ObjectiveTo evaluate whether intravascular volume expansion would improve renal blood flow and function during prolonged CO 2 pneumoperitoneum. Summary Background DataAlthough laparoscopic living donor nephrectomies have a considerably reduced risk of complications for the donors, significant concerns exist regarding procurement of a kidney in the altered physiologic environment of CO 2 pneumoperitoneum. Recent studies have documented adverse effects of CO 2 pneumoperitoneum on renal hemodynamics. MethodsRenal and systemic hemodynamics and renal histology were studied in a porcine CO 2 pneumoperitoneum model. After placement of a pulmonary artery catheter, carotid arterial line, Foley catheter, and renal artery ultrasonic flow probe, CO 2 pneumoperitoneum (15 mmHg) was maintained for 4 hours. Pigs were randomized into three intravascular fluid protocol groups: euvolemic (3 mL/kg/hour isotonic crystalloid), hypervolemic (15 mL/kg/hour isotonic crystalloid), or hypertonic (3 mL/kg/hour isotonic crystalloid plus 1.2 mL/kg/hour 7.5% NaCl). ResultsIn the euvolemic group, prolonged CO 2 pneumoperitoneum caused decreased renal blood flow, oliguria, and impaired creatinine clearance. Both isotonic and hypertonic volume expansions reversed the changes in renal blood flow and urine output, but impaired creatinine clearance persisted. ConclusionsIntravascular volume expansion alleviates the effects of CO 2 pneumoperitoneum on renal hemodynamics in a porcine model. Hypertonic saline (7.5% NaCl) solution may maximize renal blood flow in prolonged pneumoperitoneum, but it does not completely prevent renal dysfunction in this setting. This study suggests that routine intraoperative volume expansion is important during laparoscopic live donor nephrectomy.Living donor renal transplantation has achieved a high level of acceptance from the general public and is the ideal renal replacement therapy for those with end-stage renal disease. Living donor nephrectomy has been proven safe and is associated with minimal complications and a negligible death rate. 1The recipient benefits of living donor renal transplantation are multiple: superior patient and graft survival, no prolonged waiting time, decreased incidence of delayed allograft function, and a shorter hospital stay.2 These superior results and the current shortage of cadaver kidneys provide an incentive to increase the frequency of living donor transplantation. However, a significant disincentive is the invasive nature of the donor nephrectomy and its relatively long postoperative recovery period. Recent reports of laparoscopically assisted living donor nephrectomy have shown that this less invasive approach results in reduced postoperative pain, a shorter hospital stay, and a more rapid return to the work for the donor. [3][4][5][6] In addition, decreased donor discomfort and a shorter convalescence have resulted in a substantially increased rate of consent to living donation and may help to alleviate the ongoing transplant organ shortage.

Hypothesis: Radiocephalic fistulas for maintenance hemodialysis access are not feasible in all patients with endstage renal disease. Our aim was to review our experience with 3 types of upper arm arteriovenous fistula (AVF) to ascertain whether they are reasonable alternatives to radiocephalic fistulas and which, if any, have superior performance. Patients and Methods: Patient medical records were retrospectively reviewed. The main outcomes were maturation rate, time to maturation, assisted maturation rate, complication rates, reintervention rates, primary and assisted primary patency rates, and effects of comorbidities. Results: Eighty-six patients with end-stage renal disease underwent creation of a brachiocephalic, brachiobasilic, or brachial artery-to-median antecubital vein AVF. Overall, 80% matured, with 23% requiring an intervention to achieve maturity. The mean time to maturation was 3.8 months; 47% had a complication (inability to access, thrombosis, and so on), and 43% required additional interventions. The overall primary patency and assisted primary patency rates at 12 months were 50% and 74%, respectively. Brachiobasilic AVFs not superficialized immediately often needed a second operation. There were no significant differences in patency rates among the 3 AVF types. The AVFs in patients with diabetes took 2 months longer to mature than did those in patients without diabetes. Conclusions: An upper arm AVF is a reasonable alternative for maintenance hemodialysis access when a radiocephalic AVF is not possible. There are 3 valid options from which to choose to best accommodate each patient's antecubital anatomy. Diabetes may adversely affect outcomes. Our data suggest that brachiobasilic AVFs should be superficialized at the initial procedure, if feasible.

Hepatic ischemia/reperfusion (I/R) injury is characterized by the generation of reactive oxygen species (ROS), such as superoxide anions and hydrogen peroxide. The aim of this study is to investigate whether antioxidative gene delivery by our polylipid nanoparticles (PLNP) is an effective approach for prevention of the injury. Polyplexes of extracellular superoxide dismutase (EC-SOD) and/or catalase genes were injected via the portal vein 1 day prior to a warm I/R procedure in mice. The effects of the gene delivery were determined 6 hours after starting reperfusion. PLNP-mediated antioxidative gene delivery led to a marked increase in human EC-SOD and catalase gene expression in the liver. Liver superoxide dismutase (SOD) and catalase activity both increased approximately 10-fold. Increased liver superoxide anion levels caused by the I/R procedure were reduced to normal levels by EC-SOD gene delivery. The overexpression of these 2 antioxidative genes significantly suppressed the I/R-induced elevation of serum alanine aminotransferase (ALT) levels, decreased liver malondialdehyde content, restored glutathione reserve, and improved liver histology. In conclusion, EC-SOD or catalase gene delivery by PLNP resulted in high levels of the transgene activity in the liver, and markedly attenuated hepatic I/R injury. The protection is directly associated with elevated antioxidative enzyme activity as the result of the gene delivery. This novel approach may become a potential therapy to improve graft function and survival after liver transplantation.

Sirolimus, a potent new immunosuppressant, has been anecdotally associated with surgical wound complications. We studied postoperative surgical wound complications in 15 kidney recipients receiving sirolimus, prednisone, and tacrolimus or cyclosporine (study group) compared with 15 recipients receiving tacrolimus, prednisone, and mycophenolate mofetil who were pair-matched for surgical wound complication risk factors. Surgical wound complications were defined as any complication related to the surgical transplant wound requiring reintervention. Fifty-three percent of the study group and 7% of the control group experienced more than one surgical wound complication (P=0.014), and the relaparotomy incidence was 33% and 7%, respectively. Four graft losses have occurred since the beginning of the study: one chronic rejection and two deaths with function in the study group, and one death with function in the control group. At 1 year, graft survival for study recipients compared with control recipients was 87% and 93%, respectively; patient survival was 93% in both groups. Recipients receiving sirolimus demonstrated a significantly higher surgical wound complication rate, but graft and patient survival were not affected. Peritransplant immunosuppression with sirolimus and steroids warrants careful consideration, particularly in recipients with surgical complication risk factors.

Background: For anatomical and technical reasons, many transplant centers restrict laparoscopic live donor nephrectomy (in contrast with open live donor nephrectomy) to left kidneys.Hypothesis: This change in surgical practice increases procurement and transplantation rates of live donor kidneys with multiple renal arteries (RAs), without affecting donor and recipient outcomes.Design and Setting: Retrospective review at an academic tertiary care referral center comparing laparoscopically procured single-vs multiple-RA kidney grafts (April 1997 to October 2000.Patients: Seventy-nine consecutive left laparoscopic live kidney donors and 78 transplant recipients.Main Outcome Measures: Donor and recipient complications and postoperative length of stay; cold and warm ischemia time; operating time; short-term and longterm graft function; and survival. Results:We noted multiple RAs in 21 (27%) of all kidneys. The proportion of donors with 1 or more periop-