This study investigates the effect of renal artery multiplicity on donor and recipient outcomes after laparoscopic donor nephrectomy. Three-hundred and sixty-one sequential procedures were performed over a 4-year period. Forty-nine involved accessory renal arteries; of these, 36 required revascularization and 13 were small polar vessels and ligated. The 312 remaining kidneys with single arteries served as controls. Study variables included operative times, blood loss, hospital stay, graft function and donor and recipient complications.Kidneys with multiple revascularized arteries had a longer mean warm ischemia time (35.3 vs. 29.2 min, p = 0.0003), and more ureteral complications (6/36 vs. 10/312, p = 0.0013) than single-artery controls. In contrast, ligation of a small superior accessory artery had no significant effect on donor operative time, blood loss, or complication rate while providing similar recipient graft function compared to single-artery controls.Renal artery number is important in selecting the appropriate kidney for laparoscopic procurement. Given the current excellent results with right-sided donor nephrectomy, kidneys with single arteries should be preferentially procured, irrespective of side.

This large single-center experience demonstrates that laparoscopic right donor nephrectomy performed without hand-assist devices is safe and yields kidneys with excellent function. The authors conclude that selection of the appropriate kidney for donation using this approach can be based on the same criteria that have traditionally governed open donor nephrectomy.

Sirolimus (SRL) provides effective immunosuppression for kidney transplantation and may be useful in patients with delayed allograft function after kidney transplantation. We review our experience with SRL in liver transplant recipients for whom calcineurin inhibitors are undesirable. Fourteen patients with renal insufficiency or acute mental status impairment were administered SRL after liver transplantation (5-to 10-mg load, 1 to 4 mg/d). Immunosuppression also consisted of mycophenolate mofetil and corticosteroids. On resolution of neurological or renal dysfunction (return to baseline mental status or serum creatinine level), tacrolimus (TAC) therapy was initiated. Twelve patients received primary transplants, 1 patient received a combined liver-kidney transplant, and 1 patient received a third transplant. C urrently, calcineurin inhibitors are the mainstay drugs in regimens to prevent acute rejection in liver transplantation. In the past decade, the efficacy of calcineurin inhibitors has revolutionized solid-organ transplantation. However, both cyclosporine and tacrolimus are limited by their toxicities, most prominently nephrotoxicity and neurotoxicity. Unfortunately, both renal dysfunction and encephalopathy are often prominent features in the clinical presentation of many liver transplant recipients before transplantation. In these patients, the management of posttransplantation immunosuppression is particularly challenging because of the need to provide adequate immunosuppression without exacerbating renal dysfunction or causing neurotoxicity. In this setting, calcineurin inhibitors are often withheld, which may result in an increased risk for allograft rejection.Sirolimus (SRL; rapamycin; Wyeth-Ayerst, Philadelphia, PA), a macrocyclic lactone produced by Streptomyces hygroscopicus, has been shown to be a potent therapeutic agent in combination with cyclosporine (CsA). It resembles tacrolimus (TAC; Prograf; Fujisawa Healthcare, Deerfield, IL) structurally and binds the same immunophilin FK506 12-kd binding protein . Whereas CsA and TAC inhibit interleukin-2 gene transcription, SRL acts by blocking postreceptor signal transduction and interleukin-2-dependent proliferation. 1 SRL has been shown to be a powerful immunosuppressant in in vitro and animal models. 2,3 More recently, used in combination with CsA, it has been shown to be a potent therapeutic antirejection agent for kidney transplantation in humans. 4 The side-effect profile of SRL differs from that of the calcineurin inhibitors. Notably, no nephrotoxicity or neurotoxicity has been observed; however, leukopenia, thrombocytopenia, hypertriglyceridemia, and hypercholesterolemia have been noted. 5 We and others have used SRL in combination with anti-CD25 monoclonal antibody induction in a calcineurin-inhibitorsparing regimen for renal transplant recipients with delayed or impaired initial graft function. When therapeutic dosages of SRL were administered and titrated to maintain serum trough levels greater than 8 to

With the introduction of more potent immunosuppressive agents, rejection has decreased in simultaneous pancreas/kidney transplant (SPK) recipients. However, as a consequence, opportunistic infections have increased. The purpose of this report is to outline the course of SPK patients who developed polyomavirusassociated nephropathy (PVAN). A retrospective review of 146 consecutive SPK recipients from January 1, 1996 to December 31, 2002 was performed. Immunosuppression, rejection and development of PVAN were reviewed. Nine patients were identified. All received induction with either OKT3 or thymoglobulin. Immunosuppression included tacrolimus/cyclosporine, MMF/azathioprine and sirolimus/prednisone. Two patients were treated for kidney rejection prior to the diagnosis of PVAN. Time to diagnosis was an average of 359.3 days post-transplantation. Immunosuppression was decreased but five ultimately lost function. However, none developed pancreatic abnormalities as demonstrated by normal glucose and amylase. Two underwent renal retransplantation after PVAN diagnosis and both have normal kidney function. PVAN was the leading cause of renal loss in SPK patients in the first 2 years after transplantation and is a serious concern for SPK recipients. The pancreas, however, is spared from evidence of infection, and no pancreatic rejection occurred when immunosuppression was decreased.

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