Orthotopic kidney transplantation: an alternative surgical technique in selected patients.

Musquera M¹, Peri LL, Alvarez-Vijande R, Oppenheimer F, Gil-Vernet JM, Alcaraz A.

• ¹Department of Urology, Hospital Clinic - University of Barcelona, Barcelona, Spain. mmusquer@clinic.ub.es

BACKGROUND:

A renal transplant is the treatment of choice for patients with end-stage renal disease due to its superior short- and long-term survival benefits compared with dialysis treatment. A common trend for kidney transplantation in developed countries is an increasing acceptance of older patients, patients with comorbidities, and patients with vascular problems (eg, atheromatosis, venous thrombosis). For those patients, an orthotopic kidney transplant (OKT) is an option.

OBJECTIVE:

Our aim was to analyze the results of the largest OKT series in the world (surgical technique, complications, and outcomes) and to compare indications, surgical techniques, and long-term results from two different periods (before and after February 1987).

DESIGN, SETTINGS, AND PARTICIPANTS:

Between April 1978 and September 2009, 223 OKT were performed. We compared the results of transplants performed in two different periods: from April 1978 to January 1987 with 139 patients and from February 1987 to September 2009 with 84 patients.

INTERVENTION:

OKT were performed in all cases as described in the first report published in 1989 by Gil-Vernet et al.

MEASUREMENTS:

The clinical data, surgical reports, and complications rate of all patients were reviewed retrospectively. From a database maintained prospectively, two different periods were described, and the long-term results of the OKT were compared. Graft and patient survival in orthotopic versus heterotopic transplants from the same period were also compared.

RESULTS AND LIMITATIONS:

During the second period an important decrease in the number of OKT was observed due to the change in indication for this specific technique. No important differences between periods were noted in terms of surgical technique. The rate of urinary complications rate was similar in both periods. No differences in graft survival between series have been observed (p=0.22), but a higher mortality rate was seen in the second period mostly due to an older unfit population (p=0.031). No differences were observed in overall graft and patient survival between orthotopic and heterotopic kidney transplants performed during the same period.

CONCLUSIONS:

OKT is a good alternative with acceptable rates of urologic and vascular complications for those patients for whom heterotopic transplant is considered unsuitable.

Copyright © 2010 European Association of Urology. Published by Elsevier B.V. All rights reserved.

Source:
http://www.ncbi.nlm.nih.gov/pubmed/20888120 

Solitary Kidney

What is a solitary kidney?

When a person has only one kidney or one working kidney, this kidney is called a solitary kidney. The three main causes of a solitary kidney are

• birth defects. People with kidney agenesis are born with only one kidney. People born with kidney dysplasia have both kidneys; however, one kidney does not function. Many people with kidney agenesis or kidney dysplasia do not discover that they have a solitary kidney until they have an x ray, an ultrasound, or surgery for an unrelated condition.
• surgical removal of a kidney. Some people must have a kidney removed to treat cancer or another disease or injury. When a kidney is removed surgically due to disease or for donation, both the kidney and ureter are removed.
• kidney donation. A growing number of people are donating a kidney to be transplanted into a family member or friend whose kidneys have failed.

In general, people with a solitary kidney lead full, healthy lives. However, some people are more likely to develop kidney disease.

When a person has only one kidney or one working kidney, this kidney is called a solitary kidney. People born with kidney dysplasia have both kidneys; however, one kidney does not function (top right). When a kidney is removed surgically due to disease or for donation, both the kidney and ureter are removed (bottom right).

What are the kidneys and what do they do?

The kidneys are two bean-shaped organs, each about the size of a fist. They are located just below the rib cage, one on each side of the spine. Every day, the kidneys filter about 120 to 150 quarts of blood to produce about 1 to 2 quarts of urine, composed of wastes and extra fluid. The urine flows from the kidneys to the bladder through tubes called ureters. The bladder stores urine until releasing it through urination.

Do people with a solitary kidney need to be monitored for kidney damage?

People with a solitary kidney should be tested regularly for the following signs of kidney damage:

• albuminuria
• decreased glomerular filtration rate (GFR)
• high blood pressure

Albuminuria Testing
Albuminuria is an elevated level of the protein albumin in the urine. Albumin acts like a sponge, drawing extra fluid from the body into the bloodstream, where it remains until removed by the kidneys. When albumin leaks into the urine, the blood loses its capacity to absorb extra fluid from the body. Although the increased albumin in the urine may not cause any symptoms, it often indicates an increased chance of kidney disease.
Dipstick test for albumin. The presence of albumin in the urine can be detected with a dipstick test performed on a urine sample. The urine sample is collected in a special container in a health care provider’s office or a commercial facility and can be tested in the same location or sent to a lab for analysis. With a dipstick test, a nurse or technician places a strip of chemically treated paper, called a dipstick, into the person’s urine sample. Patches on the dipstick change color when protein is present in urine.
Albumin and creatinine measurement. A more precise measurement is usually needed to confirm albuminuria. A single urine sample or a 24-hour collection of urine is sent to a lab for analysis. With the single urine sample, the lab measures both albumin and creatinine, a waste product of normal muscle breakdown. The results are reported as a urine albumin-to-creatinine ratio. A urine sample containing more than 30 mg of albumin for each gram of creatinine may signal a problem. With a 24-hour collection of urine, the lab measures only the amount of albumin present. Although both tests are effective, the single urine sample is easier to collect than the 24-hour sample and is usually sufficient to diagnose and monitor kidney disease.
Decreased GFR Testing Blood drawn at a health care provider’s office or a commercial facility and sent to a lab for analysis can be tested to estimate how much blood the kidneys filter each minute, called the estimated glomerular filtration rate (eGFR). The results of the test indicate the following:

• eGFR of 60 or above is in the normal range.
• eGFR below 60 may indicate kidney damage.
• eGFR of 15 or below may indicate kidney failure.

High Blood Pressure Monitoring Blood pressure is the force of blood pushing against the blood vessel walls as the heart pumps out blood. Blood vessels are also called arteries. High blood pressure, also called hypertension, is an increase in the amount of force the blood places on the blood vessels as it moves through the body. Blood pressure is written with two numbers separated by a slash. For example, a blood pressure result of 120/80 is said as “120 over 80.” The first number is called the systolic pressure and represents the pressure as the heart beats and pushes blood through the blood vessels. The second number is called the diastolic pressure and represents the pressure as the heart rests and the blood vessels relax between heartbeats.
A person’s blood pressure is considered normal if it stays below 120/80. Prehypertension is a systolic pressure of 120 to 139 or a diastolic pressure of 80 to 89. High blood pressure is a systolic pressure of 140 or above or a diastolic pressure of 90 or above.¹ High blood pressure is diagnosed when multiple blood pressure tests—often repeated over several visits to the health care provider’s office—show that blood pressure is consistently above 140/90. Health care providers measure blood pressure with a blood pressure cuff. People can also buy blood pressure cuffs at places such as discount chain stores and drugstores to monitor their blood pressure at home.
High blood pressure can damage blood vessels in the kidneys, reducing their ability to work properly. Damaged kidneys may be less able to remove salt and extra fluid, raising blood pressure further and creating a dangerous cycle.

¹National Heart, Lung, and Blood Institute. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Washington, D.C.: U.S. Government Printing Office; 2004. NIH publication 04–5230. Report.

What steps can people with a solitary kidney take to protect their health?

People with a solitary kidney can protect their health by eating a nutritious diet, keeping their blood pressure at the appropriate level, and preventing injury to the working kidney.

Eating, Diet, and Nutrition

People with a solitary kidney do not need to eat a special diet. However, people with reduced kidney function may need to make changes to their diet to slow the progression of kidney disease. Read more about recommended dietary changes in Nutrition for Early Chronic Kidney Disease in Adults and Nutrition for Advanced Chronic Kidney Disease in Adults at www.kidney.niddk.nih.gov and on the National Kidney Disease Education Program website at www.nkdep.nih.gov/living/diet-lifestyle-changes.shtml. People should talk with their health care provider about what diet is right for them.

Controlling Blood Pressure
People can control their blood pressure by not smoking, eating a healthy diet, and taking certain medications. Medications that lower blood pressure can also significantly slow the progression of kidney disease. Two types of blood pressure–lowering medications, angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs), have proven effective in slowing the progression of kidney disease. Many people require two or more medications to control their blood pressure. In addition to an ACE inhibitor or ARB, a diuretic—a medication that helps the kidneys remove fluid from the blood—may be prescribed. Beta-blockers, calcium channel blockers, and other blood pressure medications may also be needed.
Preventing Injury
For people with a solitary kidney, loss of the remaining working kidney results in the need for dialysis or kidney transplant. People should make sure their health care providers know they have a solitary kidney to prevent injury from medications or medical procedures. People who participate in certain sports may be more likely to injure the kidney; this risk is of particular concern with children, as they are more likely to play sports. The American Academy of Pediatrics recommends individual assessment for contact, collision, and limited-contact sports. Protective equipment may reduce the chance of injury to the remaining kidney enough to allow participation in most sports, provided that such equipment remains in place during activity. Health care providers, parents, and patients should consider the risks of any activity and decide whether the benefits outweigh those risks.

Points to Remember

• When a person has only one kidney or one working kidney, this kidney is called a solitary kidney. The three main causes of a solitary kidney are birth defects, surgical removal of a kidney, and kidney donation.
• In general, people with a solitary kidney lead full, healthy lives. However, some people are more likely to develop kidney disease.
• People with a solitary kidney should be tested regularly for the following signs of kidney damage:
  • albuminuria
  • decreased glomerular filtration rate (GFR)
  • high blood pressure
• People with a solitary kidney can protect their health by eating a nutritious diet, keeping their blood pressure at the appropriate level, and preventing injury to the working kidney. 

Source:
http://kidney.niddk.nih.gov/KUDiseases/pubs/solitarykidney/index.aspx

Acquired Cystic Kidney Disease

• Author: Dwarakanathan Ranganathan, MD, FRCP, FRACP; Chief Editor: Vecihi Batuman, MD, FACP, FASN

Renal cystic disease is a term that represents a wide spectrum of diseases that may be hereditary, developmental, or acquired; these diseases share the feature of renal cysts. These cysts can occur in the cortex, the corticomedullary junction, and/or the medulla depending on the underlying disease process. Acquired cysts can be simple or part of acquired cystic kidney disease (ACKD), also called acquired renal cystic disease (ARCD). Acquired renal cystic disease is characterized by the development of numerous fluid-filled cysts in the kidneys in individuals who have no history of hereditary cystic disease. Acquired renal cystic disease is a bilateral condition. It can antedate the clinical recognition of end-stage renal failure. In the early stages, acquired renal cystic disease does not produce symptoms and is usually discovered inadvertently in the course of abdominal imaging procedures.

 

sumber: Medscape

TRANSPLANTATION--Kidney Donors Face Higher ESRD Risk

Kidney Donors Face Higher ESRD Risk

by: Jody A. Charnow

Living kidney donors are at increased risk for end-stage renal disease (ESRD) and cardiovascular and all-cause mortality, according to a new study.Investigators led by Hallvard Holdaas, MD, of Oslo University Hospital in Oslo, Norway, compared 1,901 individuals who donated a kidney from 1963 to 2007 with a control group of 32,621 potentially eligible kidney donors. The median follow-up for the donors and controls was 15.1 and 24.9 years, respectively.

Compared with controls, kidney donors had a significant 11.4 times increased risk of ESRD, 1.4 times increased risk of cardiovascular death, and 1.3 times increased risk of death from any cause, after adjusting for potential confounders.ESRD developed in 9 donors (0.47%). The median time from donation was 18.7 years. 

ESRD was mainly caused by immunologic renal diseases.“Our findings raise some medical and ethical considerations regarding live-kidney donation,” the authors wrote in Kidney International(2014;86:162-167). “The present study indicates potential increased long-term risks for kidney failure and mortality in kidney donors. However, this has to be put into perspective.”

Living donor transplantation, they noted, has been a necessary and essential part of providing ESRD patients with freedom from dialysis and enabling transplant recipients to enjoy a superior quality of life. “Most potential living donors are willing to accept a degree of risk when the recipient is a family member of a close friend.”

Previous studies have suggested that living kidney donors maintain long-term renal function and have no increase in cardiovascular or all-cause mortality, Dr. Holdaas' group stated. Most investigations, however, have included control groups that were less healthy than the living donor population and have had relatively short follow-up periods, they pointed out.

The researchers said their findings will not change their opinion about promoting live kidney donation. “However,” they pointed out, “potential donors should be informed of increased risks, although small, associated with donation in short-term and long-term perspective.”

In an editorial accompanying the new report (pp. 20-22), Neil Boudville, MD, of the University of Western Australia in Perth, and Amit X. Garg, MD, of Western University in London, Ontario, pointed out that the elevated risk of ESRD in living kidney donors found by Dr. Holdaas and colleagues is comparable to that found in a study by Abimereki D. Muzaale, MD, MPH, of Johns Hopkins University School of Medicine in Baltimore, and colleagues.

The study, published in the Journal of the American Medical Association(2014;311:579-586), compared 96,217 living kidney donors with 20,024 participants in the Third National Health and Nutrition Examination Survey (NHANES III). In this study, the incidence rate of ESRD was 8-fold higher in the donor cohort.“The findings of these two studies are very important and should influence the information we provide to potential donors,” Drs. Boudville and Garg wrote.

They noted that the findings may impact criteria for donor selection. “We will likely want a higher level of pre-donation kidney function … for younger individuals who are expected to live 50 or more years with one kidney (recognizing we do not have ideal evidence to inform what is the optimal acceptance threshold),” they wrote.Related ArticlesKidney Donation Safe for Older DonorsKidney Remaining After Donor Nephrectomy Increases in SizeBiopsy-Based Discard of Donor Kidneys May Be Misguidedsed risk for end-stage renal disease (ESRD) and cardiovascular and all-cause mortality, according to a new study.Investigators led by Hallvard Holdaas, MD, of Oslo University Hospital in Oslo, Norway, compared 1,901 individuals who donated a kidney from 1963 to 2007 with a control group of 32,621 potentially eligible kidney donors. The median follow-up for the donors and controls was 15.1 and 24.9 years, respectively.Compared with controls, kidney donors had a significant 11.4 times increased risk of ESRD, 1.4 times increased risk of cardiovascular death, and 1.3 times increased risk of death from any cause, after adjusting for potential confounders.ESRD developed in 9 donors (0.47%). The median time from donation was 18.7 years. ESRD was mainly caused by immunologic renal diseases.“Our findings raise some medical and ethical considerations regarding live-kidney donation,” the authors wrote in Kidney International(2014;86:162-167). “The present study indicates potential increased long-term risks for kidney failure and mortality in kidney donors. However, this has to be put into perspective.”Living donor transplantation, they noted, has been a necessary and essential part of providing ESRD patients with freedom from dialysis and enabling transplant recipients to enjoy a superior quality of life. “Most potential living donors are willing to accept a degree of risk when the recipient is a family member of a close friend.”Previous studies have suggested that living kidney donors maintain long-term renal function and have no increase in cardiovascular or all-cause mortality, Dr. Holdaas' group stated. Most investigations, however, have included control groups that were less healthy than the living donor population and have had relatively short follow-up periods, they pointed out.The researchers said their findings will not change their opinion about promoting live kidney donation. “However,” they pointed out, “potential donors should be informed of increased risks, although small, associated with donation in short-term and long-term perspective.”In an editorial accompanying the new report (pp. 20-22), Neil Boudville, MD, of the University of Western Australia in Perth, and Amit X. Garg, MD, of Western University in London, Ontario, pointed out that the elevated risk of ESRD in living kidney donors found by Dr. Holdaas and colleagues is comparable to that found in a study by Abimereki D. Muzaale, MD, MPH, of Johns Hopkins University School of Medicine in Baltimore, and colleagues.The study, published in the Journal of the American Medical Association(2014;311:579-586), compared 96,217 living kidney donors with 20,024 participants in the Third National Health and Nutrition Examination Survey (NHANES III). In this study, the incidence rate of ESRD was 8-fold higher in the donor cohort.“The findings of these two studies are very important and should influence the information we provide to potential donors,” Drs. Boudville and Garg wrote.They noted that the findings may impact criteria for donor selection. “We will likely want a higher level of pre-donation kidney function … for younger individuals who are expected to live 50 or more years with one kidney (recognizing we do not have ideal evidence to inform what is the optimal acceptance threshold),” they wrote.Related ArticlesKidney Donation Safe for Older DonorsKidney Remaining After Donor Nephrectomy Increases in SizeBiopsy-Based Discard of Donor Kidneys May Be Misguided

Severe Erectile Dysfunction May Respond to Shockwave Therapy

Low-intensity extracorporeal shockwave therapy may benefit men with severe erectile dysfunction, researchers reported online ahead of print in the International Journal of Urology.Chi-Hang Yee, MD, and colleagues at The Chinese University of Hong Kong studied 58 men with ED who received either low-intensity shockwave therapy (30 patients) or a sham treatment (28 patients). The two groups did not differ significantly in baseline International Index of Erectile Function-Erectile Function (IIEF-EF) domain score and Erection Hardness Score.At week 13, the mean IIEF-EF domain score in the shockwave therapy and sham arms was 17.8 and 15.8, respectively. The mean Erection Hardness Score was 2.7 and 2.4. These differences were not statistically significant. The shockwave therapy, however, was superior to sham treatment in a subgroup of men with severe ED (mean IIEF-EF domain score 10.1 vs. 3.2).

Source: Renal & Urology News

Sejarah Batu Saluran Kemih

Batu Saluran Kemih (BSK) atau sering disebut juga urolitiasis  merupakan masa kristal terbentuk dari protein dan mineral, yang secara alami terjadi di saluran kemih. BSK merupakan penyakit saluran kemih terbanyak ketiga, setelah penyakit infeksi saluran kemih dan penyakit prostat. Penyakit ini sudah ada sejak awal peradaban manusia. Sejak zaman Mesir kuno hingga saat ini, batu ginjal tampaknya sudah membingungkan para pasien dan tenaga medis, namun perkembangan proses penanganan BSK sudah mengalami banyak sekali kemajuan, diawali dari pengambilan dengan cara yang sangat menyakitkan hingga saat ini dengan cara sangat memuaskan. Namun demikian, cara untuk mencegah kembali terjadi batu ini masih menjadi tantangan para urolog dan nefrolog.

            Sekitat 6.000 tahun yang lalu, sejak ditemukannya BSK pertama kali, pola munculnya penyakit ini sudah mengalami banyak perubahan, terutama seabad belakangan ini. Sebagai contoh, di dunia barat pada tahun 1900, kejadian BSK pada umumnya terjadi pada anak-anak terutama laki-laki, dan paling sering berlokasi di kandung kemih. BSK biasanya mengandung ammonium urate dan/atau calcium oxalate, dan biasanya disebabkan nutrisi yang tidak baik pada anak. Saat ini, kondisi tersebut masih ditemukan di daerah pedesaan, khususnya pada daerah “Sabuk Batu (Stone Belt)”, menyebar mulai dari Yordania, menuju Iraq, Iran, dan India hingga penghujung Asia Tenggara. Namun kondisi tersebut menghilang dengan cepat sejalan dengan ditingkatkannya pemberian nutrisi., seperti yang juga dilakukan oleh negara-negara berkembang sekitar 100 tahun yang lalu. Saat itu, kejadian batu kandung kemih pada anak mengalami penurunan, namun kejadian BSK pada dewasa mengalami peningkatan. Hal ini terjadi berkaitan dengan kondisi kemakmuran dan kemunduran suatu negara

Referensi:

1.      Robertson, WG. The Scientific Basis of Urinary Stone Formation. The Sientific Basis of Urology, 2010: 10:162

2.      Stoller, ML. Urinary Stone Disease. Smith’s General Urology-17th edition. 2007; 16:246

Introduction of Urinary Tract Stone

Urinary tract stones are crystialline masses that form from the minerals and proteins, which naturally occur in urinary tract. Urinary tract stone disease is sometimes called urinary calculus or urolithiasis. It is the third most common affliction of the urinary tract, exceeded only by urinary tract infection and pathologic condition of prostate. Urinary stones have plagued humans since the earliest records of civilization. From the days of predynastic Egyptians until the present time, kidney stones have perplexed patients and physicians alike and, although during that time the methods for removing stones have advanced from the crudely barbaric to the highly sophisticated, the problem of how successfully  to prevent the recurrent stones continiues to challenge urologist and nephrologist

During the six millennia since the formation of the earliest recorded stone, the pattern of urolithiasis has changed in many respect, particularly within the past century. For example, in Western countries before 1900, stones occurred commonly in children particularly in boys, and were form commonly in bladder. The stones usually consisted of ammonium urate and/or calcium oxalate and were caused by poor nutrition. Although this form of the disorder is still found today in rural areas within the “endemic stone belt”, stretching from Jordan, through Iraq, Iran, and the Indian subcontinent until to the furthest extremities of South-East Asia, is is rapidly disappearing with improving strandard of nutrition, as it did in most of developed countries about 100 years ago. As the incidence, the bladder stones in children has decreased, however the prevalence of stones in adults has increased, there have been peaks and troughs in incidence that coincide with period of economic prosperity and recession.

 

Reference:

1.  Robertson, WG. The Scientific Basis of Urinary Stone Formation. The Sientific Basis of Urology, 2010: 10:162

2.  Stoller, ML. Urinary Stone Disease. Smith’s General Urology-17th edition. 2007; 16:246