Preoperative Embolization May Offer Benefits

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FORT LAUDERDALE, Fla.—Preoperative angiographic kidney embolization (PAKE) may result in less intraoperative blood loss, fewer transfusions, and fewer surgical complications in patients undergoing allograft nephrectomy following kidney transplantation, according to new findings.

In the United States, allograft nephrectomy (AN) is performed in 20% to 35% of all kidney transplant recipients with graft failure.

The procedure is associated with high morbidity and may result in patients becoming sensitized. Researchers at Wake Forest University Baptist Medical Center in Winston-Salem, N.C., reviewed of all their patients undergoing AN following deceased donor (DD) kidney transplantation and looked at a subset of these patients who underwent PAKE prior to AN.

A total of 578 adult patients underwent DD kidney transplantation from January 2001 through June of 2008. Of these, 120 (21%) experienced graft failure; 31 of the 120 patients (26%) underwent AN.  AN was not performed routinely but only for specific indications such as pain, allograft swelling or tenderness, fever, and hematuria.

The incidence of AN was similar regardless of DD category, but investigators observed an increased incidence of AN among patients with delayed graft function (12% vs. 3% who did not have delayed graft function). In addition, the incidence of AN was much higher in patients with early graft failure (41% vs. 18%).

For the nine patients undergoing PAKE, the estimated blood loss (EBL) was 164 mL and the mean perioperative transfusion requirement was 0.4 units of blood. In contrast, a control group of patients who underwent AN without PAKE had an estimated mean EBL of 517 mL and a mean perioperative transfusion requirement of 1.5 units.

The operating time was reduced from 178 to 134 minutes and length of hospital stay was reduced from nine to six days. Moreover, the investigators observed no complications with the arterial access among patients who underwent PAKE, which was usually performed the day prior to scheduled AN.  The surgical complication rate was reduced from 33% to 11% in PAKE patients.

Lead investigator Samer Al-Geizawi, MD, a transplant fellow, said the findings from this study suggest that PAKE is a safe procedure and may result in improved outcomes in patients undergoing AN, which he noted can be a very difficult surgery. PAKE shortens operating times because surgeons have fewer problems with bleeding, he said. PAKE is being performed routinely prior to AN at his institution in failed allografts that remain vascularized but have become symptomatic, he noted.

His study did not specifically include a cost analysis, but he pointed out that the added cost of embolizations may be offset by reduced hospital stays, lower rates of surgical complications, and reduced patient morbidity.

He presented study findings here at the American Society of Transplant Surgeons 10th Annual State of the Art Winter Symposium.

Commenting on the study, Anil Paramesh, MD, Assistant Professor of Surgery at Tulane University School of Medicine in New Orleans, said the study is intriguing but noted that the study only included nine patients who underwent PAKE. Still, he said he believes a subset of patients may benefit from preoperative embolization.

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