Summary
The increasing use of donation after circulatory death (DCD) and extended criteria donor (ECD) organs has raised awareness of the need to improve the quality of kidneys for transplantation. Treating kidneys during the preservation interval could improve early and long‐term graft function and survival. Dynamic modes of preservation including hypothermic machine perfusion (HMP) and normothermic machine perfusion (NMP) may provide the functional platforms to treat these kidneys. Therapies in the field of regenerative medicine including cellular therapies and genetic modification and the application of biological agents targeting ischaemia reperfusion injury (IRI) and acute rejection are a growing area of research. This review reports on the application of cellular and gene manipulating therapies, nanoparticles, anti‐inflammatory agents, anti‐thrombolytic agents and monoclonal antibodies administered during HMP and NMP in experimental models. The review also reports on the clinical effectiveness of several biological agents administered during HMP. All of the experimental studies provide proof of principle that therapies can be successfully delivered during HMP and NMP. However, few have examined the effects after transplantation. Evidence for clinical application during HMP is sparse and only one study has demonstrated a beneficial effect on graft function. More investigation is needed to develop perfusion strategies and investigate the different experimental approaches.
As there is usually considerable overlap in the renal venous drainage, it is often possible to ligate supernumerary transplant renal veins in order to simplify the implantation procedure. Nonetheless, decisions about whether to implant multiple veins can be difficult and are usually made subjectively. Here, we describe the use of intraoperative Doppler ultrasound as an adjunct to decision-making when there are two renal veins and a novel technique for the sequential anastomosis of dual veins. The kidney was reperfused after anastomosis of the main renal vein with the second vein clamped. On-table Doppler ultrasound demonstrated reversed flow in diastole indicating that the second renal vein also needed to be anastomosed. By clamping the external iliac vein inferior to the first venous anastomosis it was possible to complete the lower polar renal vein anastomosis to the external iliac vein without interrupting the perfusion of the kidney.
Liver transplantation is the only life-saving treatment for end-stage liver failure but is limited by the organ shortage and consequences of immunosuppression. Repopulation of decellularised scaffolds with recipient cells provides a theoretical solution, allowing reliable and timely organ sourcing without the need for immunosuppression. Recellularisation of the vasculature of decellularised liver scaffolds was investigated as an essential prerequisite to the survival of other parenchymal components. Liver decellularisation was carried out by portal vein perfusion using a detergent-based solution. Decellularised scaffolds were placed in a sterile perfusion apparatus consisting of a sealed organ chamber, functioning at 37 C in normal atmospheric conditions. The scaffold was perfused via portal vein with culture medium. A total of 10 7 primary cultured bone marrow stem cells, selected by plastic adherence, were infused into the scaffold, after which repopulated scaffolds were perfused for up to 30 days. The cultured stem cells were assessed for key marker expression using fluorescence-activated cell sorting (FACS), and recellularised scaffolds were analysed by light, electron and immunofluorescence microscopy. Stem cells were engrafted in portal, sinusoidal and hepatic vein compartments, with cell alignment reminiscent of endothelium. Cell surface marker expression altered following engraftment, from haematopoietic to endothelial phenotype, and engrafted cells expressed sinusoidal endothelial endocytic receptors (mannose, Fc and stabilin receptors). These results represent one step towards complete recellularisation of the liver vasculature and progress towards the objective of generating transplantable neo-organs.
Preoperative hypoalbuminemia (<35 mg/dL) is independently associated with 40% reduction in the functional maturation of RCAVF. Stratification of this readily available biomarker prior to RCAVF formation may require consideration subjected to further research.
By performing this sequence of events, the narrow femur distal to the metaphyseal shaft junction is rasped first, which will help facilitate the 37.5mm No. 0 rasp and stem if required. This is demonstrated in figures 3 and 4.Being aware of this will help when dealing with proximal tight canal femurs to help minimise any untoward intraoperative complications and aid in the smooth, easy preparation of the femur.
DISCUSSIONThis technique has proved effective and efficient in safely and adequately preparing the narrow femur to accept a more appropriate size stem in both total hip replacement and hemiarthroplasty. This technique does not require any extra equipment and is therefore cost neutral.
According to National Institute of Clinical Excellence guidelines, the ankle-brachial pressure index coupled with a full clinical evaluation has been the mainstay of detecting peripheral arterial disease on its suspicion. However, this technique is not free of its own limitations in calcified arteries, ulcerative and diabetic patients. We introduce a new, novel, and effective assessment device (BlueDop) with a minimal learning curve that could overcome such barriers and serve as a valid replacement in perihospital settings.
Background: The aim of this study is to establish and evaluate whether the use of prophylactic antibiotics in the creation of any autogenous arteriovenous fistula in hemodialysis patients is indicated, evidence-based and/or recommended.
Methods: A systematic review and meta-aggregation of the literature from 1966 to August 2016 in the English language in Medline, Scopus, Embase and Cochrane Library was conducted.
Results: The search produced a total of n=94 articles. Following the application of the recruitment criteria in accordance to PRISMA one (n=1) article was found eligible with a population of n=611 patients undergoing autogenous fistula formation. A total of n=136 patients received prophylactic antibiotics with no incidence of surgical site infection (SSI). The reported incidence of SSI in the group of patients (n=475) that did not receive prophylactic antibiotics was 0.2% (n=1). The quality of the article was assessed by the Oxford Critical Appraisal Skills Programme (CASP) and their recommendation for practice was evaluated through National Institute for Health and Care Excellence (NICE).
Conclusion: The first systematic review of the literature demonstrates that the current use of prophylactic antibiotics in the creation of any autogenous AVF is not evidence-based and further research in this area is highly advocated.
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