The Elimination of Warm Ischemic Time in Kidney Transplantation Using the Ice Bag Technique: A Feasibility Study

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SHORT COMMUNICATION

The Elimination of Warm Ischemic Time in Kidney Transplantation Using the Ice

Bag Technique: A Feasibility Study

Jorge Ortiz

1

, Madhu Siddeswarappa

1 *

, Stephanie Sea

2

, Afshin Parsikia

1

, Stalin Campos

1

,

Kamran Khanmoradi

1

, Radi Zaki

1

1_{Department of Transplant Surgery, Albert Einstein Medical Center, Philadelphia, PA, USA} 2_{Department of General Surgery, Albert Einstein Medical Center, Philadelphia, PA, USA}

a r t i c l e i n f o

Article history: Received: Oct 25, 2010 Revised: Feb 27, 2011 Accepted: Apr 21, 2011 KEY WORDS: delayed graft function; kidney transplantation; operative technique; vascular anastamosis

Warm ischemic time is an established risk factor for delayed graft function (DGF) after kidney trans-plantation. DGF is a negative prognostic indicator for long-term allograft survival. We propose a tech-nique that eliminates warm ischemic time during the arterial and venous anastomoses. This is a retrospective review of theﬁrst 20 cases performed between January and May 2010 at Albert Einstein Medical Center, Philadelphia, Pennsylvania, a nonuniversity tertiary care center. Approximately one-half of the patients who underwent kidney transplantation were selected for this method of implantation while the feasibility of this technique was evaluated. Fifteen patients were male. DGF was seen in 6 of 20 patients (30%). There were no graft losses. Operative time was not lengthened. There were no compli-cations related to the use of this technique. Renal parenchyma frostbite was never encountered. We propose a technique that eliminates warm ischemic time. This may lead to less DGF. In the case of a difﬁcult anastomosis or if an anastomosis needs to be performed again, damage to the kidney is minimized. Right and left donor kidneys and kidneys with multiple vessels can safely be transplanted with this technique. It also allows for improved resident and fellow teaching.

1. Introduction

Warm ischemic time, the time necessary to perform the vascular anastomosis during kidney transplantation, may be associated with delayed graft function (DGF) or even nonfunction. DGF is a well-established negative prognostic indicator for long-term allograft survival. Attempts to minimize warm ischemic time include wrapping the kidney in an ice-soaked laparotomy pad. Some surgeons eschew this technique, preferring to sew as quickly as possible (Figure 1). This may lead to technical errors, excessive bleeding, worse long-term outcomes, and a poor learning experi-ence for the resident staff. Other techniques, such as a raytech sponge (Figure 2), stockinet,1a cooling jacket,2and a clear sterilized bag,3have not been addressed in the literature since the turn of the century. We sought to review our preliminary experience with the “ice bag technique.” We wished to determine its feasibility and lay the groundwork for future studies evaluating its possible effect on DGF and allograft survival.

2. Materials and Methods

An institutional review board approved retrospective chart review of 20 kidney transplant patients from January 29 to May 5, 2010 was conducted to evaluate the“ice bag technique” in a community teaching hospital. Parameters recorded included recipient demo-graphics, primary diagnosis of kidney disease, donor demodemo-graphics, and presence of DGF. Patients were followed until discharge from hospital. Results were complied into a series of Excel databases to be reviewed at the end of the specified time period. A right or left lower quadrant Gibson incision was used to gain access into the retroperitoneum. A Bookwalter was used for retraction. The external iliac artery and vein were freed from their adventitial attachments in the usual fashion. On the back table, the kidneys were prepared for implantation with standard techniques. The craniad side of both the artery and vein were marked to maintain orientation. At this point, the transport bag in which the kidney was shipped wasfilled with a small amount of ice and preservation fluid. The kidney was introduced into the bag. A small hole was made near the hilum and the renal artery and vein were passed through the hole. A Kelly clamp was used to maintain thefluid and ice in place and as a handle (Figure 3). The kidney was introduced into thefield. A penetrating towel clamp affixed the kidney to one side of the wound while the anastomoses were performed

* Corresponding author. Department of Transplant Surgery, Albert Einstein Medical Centre, 5401 Old York Road, Klein 510, Philadelphia, PA 19141, USA.

E-mail:siddeswm@einstein.edu(M. Siddeswarappa).

Contents lists available atScienceDirect

Journal of Experimental and Clinical Medicine

j o u r n a l h o m e p a g e : h t t p : / / w w w . j e c m - o n l i n e .c o m

J Exp Clin Med 2011;-(-):1e4

Please cite this article in press as: Ortiz J, et al., The Elimination of Warm Ischemic Time in Kidney Transplantation Using the Ice Bag Technique: A Feasibility Study, Journal of Experimental and Clinical Medicine (2011), doi:10.1016/j.jecm.2011.06.004

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Figure 1 Traditional method of holding donor kidney: one of the assistants is holding the kidney while the surgeon is performing the arterial and venous anastomoses. This technique tends to prolong the warm ischemic time.

Figure 2 Raytech sponge technique: A Raytech sponge is soaked in ice-cold preser-vative solution, and wrapped around the kidney and held with a clamp.

Figure 3 Ice bag technique: The kidney is introduced into the bag with ice and a small hole was made near the hilum through which the renal artery and vein were passed. A Kelly clamp was used to maintain theﬂuid and ice in place and as a handle.

Figure 4 Ice bag technique during anastamosis. The kidney placed in ice bag is introduced into theﬁeld with a penetrating towel clamp afﬁxed it to one side of the wound, while the anastomoses are performed.

J. Ortiz et al. 2

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(Figure 4). After completion, the vascular clamps were removed and the bag was cut and passed off theﬁeld.

3. Results

We identiﬁed 20 patients who underwent renal transplants with the use of the“ice bag technique.” Recipient ages varied from 31 years to 71 years, with a mean age of 53.72 12.04 years. Fifteen were male. The most common primary diagnosis was hypertensive nephrosclerosis (n¼ 10). The donor’s mean age was 44 13.91 years. Fourteen were male. Most donors were deceased after neurological death (n¼ 14) with a mean terminal creatinine of 1.01_{0.38 mg/dL. With the ice bag technique, warm ischemic time} was an average of 34 12.31 minutes. There were two dual, ipsi-lateral kidney transplants. Of the donors, 11 were left and 7 were right kidney donors. Seventeen transplants were performed in the right lower quadrant. Average recipient body mass index was 28.17 7.4 kg/m2_{. Three kidneys had two arteries. One kidney had}

two veins. We have tabulated the donor, pre-, intra-, and post-operative data inTables 1e4. With the use of the new technique,

14 transplants showed immediate graft function. Of the six patients with DGF, two were expanded criteria donors and donors after cardiac death, one suffered an antibody-mediated rejection, one was reoperated on for compartment syndrome, and one was re-explored secondary to postoperative bleeding after heparin administration for atrialﬁbrillation. There were no complications related to the use of this technique. Allograft frostbite was not encountered.

4. Discussion

Prolonged warm ischemic time is associated with DGF and dimin-ished outcomes. If the thermal threshold of glomerular and tubular activation (18C) is never reached, the damage from warm ischemia may be eliminated. We believe that maintaining the kidney inside a bag with ice-cold preservationﬂuid keeps the temperature as low as possible (approximately 6C). This is also the temperature at which kidneys are machine perfused. Although placement of the kidney in a chilled laparotomy pad may be helpful, it is doubtful that the temperature remains under 18C during the usual 35_e45 minutes of warm ischemic time. Surely the temperature is much higher if a difﬁcult anastomosis is encountered and excessive surgical manipulation is necessary. Szostek et al4 observed an increased incidence of DGF when kidney temperature was greater than 15C. Although many cooling devices have been reported in the past,1e3there have been no new studies in the English litera-ture since the turn of the century. One recent report from Poland described a very complex polyethylene receptacle that requires 6 hours to sterilize and contains three separate containers.5 Our technique allows for excellent orientation of the kidney and visu-alization of the anastomoses. The ice bag is secured to the surgical drapes, freeing both hands of the assistant. The bag is clear; therefore, the clamps may be removed while it is still in place. This allows for a quick evaluation of the color of the kidney. If there is bleeding, the clamps may be reapplied and warm ischemia is still obviated. The bag is also free. Because warm ischemic time is eliminated, physicians in training can perform more of the proce-dure without jeopardizing the long-term outcome of the allograft. We were able to use this technique with right and left kidneys in the right and left lower quadrants, with multiple vessels and in obese patients. Because of our excellent early results, we have embarked on a randomized trial with a control arm. We will

Table 1 Donor information

Variables Values (20 donors,

22 kidneys) Donor type, n DCD 1 DND 14 ECD 2 ECD/DCD 3 Donor kidney, n Right 7 Left 11 Both 2 Donor gender, n Male 14 Female 6

Number of arteries in the donated kidney, n

One 19

Two 3

Number of veins in the donated kidney, n

One 21

Two 1

Donor age (y), mean (SD) 44 (13.91)

Terminal creatinine, mean (SD) 1.01 (0.38)

DCD¼ donation after cardiac death; DND ¼ donor after neurologic death; ECD¼ expanded criteria donor; SD ¼ standard deviation.

Table 2 Recipient preoperative information

Variables Values (20

recipients) Age at the time of transplant (y), mean (SD) 53.72 (12.04)

BMI (kg/m2_{), mean (SD)} _{28.17 (7.4)} Primary diagnosis, n IgA nephropathy 2 Focal glomerularscherosis 1 Diabetes-Type II 3 Hypertensive nephrosclerosis 10

Focal segmental glomerulosclerosis 2

Focal glomerulonephritis 1

Unknown focal glomerulonephritis 1

Recipient gender, n

Male 15

Female 5

BMI¼ body mass index; IgA ¼ immunoglobulin A; SD ¼ standard deviation.

Table 3 Operative information

Variables Values (20 recipients,

22 kidneys) Site of incision

Right 17

Left 3

EBL (mL), median (range) 200 (75e600)

WIT (min), mean (SD) 34 (12.31)

CIT (min), mean (SD) 802 (321.04)

CIT¼ cold ischemic time; EBL ¼ estimated blood loss; SD ¼ standard deviation; WIT¼ warm ischemia time.

Table 4 Postoperative information

Variables Values (20

recipients)

Creatinine at POD 10, mean (SD) 4 (3.06)

DGF 6

Rejection within 30 d 1

DGF¼ delayed graft function; POD ¼ postoperative day; SD ¼ standard deviation.

Kidney transplantation using ice bag technique to eliminate warm ischemic time 3

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analyze whether the elimination of warm ischemic time decreases the incidence of DGF and improves long-term allograft survival. References

1. Gill IS, Munch LC, Lucas BA. Use of a stockinette to minimize warm ischemia during renal transplant vascular anastomoses. J Urol 1994;152:2053e4. 2. Stephenson RN. A cooling jacket to reduce renal damage during transplantation.

Br J Urol 1993;71:384e7.

3. Schenkman E, Goldinger M, Tarry W, Lamm DL. Preventing warm ischemia with a polyurethane bag during transplantation. Urology 1997;50: 436e7.

4. Szostek M, Danielwicz R, Lagiewska B, Pacholczyk M, Rybicki Z, Michalak G, Adadynski L, Walaszewski J, Rowinski W. Successful transplantation of kidneys harvested from cadaver donors at 71 to 259 minutes following cardiac arrest. Transplant Proc 1995;27:2901e2.

5. Pupka A, Chudoba P, Patrzalek D, Janczak D, Szyber P. The modiﬁcation of renal transplantation with the usage of own polyethylene receptacle. Polim Med 2003;33:33e7.

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