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Article ; Online: Prospective assessment of the impact of intraoperative diuretics in kidney transplant recipient surgery.

Levine, Max A / Rasmussen, Andrew / Lee, Daniel / Rim, Claire / Farokhi, Kaveh / Luke, Patrick P / Sener, Alp

Canadian journal of surgery. Journal canadien de chirurgie

2024 Volume 67, Issue 2, Page(s) E158–E164

Abstract: Background: The use of intraoperative diuretics, such as furosemide or mannitol, during kidney transplantation has been suggested to reduce the rate of delayed graft function (DGF). The evidence base for this is sparse, however, and there is substantial ...

Abstract	Background: The use of intraoperative diuretics, such as furosemide or mannitol, during kidney transplantation has been suggested to reduce the rate of delayed graft function (DGF). The evidence base for this is sparse, however, and there is substantial variation in practice. We sought to evaluate whether the use of intraoperative diuretics during kidney transplantation translated into a reduction in DGF. Methods: We conducted a cohort study evaluating the use of furosemide or mannitol given intraoperatively before kidney reperfusion compared with control (no diuretic). Adult patients receiving a kidney transplant for end-stage renal disease were allocated to receive furosemide, mannitol, or no diuretic. The primary outcome was DGF; secondary outcomes were graft function at 30 days and perioperative changes in potassium levels. Descriptive and comparative statistics were used where appropriate. Results: A total of 162 patients who received a kidney transplant from a deceased donor (either donation after neurologic determination of death or donation after circulatory death) were included over a 2-year period, with no significant between-group differences. There was no significant difference in DGF rates between the furosemide, mannitol, and control groups. When the furosemide and mannitol groups were pooled (any diuretic use) and compared with the control group, however, there was a significant improvement in the odds that patients would be free of DGF (odds ratio 2.10, 95% confidence interval 1.06-4.16, 26% v. 44%, Conclusion: This study suggests the use of an intraoperative diuretic (furosemide or mannitol) may result in a reduction in DGF in patients undergoing kidney transplantation. Further study in the form of a randomized controlled trial is warranted.
MeSH term(s)	Adult ; Humans ; Diuretics ; Kidney Transplantation ; Furosemide ; Delayed Graft Function/prevention & control ; Cohort Studies ; Prospective Studies ; Tissue Donors ; Mannitol ; Risk Factors
Chemical Substances	Diuretics ; Furosemide (7LXU5N7ZO5) ; Mannitol (3OWL53L36A)
Language	English
Publishing date	2024-04-04
Publishing country	Canada
Document type	Journal Article
ZDB-ID	410651-9
ISSN	1488-2310 ; 0008-428X
ISSN (online)	1488-2310
ISSN	0008-428X
DOI	10.1503/cjs.006422
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Article: Staged vs. simultaneous bilateral nephrectomy and kidney transplantation in patients with autosomal dominant polycystic kidney disease: Outcomes and costs.

Rasmussen, Andrew / Levine, Max A / Mandurah, Moaath M / Sener, Alp / Luke, Patrick P

Canadian Urological Association journal = Journal de l'Association des urologues du Canada

2023 Volume 16, Issue 12, Page(s) 424–429

Abstract: Introduction: We sought to compare cost and safety outcomes of patients who received a kidney transplant and bilateral nephrectomy in either a simultaneous or staged approach.: Methods: We reviewed all adult patients with autosomal dominant ... ...

Abstract	Introduction: We sought to compare cost and safety outcomes of patients who received a kidney transplant and bilateral nephrectomy in either a simultaneous or staged approach. Methods: We reviewed all adult patients with autosomal dominant polycystic kidney disease (ADPKD) who received a kidney transplant and underwent bilateral nephrectomy between 2008 and 2019. Patients were divided into two groups: staged (nephrectomy prior to transplant) and simultaneous (nephrectomy at the time of transplant). The primary outcome was cumulative cost of nephrectomy and transplantation ($CAD). We analyzed several secondary outcomes, including 90-day Clavien-Dindo complication rates. Results: A total of 114 patients with ADPKD received a kidney transplant over 11 years. Of these, 28 patients underwent both nephrectomy and transplantation (10 staged, 18 simultaneous). More patients in the simultaneous group had a living donor transplant (83% vs. 0%, p<0.001). Creatinine clearance at one year/last followup did not differ between groups (p=0.12). With similar overall complication rates between groups, the transfusion rate was also similar between groups (simultaneous 50% vs. staged 40%, p=0.91). Total cost was lower in the simultaneous group ($23 775.33 CAD vs. $35 048.83 CAD, p<0.001), largely owing to a longer total length of stay in the staged group as compared to the simultaneous group (8.1 vs. 14.5 days, p<0.001). Conclusions: These data suggest that a simultaneous approach to bilateral nephrectomy and kidney transplantation provides potential cost savings with no adverse outcomes. This provides a rationale to investigate simultaneous nephrectomy and transplantation in the deceased donor setting.
Language	English
Publishing date	2023-01-19
Publishing country	Canada
Document type	Journal Article
ZDB-ID	2431403-1
ISSN	1911-6470
ISSN	1911-6470
DOI	10.5489/cuaj.7816
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Article ; Online: Canadian survey on the rates of use of intraoperative diuretics and justification for their use during renal allograft reperfusion.

Levine, Max A / Luke, Patrick P / Sener, Alp

Canadian journal of surgery. Journal canadien de chirurgie

2020 Volume 63, Issue 5, Page(s) E483–E488

Abstract: Background: Mannitol and furosemide have been used as diuretics intraoperatively to facilitate early renal allograft function and reduce delayed graft function. As the evidence of any efficacy of these agents is limited, we sought to characterize the ... ...

Abstract	Background: Mannitol and furosemide have been used as diuretics intraoperatively to facilitate early renal allograft function and reduce delayed graft function. As the evidence of any efficacy of these agents is limited, we sought to characterize the use of diuretics among transplant surgeons. Methods: An anonymous online survey was sent to all Canadian transplant programs where kidney transplants are routinely performed. Questions were related to the use and indications for mannitol and furosemide. Responses were collected and analyzed as counts and percentages of respondents. We used χ2 analysis to assess the relationship between demographic factors and survey responses. Results: Thirty-five surgeons completed the survey (response rate 50%). Seventy per cent of respondents reported performing 26 or more transplants per year, 88% had formal transplant fellowship training and 67% indicated that they currently train fellows. Only 24% and 12% reported believing that delayed graft function is reduced by mannitol and furosemide use, respectively. However, 73% routinely gave mannitol to patients and 53% routinely gave furosemide. The most common justification given for mannitol use was to induce diuresis (54%); 37% of respondents reported using mannitol because of training dogma. Likewise, 57% used furosemide for diuresis, with 23% reporting that their use of this agent was based on dogma. No relationship emerged between fellowship training, case volume or training program status and the use of any agent. Interestingly, 71% of respondents indicated that a randomized controlled trial evaluating the utility of intraoperative diuretics is needed and that they were interested in participating in such a trial. Conclusion: Use of intraoperative diuretics and the rationale for their use vary among surgeons. A substantial proportion of surgeons use these medications on the basis of dogma alone. A randomized controlled trial is needed to clarify the role of intraoperative diuretics in kidney transplant surgery.
MeSH term(s)	Allografts/drug effects ; Allografts/physiology ; Canada ; Delayed Graft Function/etiology ; Delayed Graft Function/physiopathology ; Delayed Graft Function/prevention & control ; Diuresis/drug effects ; Diuresis/physiology ; Diuretics/administration & dosage ; Furosemide/administration & dosage ; Humans ; Intraoperative Care/methods ; Intraoperative Care/statistics & numerical data ; Kidney/drug effects ; Kidney/physiology ; Kidney Transplantation/adverse effects ; Kidney Transplantation/statistics & numerical data ; Mannitol/administration & dosage ; Reperfusion/methods ; Reperfusion/statistics & numerical data ; Surveys and Questionnaires/statistics & numerical data ; Treatment Outcome
Chemical Substances	Diuretics ; Mannitol (3OWL53L36A) ; Furosemide (7LXU5N7ZO5)
Language	English
Publishing date	2020-10-27
Publishing country	Canada
Document type	Journal Article
ZDB-ID	410651-9
ISSN	1488-2310 ; 0008-428X
ISSN (online)	1488-2310
ISSN	0008-428X
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Article ; Online: Characterizing the presentation, management, and clinical outcomes of patients with intradural spinal chordomas: a systematic review.

Saint-Germain, Max A / Kramer, Patrick / Weber-Levine, Carly / Jiang, Kelly / Al-Mistarehi, Abdel-Hameed / Redmond, Kristin J / Lee, Sang H / Bettegowda, Chetan / Theodore, Nicholas / Lubelski, Daniel

Neurosurgical focus

2024 Volume 56, Issue 5, Page(s) E14

Abstract: Objective: Chordomas are locally aggressive neoplasms of the spine or skull base that arise from embryonic remnants of the notochord. Intradural chordomas represent a rare subset of these neoplasms, and few studies have described intradural chordomas in ...

Abstract	Objective: Chordomas are locally aggressive neoplasms of the spine or skull base that arise from embryonic remnants of the notochord. Intradural chordomas represent a rare subset of these neoplasms, and few studies have described intradural chordomas in the spine. This review evaluates the presentation, management, and outcomes of intradural spinal chordomas. Methods: A systematic review of PubMed/MEDLINE, EMBASE, Cochrane Library, Scopus, and Web of Science was performed. Studies describing at least 1 case of intradural chordomas anywhere in the spine were included. Extracted details included presenting symptoms, radiological findings, treatment course, follow-up, and disease progression. Results: Thirty-one studies, with a total of 41 patients, were included in this review. Seventy-six percent (31/41) of patients had primary intradural tumors, whereas 24% (10/41) presented with metastasis. The most common signs and symptoms were pain (n = 27, 66%); motor deficits (n = 20, 49%); sensory deficits (n = 17, 42%); and gait disturbance (n = 10, 24%). The most common treatment for intradural chordoma was resection and postoperative radiotherapy. Sixty-six percent (19/29) of patients reported improvement or complete resolution of symptoms after surgery. The recurrence rate was 37% (10/27), and the complication rate was 25% (6/24). The median progression-free survival was 24 months (range 4-72 months). Four patient deaths were reported. The median follow-up time was 12 months (range 13 days-84 months). Conclusions: Treatment of intradural spinal chordomas primarily involves resection and radiotherapy. A significant challenge and complication in management is spinal tumor seeding after resection, with 9 studies proposing seeding as a mechanism of tumor metastasis in 11 cases. Factors such as tumor size, Ki-67 positivity, and distant metastasis may correlate with worse outcomes and demonstrate potential as prognostic indicators for intradural spinal chordomas. Further research is needed to improve understanding of this tumor and develop optimal treatment paradigms for these patients.
MeSH term(s)	Humans ; Chordoma/surgery ; Chordoma/diagnostic imaging ; Spinal Cord Neoplasms/surgery ; Spinal Cord Neoplasms/therapy ; Treatment Outcome ; Spinal Neoplasms/surgery ; Spinal Neoplasms/diagnostic imaging ; Disease Management
Language	English
Publishing date	2024-05-01
Publishing country	United States
Document type	Systematic Review ; Journal Article
ZDB-ID	2026589-X
ISSN	1092-0684 ; 1092-0684
ISSN (online)	1092-0684
ISSN	1092-0684
DOI	10.3171/2024.2.FOCUS2419
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Article ; Online: A Prospective Study of the Effect of Gastroduodenal Artery Reconstruction on Duodenal Oxygenation and Enzyme Content After Pancreas Transplantation.

Offerni, Juliano C M / Ai Li, Erica / Rasmussen, Andrew / Xie, Wen Y / Levine, Max A / Murkin, John / McAlister, Vivian C / Luke, Patrick P / Sener, Alp

World journal of surgery

2023 Volume 47, Issue 11, Page(s) 2846–2856

Abstract: Background: Whole pancreas transplantation provides durable glycemic control and can improve survival rate; however, it can carry an increased risk of surgical complications. One devastating complication is a duodenal leak at the site of enteroenteric ... ...

Abstract	Background: Whole pancreas transplantation provides durable glycemic control and can improve survival rate; however, it can carry an increased risk of surgical complications. One devastating complication is a duodenal leak at the site of enteroenteric anastomosis. The gastroduodenal artery (GDA) supplies blood to the donor duodenum and pancreas but is commonly ligated during procurement. Since we have not had expressive changes in pancreatic back table surgical techniques in the recent decades, we hypothesized whether back table GDA reconstruction, improving perfusion of the donor duodenum and head of the pancreas, could lead to fewer surgical complications in simultaneous pancreas-kidney (SPK) transplants. Material and methods: Between 2017 and 2021, we evaluated demographic information, postoperative complications, intraoperative donor duodenum, recipient bowel O Results: A total of 26 patients were included: 13 underwent GDA reconstruction (GDA-R), and 13 had GDA ligation (GDA-L). There were no pancreatic leaks in the GR group compared to 38% (5/13) in the GDA-L group (p = 0.03913). Intraoperative tissue oxygen saturation was higher in the GDA-R group than in the GDA-L (95.18 vs.76.88%, p < 0,001). We observed an increase in transfusion rate in GDA-R (p < 0.05), which did not result in a higher rate of exploration (p = 0.38). CCI® patient morbidity was also significantly lower in the GDA-R group (s < 0.05). Conclusions: This study identified improved intraoperative duodenal tissue oxygen saturation in the GDA-R group with an associated reduction in pancreatic leaks and CCI® morbidity risk. A larger prospective multicenter study comparing the two methods is warranted.
MeSH term(s)	Humans ; Pancreas Transplantation/methods ; Prospective Studies ; Duodenum/surgery ; Pancreas/surgery ; Pancreas/blood supply ; Hepatic Artery
Language	English
Publishing date	2023-09-12
Publishing country	United States
Document type	Multicenter Study ; Journal Article
ZDB-ID	224043-9
ISSN	1432-2323 ; 0364-2313
ISSN (online)	1432-2323
ISSN	0364-2313
DOI	10.1007/s00268-023-07149-4
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Article: Understanding failures in getting it up: The prevalence and predictors of failed ureteral access in ureteroscopy.

Lavoie, Callum A / Levine, Max / Schuler, Trevor D / Wollin, Timothy A / De, Shubha

Canadian Urological Association journal = Journal de l'Association des urologues du Canada

2020 Volume 15, Issue 3, Page(s) E135–E138

Abstract: Introduction: Failed access ureteroscopy (FA) describes the inability to gain adequate access to a stone to allow for treatment. The purpose of this study was to identify the prevalence of, and factors predicting FA in patients presenting with renal and ...

Abstract	Introduction: Failed access ureteroscopy (FA) describes the inability to gain adequate access to a stone to allow for treatment. The purpose of this study was to identify the prevalence of, and factors predicting FA in patients presenting with renal and ureteral stones. Methods: We conducted a retrospective review of all ureteroscopy (URS) procedures performed for renal and ureteral stones by three endourologists over a six-month period at our center. All patients who underwent URS for the purpose of stone treatment were included. Patients were excluded if they underwent URS for non-stone diagnosis or treatment. FA was investigated in relation to demographics, medical history, stone-specific characteristics, procedure-specific characteristics, etc. Statistical analysis consisted of descriptive statistics, as well as Chi-squared and t-test analysis using SPSS statistical software version 24.0. Results: A total of 188 cases were reviewed, with 8% of patients experiencing FA. Patient age, gender, body mass index (BMI), American Society of Anesthesiologists (ASA) score, emergency cases, previous stone treatment, use of computed tomography (CT) imaging, presence of hydronephrosis, and surgeon did not differ significantly between FA and successful access (SA) groups. Stone size (9.88±5.8 vs. 8.76±4.3 mm; p=0.361) was also not significantly different. However, a significant difference was noted in time from first diagnosis to URS (128 vs. 65 days, p=0.044) between the FA and SA groups, respectively. Similarly, for ureteral stones, the FA group had a significantly greater proportion of stones located in the proximal ureter (62.5% vs. 22.0%, p=0.043). Conclusions: Proximal ureteric stones were more likely to result in FA URS, and FA procedures were more likely to be preceded by extended time from first diagnosis to URS. Further investigation is necessary, and all endourology centers should track their own personal outcome data to allow for more meaningful analysis to be performed to improve patient outcomes.
Language	English
Publishing date	2020-08-27
Publishing country	Canada
Document type	Journal Article
ZDB-ID	2431403-1
ISSN	1911-6470
ISSN	1911-6470
DOI	10.5489/cuaj.6059
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Article: Complications in the 90-day postoperative period following kidney transplant and the relationship of the Charlson Comorbidity Index.

Levine, Max A / Schuler, Trevor / Gourishankar, Sita

Canadian Urological Association journal = Journal de l'Association des urologues du Canada

2017 Volume 11, Issue 12, Page(s) 388–393

Abstract: Introduction: Renal transplant experiences widespread success, but little is published regarding the postoperative complications. The Charlson Comorbidity Index (CCI) is a system of mortality risk assessment. Our purpose is to assess the 90-day ... ...

Abstract	Introduction: Renal transplant experiences widespread success, but little is published regarding the postoperative complications. The Charlson Comorbidity Index (CCI) is a system of mortality risk assessment. Our purpose is to assess the 90-day postoperative complications after renal transplantation. The secondary objective is to clarify whether CCI predicts complications. We hypothesized increased CCI corresponds to worse complication on the Clavien scale. Methods: This is a retrospective analysis of renal recipients at our institution (2011-2013) who were ≥18 years old and received complete follow up. CCI, age, gender, body mass index (BMI), and graft type were extracted from the electronic medical records. Complications were scored using the Clavien scale. Descriptive statistics and logistic regression were used to analyze 198 patients. Results: The mean age was 53 (standard deviation [SD] 14), mean BMI 27.4 (SD 14), median CCI 1. Grade 2 or higher (significant) complications occurred in 60% of patients and Grade 3b or higher (severe) in 15% of patients in the 90-day postoperative period. Sixty-eight different complications were identified, the most common being blood transfusion (19%). Logistic regression suggests a predictive value of CCI (odds ratio [OR] 1.70; 95% confidence interval [CI] 1.3-2.3) for severe complications, with diabetes mellitus and peripheral vascular disease conferring increased risk. Conclusions: Renal transplant carries significant risk. This data can be used to improve patient counselling on the likely postoperative course. Study limitations include the retrospective design, predisposing to potential bias in data capture.
Language	English
Publishing date	2017-11-01
Publishing country	Canada
Document type	Journal Article
ZDB-ID	2431403-1
ISSN	1911-6470
ISSN	1911-6470
DOI	10.5489/cuaj.4378
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Article: The Impact of Nutritional Supplementation on Donor Kidneys During Oxygenated Ex Vivo Subnormothermic Preservation.

Bhattacharjee, Rabindra N / Jackson, Ashley / Ruthirakanthan, Aushanth / Juriasingani, Smriti / Levine, Max A / Jiang, Larry / Patel, Ram / Richard-Mohamed, Mahms / Forrest, Sheryl / Ravichandran, Sevanthi / Sener, Alp / Luke, Patrick P

Transplantation direct

2022 Volume 8, Issue 10, Page(s) e1382

Abstract: Evidence suggests that nutritional supplementation during normothermic ex vivo perfusion improves organ preservation. However, it is unclear whether the same benefit is observed during room temperature (subnormothermic) oxygenated perfusion. In this ... ...

Abstract	Evidence suggests that nutritional supplementation during normothermic ex vivo perfusion improves organ preservation. However, it is unclear whether the same benefit is observed during room temperature (subnormothermic) oxygenated perfusion. In this study, we tested the impact of providing complete nutrition during subnormothermic perfusion on kidney outcomes. Methods: Porcine kidneys were recovered after 30 min of cross clamping the renal artery in situ to simulate warm ischemic injury. After flushing with preservation solution, paired kidneys were cannulated and randomly assigned to perfusion with either (1) hemoglobin-carrier hemoglobin-based oxygen carrier or (2) hemoglobin-based oxygen carrier + total parenteral nutrition (TPN) for 12 h at 22 °C. To mimic reperfusion injury, all kidneys were reperfused with whole blood for an additional 4 h at 37 °C. Kidney function and damage were assessed. Results: Kidneys preserved with or without TPN performed equally well, showing similar renal function postreperfusion. Histological findings indicated similar levels of damage from apoptosis staining and acute tubular necrosis scores in both groups. Additionally, markers of renal damage (KIM-1) and inflammation (IL-6; high-mobility group box 1) were similar between the groups. Conclusions: Unlike other studies using normothermic oxygenated perfusion platforms, nutritional supplementation does not appear to provide any additional benefit during ex vivo kidney preservation over 12 h evaluated by whole blood-based reperfusion method at subnormothermic temperature. Further study should include a kidney autotransplant model to assess the role of TPN in vivo.
Language	English
Publishing date	2022-09-22
Publishing country	United States
Document type	Journal Article
ISSN	2373-8731
ISSN	2373-8731
DOI	10.1097/TXD.0000000000001382
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Article: Open removal as a first-line treatment of magnetic intravesical foreign bodies.

Levine, Max A / Evans, Howard

Canadian Urological Association journal = Journal de l'Association des urologues du Canada

2012 Volume 7, Issue 1-2, Page(s) E25–8

Abstract: Intravesical foreign bodies are an uncommon, but significant, cause of urologic consultation. We present 3 patients who all inserted magnetic beads per urethra into the urinary bladder, which subsequently became retained. Endoscopic attempts were ... ...

Abstract	Intravesical foreign bodies are an uncommon, but significant, cause of urologic consultation. We present 3 patients who all inserted magnetic beads per urethra into the urinary bladder, which subsequently became retained. Endoscopic attempts were unsuccessfully tried in the first 2 cases, necessitating open cystotomy to remove the beads. The third went straight to open removal. Given the failure of minimally invasive techniques, we believe that open removal should be the first-line treatment for these types of foreign bodies.
Language	English
Publishing date	2012-12-01
Publishing country	Canada
Document type	Journal Article
ZDB-ID	2431403-1
ISSN	1911-6470
ISSN	1911-6470
DOI	10.5489/cuaj.12043
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Article: Daily use of a muscle pump activator device reduces duration of hospitalization and improves early graft outcomes post-kidney transplantation: A randomized controlled trial.

Xie, Wen / Levine, Max A / Aquil, Shahid / Pacoli, Katharine / Al-Ogaili, Rafid / Luke, Patrick P / Sener, Alp

Canadian Urological Association journal = Journal de l'Association des urologues du Canada

2020 Volume 15, Issue 2, Page(s) 26–32

Abstract: Introduction: Kidney and simultaneous pancreas-kidney (SPK) transplant recipients can have prolonged postoperative hospitalization due to edema. Thrombo-embolic-deterrent (TED) stockings with intermittent pneumatic compression devices (TED+IPC) have ... ...

Abstract	Introduction: Kidney and simultaneous pancreas-kidney (SPK) transplant recipients can have prolonged postoperative hospitalization due to edema. Thrombo-embolic-deterrent (TED) stockings with intermittent pneumatic compression devices (TED+IPC) have been used to improve venous return during the perioperative period. The objective of this trial was to evaluate the effects of TED+IPC vs. muscle pump activator (MPA) devices on factors that could reduce postoperative complications and duration of hospitalization. Methods: In this single-center, prospective, randomized, controlled trial, 221 kidney and SPK transplant recipients were randomized to either wearing TED+IPC or MPA for six days postoperatively. Groups were compared with respect to postoperative urine output, lower limb edema, weight, days in hospital, mobility, serum creatinine, delayed graft function, need for dialysis, and lower extremity blood flow. Results: Patients in the MPA group had significantly higher urine output and less increase in mid-calf leg circumference and weight gain compared to the TED+IPC group (p=0.003, p=0.001, and p=0.003, respectively). The MPA group also experienced shorter hospitalization (p=0.038), higher femoral vein velocity (p=0.001), and took more steps (p=0.009). Incidence of delayed graft function (p=0.72) and number of dialysis runs (p=0.39) was not different between study groups. Subgroup analysis of primary endpoints in donation after cardiac death recipients and SPK recipients did not yield any significance between the study arms. Conclusions: Postoperative use of the MPA device increases urine output, decreases leg edema, minimizes weight gain, and decreases duration of hospitalization after kidney transplantation. A larger and longer-term trial is needed to evaluate the impact on graft function.
Language	English
Publishing date	2020-08-03
Publishing country	Canada
Document type	Journal Article
ZDB-ID	2431403-1
ISSN	1911-6470
ISSN	1911-6470
DOI	10.5489/cuaj.6487
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