Delayed Grafting as a Valid Technique in Burn Management: Experience from a Burn Unit in Oman

Background: Early excision and grafting has been the preferred method of managing major burns around the world since 1970. Considering the advances in health care and the development of new antibiotics over the past 50 years, delayed grafting as a technique for the management of burns over 15%-20% of total body surface area (TBSA) could have comparable results to that of early excision. This study aims to highlight the outcomes of practicing delayed grafting in burn patients. Methods: A case series analysis was performed of 51 patients who were admitted to the burns unit in Sultan Qaboos Hospital Salalah with over 20% TBSA between January 2014 and December 2019. The patients received prophylactic antibiotics and silver sulphadiazine dressing until the burn eschar had completely separated, followed by grafting. Results: Two patients were lost during the entire duration of the study. The mortality rate was comparable to that of early excision, while the rate of hypertrophic scarring was lower than the range reported by other studies. Conclusion: In the management of patients with over 20% TBSA, delayed grafting after complete separation of eschar is still a valid technique.

Perioperative risk factors associated with delayed graft function following deceased donor kidney transplantation:A retrospective,single center study

BACKGROUND There is an abundant need to increase the availability of deceased donor kidney transplantation(DDKT)to address the high incidence of kidney failure.Challenges exist in the utilization of higher risk donor organs into what appears to be increasingly complex recipients;thus the identification of modifiable risk factors associated with poor outcomes is paramount.AIM To identify risk factors associated with delayed graft function(DGF).METHODS Consecutive adults undergoing DDKT between January 2016 and July 2017 were identified with a study population of 294 patients.The primary outcome was the occurrence of DGF.RESULTS The incidence of DGF was 27%.Under logistic regression,eight independent risk factors for DGF were identified including recipient body mass index≥30 kg/m^(2),baseline mean arterial pressure<110 mmHg,intraoperative phenylephrine administration,cold storage time≥16 h,donation after cardiac death,donor history of coronary artery disease,donor terminal creatinine≥1.9 mg/dL,and a hypothermic machine perfusion(HMP)pump resistance≥0.23 mmHg/mL/min.CONCLUSION We delineate the association between DGF and recipient characteristics of preinduction mean arterial pressure below 110 mmHg,metabolic syndrome,donorspecific risk factors,HMP pump parameters,and intraoperative use of phenylephrine.

Values of Donor Serum Lipids and Calcium in Predicting Graft Function after Kidney Transplantation:A Retrospective Study

Objective Delayed graft function(DGF)and early graft loss of renal grafts are determined by the quality of the kidneys from the deceased donor.As“non-traditional”risk factors,serum biomarkers of donors,such as lipids and electrolytes,have drawn increasing attention due to their effects on the postoperative outcomes of renal grafts.This study aimed to examine the value of these serum biomarkers for prediction of renal graft function.Methods The present study consecutively collected 306 patients who underwent their first single kidney transplantation(KT)from adult deceased donors in our center from January 1,2018 to December 31,2019.The correlation between postoperative outcomes[DGF and abnormal serum creatinine(SCr)after 6 and 12 months]and risk factors of donors,including gender,age,body mass index(BMI),past histories,serum lipid biomarkers[cholesterol,triglyceride,high-density lipoprotein(HDL)and low-density lipoprotein(DL)],and serum electrolytes(calcium and sodium)were analyzed and evaluated.Results(1)Donor age and pre-existing hypertension were significantly correlated with the incidence rate of DGF and high SCr level(≥2 mg/dL)at 6 and 12 months after KT(P<0.05);(2)The donor’s BMI was significantly correlated with the incidence rate of DGF after KT(P<0.05);(3)For serum lipids,merely the low level of serum HDL of the donor was correlated with the reduced incidence rate of high SCr level at 12 months after KT[P<0.05,OR(95%CI):0.425(0.202–0.97)];(4)The serum calcium of the donor was associated with the reduced incidence rate of high SCr level at 6 and 12 months after KT[P<0.05,OR(95%CI):0.184(0.045–0.747)and P<0.05,OR(95%CI):0.114(0.014–0.948),respectively].Conclusion The serum HDL and calcium of the donor may serve as predictive factors for the postoperative outcomes of renal grafts after KT,in addition to the donor’s age,BMI and pre-existing hypertension.

Kidney donation after cardiac death

There is continuing disparity between demand for and supply of kidneys for transplantation. This review describes the current state of kidney donation after cardiac death （DCD） and provides recommendations for a way forward. The conversion rate for potential DCD donors varies from 40%-80%. Compared to con-trolled DCD, uncontrolled DCD is more labour intensive, has a lower conversion rate and a higher discard rate. The super-rapid laparotomy technique involving direct aortic cannulation is preferred over in situ perfusion in controlled DCD donation and is associated with lower kidney discard rates, shorter warm ischaemia times and higher graft survival rates. DCD kidneys showed a 5.73-fold increase in the incidence of delayed graft function （DGF） and a higher primary non function rate compared to donation after brain death kidneys, but the long term graft function is equivalent between the two. The cold ischaemia time is a controllable factor that signifcantly infuences the outcome of allografts, for example, limiting it to 〈 12 h markedly reduces DGF. DCD kidneys from donors 〈 50 function like stan-dard criteria kidneys and should be viewed as such. As the majority of DCD kidneys are from controlled dona-tion, incorporation of uncontrolled donation will expand the donor pool. Efforts to maximise the supply of kid-neys from DCD include： implementing organ recovery from emergency department setting; improving family consent rate; utilising technological developments to optimise organs either prior to recovery from donors or during storage; improving organ allocation to ensure best utility; and improving viability testing to reduce primary non function.

Successful kidney transplantation from an expanded criteria donor with long-term extracorporeal membrane oxygenation treatment: A case report

BACKGROUND Due to a shortage of donor kidneys, many centers have utilized graft kidneys from brain-dead donors with expanded criteria. Kidney transplantation(KT)from donors on extracorporeal membrane oxygenation(ECMO) has been identified as a successful way of expanding donor pools. However, there are currently no guidelines or recommendations that guarantee successful KT from donors undergoing ECMO treatment. Therefore, acceptance of appropriate allografts from those donors is solely based on clinician decision.CASE SUMMARY We report a case of successful KT from a brain-dead donor supported by ECMO for the longest duration to date. A 69-year-old male received a KT from a 63-yearold brain-dead donor who had been on therapeutic ECMO treatment for the previous three weeks. The recipient experienced slow recovery of graft function after surgery but was discharged home on post-operative day 17 free from hemodialysis. Allograft function gradually improved thereafter and was comparatively acceptable up to the 12 mo follow-up, with serum creatinine level of 1.67 mg/d L.CONCLUSION This case suggests that donation even after long-term ECMO treatment could provide successful KT to suitable candidates.

Innovative immunosuppression in kidney transplantation:A challenge for unmet needs

Due to the optimal results obtained in kidney transplantation and to the lack of interest of the industries,new innovative drugs in kidney transplantation are difficult to be encountered.The best strategy to find the new drugs recently developed or under development is to search in the sections of kidney transplantation still not completely covered by the drugs on the market.These unmet needs are the prevention of delayed graft function(DGF),the protection of the graft over the long time and the desensitization of preformed anti human leukocyte antigen antibodies and the treatment of the acute antibody-mediated rejection.These needs are particularly relevant due to the expansion of some kind of kidney transplantation as transplantation from non-heart beating donor and in the case of antibody-incompatible grafts.The first are particularly exposed to DGF,the latter need a safe desensitization and a safe treatments of the antibody mediated rejections that often occur.Particular caution is needed in treating these drugs.First,they are described in very recent studies and the follow-up of their effect is of course rather short.Second,some of these drugs are still in an early phase of study,even if in well-conducted randomized controlled trials.Particular caution and a careful check need to be used in trials launched 2 or 3 years ago.Indeed,is always necessary to verify whether the study is still going on or whether and why the study itself was abandoned.

The Effect of Non-Invasive Goal Directed Fluid Administration on Graft Function in Deceased Donor Renal Transplantation: A Pilot Study

Background: Non-invasive goal directed fluid therapy during deceased donor renal transplant (CRT) may reduce the incidence of delayed graft function. Plethysmograph Variability Index (PVI) has been shown to predict fluid responsiveness during surgery. This pilot study evaluated the feasibility of goal directed fluid administration protocol based upon PVI studying the incidence of delayed graft function (DGF) in renal transplant recipients. Methods: Twenty patients underwent primary CRT. The Control group received intravenous fluid (IVF) at a calculated constant rate. The Treatment group received a baseline IVF infusion throughout the surgery. PVI values greater than 13% were treated with 250 ml boluses of IVF. Primary end point was DGF;total IVF administration and urinary biomarker NGAL levels were secondary endpoints. Results: Treatment group at every time point received significantly less IVF. There was no significant difference in incidence of DGF between the groups. 2 patients in the Control group and 6 in the Treatment group developed DGF. NGAL was not associated with the group assignment or total IVF given (p < 0.2). Conclusions: The effectiveness of goal directed fluid therapy with non-invasive dynamic parameters has not been validated in renal transplant surgery and larger prospective studies are needed to determine its utility in renal transplantation.

Predictive Score Model for Delayed Graft Function Based on Easily Available Variables before Kidney Donation after Cardiac Death

Background： How to evaluate the quality of donation after cardiac transplantation in China. Hence, the aim of this study was to develop kidneys before DCD. death （DCD） kidneys has become a critical problem in kidney a simple donor risk score model to evaluate the quality of DCD Methods： A total of 543 qualified kidneys were randomized in a 2：1 manner to create the development and validation cohorts. The donor variables in the development cohort were considered as candidate univariate predictors of delayed graft function （DGF）. Multivariate logistic regression was then used to identify independent predictors of DGF with P 〈 0.05. Date from validation cohort were used to validate the donor scoring model. Results： Based on the odds ratios, eight identified variables were assigned a weighted integer; the sum of the integer was the total risk score for each kidney. The donor risk score, ranging from 0 to 28, demonstrated good discriminative power with a C-statistic of 0.790. Similar results were obtained from validation cohort with C-statistic of 0.783. Based on the obtained frequencies of DGF in relation to different risk scores, we formed tour risk categories of increasing severity （scores 04, 5 9, 10-14, and 15 28）. Conclusions： The scoring model might be a good noninvasive tool for assessing the quality of DCD kidneys before donation and potentially useful for physicians to make optimal decisions about donor organ offers.

Risk factors for delayed graft function in cardiac death donor renal transplants

Background Delayed graft function （DGF） is common in kidney transplants from organ donation after cardiac death （DCD） donors. It is associated with various factors. Determination of center-specific risk factors may help to reduce the incidence of DGF and improve the transplantation results. The aim of this study is to define risk factors of DGF after renal transplantation.

Changes in biochemical parameters on the first day after kidney transplantation： risk factors for nosocomial infection？

Background Nosocomial infection in early post-transplantation period is a tough problem for kidney transplantation. Few reports have explored the relations between biochemical parameters and nosocomial infection in kidney transplantation. This retrospective study was carried out to describe the characteristics of nosocomial infection in the very early period of kidney transplantation and to determine the risk factors in biochemical parameters and their alterations. Methods Patients who underwent their first kidney transplantation from January 2001 to March 2009 in Beijing Chao-Yang Hospital were recruited and the nosocomial infectious episodes were collected for this study. Gender, age, donor type, delayed graft function （DGF） and biochemical parameters such as serum uric acid, lipids files and albumin on day 0 （before transplantation） and day 1 （24 hours after transplantation） and their changes were analyzed with Logistic regression models for nosocomial infection. Results A total of 405 patients （315 men and 90 women） were involved in this study. There were 80 patients experiencing 113 infection episodes and 105 strains of microorganism were indentified. In univariate analysis, there were significant differences in DGF, albumin on day 0, lipoprotein （a） （Lp（a）） on day 1, change in low density lipoprotein-cholesterol （LDL-C, day 1-day 0） and change in uric acid （day 1-day 0） between nosocomial infection patients and noninfectious patients （P 〈0.05）. In multivariate analysis, change in uric acid （day 1-day 0） （OR 5.139, 95% CI 1.176-22.465, P 〈0.05）, change in LDL-C （day 1-day 0） （OR4.179, 95% CI 1.375-12.703, P 〈0.05） and DGF （OR 14.409, 95% CI 1.603-129.522, P 〈0.05） were identified as independent risk factors for nosocomial infection in kidney transplantation. Conclusions Most nosocomial infections in early postoperative period of kidney transplantation are bacterial, especially with Gram-negative bacteria. The most common infection sites are respiratory tract, urinary tract and surgical site. DGF, decrease of LDL-C and increase of uric acid could increase the risk for nosocomial infections.

Predictive value of hypothermic machine perfusion parameters combined perfusate biomarkers in deceased donor kidney transplantation

Background:Delayed graft function(DGF)is the main cause of renal function failure after kidney transplantation.This study aims at investigating the value of hypothermic machine perfusion(HMP)parameters combined with perfusate biomarkers on predicting DGF and the time of renal function recovery after deceased donor(DD)kidney transplantation.Methods:HMP parameters,perfusate biomarkers and baseline characteristics of 113 DD kidney transplantations from January 1,2019 to August 31,2019 in the First Affiliated Hospital of Xi’an Jiaotong University were retrospectively analyzed using univariate and multivariate logistic regression analysis.Results:In this study,the DGF incidence was 17.7%(20/113);The multivariate logistic regression results showed that terminal resistance(OR:1.879,95%CI 1.145-3.56)and glutathione S-transferase(GST)(OR=1.62,95%CI 1.23-2.46)were risk factors for DGF;The Cox model analysis indicated that terminal resistance was an independent hazard factor for renal function recovery time(HR=0.823,95%CI 0.735-0.981).The model combining terminal resistance and GST(AUC=0.888,95%CI:0.842-0.933)significantly improved the DGF predictability compared with the use of terminal resistance(AUC=0.756,95%CI 0.693-0.818)or GST alone(AUC=0.729,95%CI 0.591-0.806).Conclusion:According to the factors analyzed in this study,the combination of HMP parameters and perfusate biomarkers displays a potent DGF predictive value.