle-arm index. Postoperative treatment consisted of long-term aspirin and warfarin therapy. It is concluded that PTFE bypass is a viable alternative when autogenous conduit is not available for bypass grafting. (Consumer Summary produced by Reliance Medical Information, Inc.)

Usage, Veins, Vascular grafts, Blood vessel prosthesis, Vascular prostheses, Venous grafts

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Increased septic complications with three-drug sequential immunosuppression for cadaver renal transplants

Article Abstract:

The introduction of cyclosporine, a fungal metabolite that has the ability to suppress the function of the immune system to avoid graft rejection, has significantly increased the success of kidney transplantation. The use of cyclosporine initially was associated with delayed function of the graft-organ function. In response to this, to avoid kidney toxicity, a regimen using sequential immune suppression was devised. A three-drug regimen including antilymphocyte globulin (ALG), prednisone, and azathioprine, followed by cyclosporine was initiated. However, the use of this three-drug regimen has been associated with an increase in complications, primarily infections. A report is presented on the results of kidney transplants performed on 152 patients; 45 patients received two-drug sequential immunosuppression with ALG and prednisone, and 107 patients received three-drug immunosuppression with ALG, prednisone, and azathioprine. For all patients, cyclosporine was begun when laboratory tests indicated an acceptable level of kidney function (serum creatinine below 2.5). Patient survival at one year was not significantly different between the two groups (93 percent for two-drug regimen, and 86 percent for three-drug). However, the survival of the transplanted kidney was better in the two-drug group (93 percent survival), than in the three-drug group (75 percent). It was confirmed that there is a higher rate of infectious complications associated with the use of the three-drug protocol than with the two-drug protocol. It is concluded that in low-risk kidney transplants, two-drug sequential immune suppression provides a better patient outcome than three-drug sequential immune suppression. (Consumer Summary produced by Reliance Medical Information, Inc.)

Complications and side effects, Drug therapy, Graft rejection, Immunosuppressive agents

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