American Journal of Transplantation 2015; 15: 1445–1446 Wiley Periodicals Inc.
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Copyright 2015 The American Society of Transplantation and the American Society of Transplant Surgeons doi: 10.1111/ajt.13228
Letter to the Editor
Delayed Graft Function in Laparoscopic Kidney Transplantation: The Importance of Prolonged Cold and Warm Ischemia—Response To the Editor: We are grateful to Dr. Khan’s interest and comments on our study and appreciate the opportunity to offer a response (1,2). It is understood that both warm ischemic and cold ischemic time are very important factors in respect of both immediate graft function and long-term graft survival. Therefore, operating theater availability has been always prioritized for kidney transplantation in our institute to minimize cold ischemic injury. In open kidney transplant, on the other hand, the warm ischemic injury may be minimized by speedy vessel anastomosis. Knowing that the vessel anastomotic time would be longer using the laparoscopic technique at this very early stage, as a result the rewarming ischemic injury is unavoidable. Therefore, in situ cooling was carefully applied in order to compensate for anticipated warm ischemic injury. Yet, the kidney graft temperature was not measured as to avoid the distraction from the vessel anastomosis. In addition, measurement of kidney parenchymal temperature was not intended, as it carried the potential to increase surgical difficulty owing to limited working space in extra peritoneal plane. Nevertheless, the efficiency of the cooling on the kidney graft by regular irrigation of cold (48C) normal saline is unsure. This has been an important question during our study from the animal model to the human clinic. Hence, we completed a further study on the temperature change of the kidney graft during laparoscopic vessel anastomosis in the porcine model (paper in preparation). It was found that the kidney parenchyma temperature increased rapidly from 4–58C to 28–308C in about 20 min after commencing vessel anastomosis and that the temperature could be maintained at about 28–308C until the kidney was reperfused after completion of vessel anastomosis. The kidney was observed functioning immediately as long as the vessel anastomoses were patent. The creatinine (Cr) level was increased to about 200 umol/L on day 3 and then returned to almost normal level after 7–14 days. There is a lack of data of kidney graft temperature change during vessel anastomosis in conventional open kidney transplant for comparison. As we discussed in our paper, in the context of partial nephrectomy, it was shown that no permanent damage was identifiable even if the kidney ischemic time was prolonged to 3 h at the temperature between 5 and
258C (3,4). Pneumoretroperitoneum may be another factor that may have adverse effect on the kidney graft function. In Dr. Modi’s study, it was noticed that the Cr clearance was a little bit slower in comparison with open kidney transplant (5). In addition, the cold ischemic time was 8 h 8 min in our study patient and 8 h 33 min in control patient. The regimen of immunosuppression for both patients was prednisolone, Tacrolimus and MMF, which is consistent with our local protocol. Both patients were given Basiliximab for induction (on Day 0 and Day 4). Both patients had no episode of rejection during 1year follow-up. The Cr level was comparable in both patients during 12 months follow-up. In conclusion, as Dr. Khan pointed out the additional warm ischemic damage is a major concern in the setting of application of laparoscopic technique to kidney transplantation due to prolonged vessel anastomotic time, which is believed unavoidable during early learning phase. Therefore, it is necessary to establish a training model to facilitate the application of this new technique. It is also mandatory to have on-going training facility and continue improving the skills of laparoscopic vessel anastomosis. Furthermore, with advancement of laparoscopic technology such as the advent of 3D high definition laparoscopic tower, it is hoped that the time of vessel anastomosis would be comparable between laparoscopic and open kidney transplant in the near future. B. He1,3,*, L. Mou1, S. Swaminathan2, J. Hamdorf 3 and L. Delriviere1,3 1 Liver and Kidney Transplant Unit, Sir Charles Gairdner Hospital, Perth, Australia 2 Renal Medicine and Kidney Transplant, Fiona Stanley Hospital, Perth, Australia 3 School of Surgery, University of Western Australia, Perth, Australia * Corresponding author: Bulang He, [email protected]
Disclosure The authors of this manuscript have no conflicts of interest to disclose as described by the American Journal of Transplantation. 1445
He et al
References 1. Khan T. Delayed graft function in laparoscopic kidney transplantation: The importance of prolonged cold and warm ischemia. Am J Transplant 2015; doi: 10.1111/ajt.13229 2. He B, Mou L, Sharpe K, et al. Laparoscopic kidney transplant by extra peritoneal approach: The safe transition from laboratory to the clinic. Am J Transplant 2014; 14: 1931–1936. 3. Herrell SD, Jahoda AE, Husain AN, Albala DM. The laparoscopic cooling sheath: Novel device for hypothermic preservation of
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kidney during temporary renal artery occlusion. J Endourol 1998; 12: 155–161. 4. Humphreys MR, Castle EP, Lohse CM, Sebo TJ, Leslie KO, Andrews PE. Renal ischemia time in laparoscopic surgery: An experimental study in a porcine model. Int J Urol 2009; 16: 105–109. 5. Modi P, Pal B, Modi J, et al. Retroperitoneoscopic living-donor nephrectomy and laparoscopic kidney transplantation: Experience of initial 72 cases. Transplantation 2013; 95: 100–105.
American Journal of Transplantation 2015; 15: 1445–1446
Copyright of American Journal of Transplantation is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
C
Copyright 2015 The American Society of Transplantation and the American Society of Transplant Surgeons doi: 10.1111/ajt.13228
Letter to the Editor
Delayed Graft Function in Laparoscopic Kidney Transplantation: The Importance of Prolonged Cold and Warm Ischemia—Response To the Editor: We are grateful to Dr. Khan’s interest and comments on our study and appreciate the opportunity to offer a response (1,2). It is understood that both warm ischemic and cold ischemic time are very important factors in respect of both immediate graft function and long-term graft survival. Therefore, operating theater availability has been always prioritized for kidney transplantation in our institute to minimize cold ischemic injury. In open kidney transplant, on the other hand, the warm ischemic injury may be minimized by speedy vessel anastomosis. Knowing that the vessel anastomotic time would be longer using the laparoscopic technique at this very early stage, as a result the rewarming ischemic injury is unavoidable. Therefore, in situ cooling was carefully applied in order to compensate for anticipated warm ischemic injury. Yet, the kidney graft temperature was not measured as to avoid the distraction from the vessel anastomosis. In addition, measurement of kidney parenchymal temperature was not intended, as it carried the potential to increase surgical difficulty owing to limited working space in extra peritoneal plane. Nevertheless, the efficiency of the cooling on the kidney graft by regular irrigation of cold (48C) normal saline is unsure. This has been an important question during our study from the animal model to the human clinic. Hence, we completed a further study on the temperature change of the kidney graft during laparoscopic vessel anastomosis in the porcine model (paper in preparation). It was found that the kidney parenchyma temperature increased rapidly from 4–58C to 28–308C in about 20 min after commencing vessel anastomosis and that the temperature could be maintained at about 28–308C until the kidney was reperfused after completion of vessel anastomosis. The kidney was observed functioning immediately as long as the vessel anastomoses were patent. The creatinine (Cr) level was increased to about 200 umol/L on day 3 and then returned to almost normal level after 7–14 days. There is a lack of data of kidney graft temperature change during vessel anastomosis in conventional open kidney transplant for comparison. As we discussed in our paper, in the context of partial nephrectomy, it was shown that no permanent damage was identifiable even if the kidney ischemic time was prolonged to 3 h at the temperature between 5 and
258C (3,4). Pneumoretroperitoneum may be another factor that may have adverse effect on the kidney graft function. In Dr. Modi’s study, it was noticed that the Cr clearance was a little bit slower in comparison with open kidney transplant (5). In addition, the cold ischemic time was 8 h 8 min in our study patient and 8 h 33 min in control patient. The regimen of immunosuppression for both patients was prednisolone, Tacrolimus and MMF, which is consistent with our local protocol. Both patients were given Basiliximab for induction (on Day 0 and Day 4). Both patients had no episode of rejection during 1year follow-up. The Cr level was comparable in both patients during 12 months follow-up. In conclusion, as Dr. Khan pointed out the additional warm ischemic damage is a major concern in the setting of application of laparoscopic technique to kidney transplantation due to prolonged vessel anastomotic time, which is believed unavoidable during early learning phase. Therefore, it is necessary to establish a training model to facilitate the application of this new technique. It is also mandatory to have on-going training facility and continue improving the skills of laparoscopic vessel anastomosis. Furthermore, with advancement of laparoscopic technology such as the advent of 3D high definition laparoscopic tower, it is hoped that the time of vessel anastomosis would be comparable between laparoscopic and open kidney transplant in the near future. B. He1,3,*, L. Mou1, S. Swaminathan2, J. Hamdorf 3 and L. Delriviere1,3 1 Liver and Kidney Transplant Unit, Sir Charles Gairdner Hospital, Perth, Australia 2 Renal Medicine and Kidney Transplant, Fiona Stanley Hospital, Perth, Australia 3 School of Surgery, University of Western Australia, Perth, Australia * Corresponding author: Bulang He, [email protected]
Disclosure The authors of this manuscript have no conflicts of interest to disclose as described by the American Journal of Transplantation. 1445
He et al
References 1. Khan T. Delayed graft function in laparoscopic kidney transplantation: The importance of prolonged cold and warm ischemia. Am J Transplant 2015; doi: 10.1111/ajt.13229 2. He B, Mou L, Sharpe K, et al. Laparoscopic kidney transplant by extra peritoneal approach: The safe transition from laboratory to the clinic. Am J Transplant 2014; 14: 1931–1936. 3. Herrell SD, Jahoda AE, Husain AN, Albala DM. The laparoscopic cooling sheath: Novel device for hypothermic preservation of
1446
kidney during temporary renal artery occlusion. J Endourol 1998; 12: 155–161. 4. Humphreys MR, Castle EP, Lohse CM, Sebo TJ, Leslie KO, Andrews PE. Renal ischemia time in laparoscopic surgery: An experimental study in a porcine model. Int J Urol 2009; 16: 105–109. 5. Modi P, Pal B, Modi J, et al. Retroperitoneoscopic living-donor nephrectomy and laparoscopic kidney transplantation: Experience of initial 72 cases. Transplantation 2013; 95: 100–105.
American Journal of Transplantation 2015; 15: 1445–1446
Copyright of American Journal of Transplantation is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
