Publications by authors named "Hendrik Apel"

12 Publications

  • Page 1 of 1

Abdominal Panniculectomy Can Simplify Kidney Transplantation in Obese Patients.

Urol Int 2021 Jun 15:1-8. Epub 2021 Jun 15.

Department of Plastic and Hand Surgery and Laboratory for Tissue Engineering and Regenerative Medicine, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany.

Background: Obesity is frequently present in patients suffering from end-stage renal disease (ESRD). However, overweight kidney transplant candidates are a challenge for the transplant surgeon. Obese patients tend to develop a large abdominal panniculus after weight loss creating an area predisposed to wound-healing disorders. Due to concerns about graft survival and postoperative complications after kidney transplantation, obese patients are often refused in this selective patient cohort. The study aimed to analyze the effect of panniculectomies on postoperative complications and transplant candidacy in an interdisciplinary setting.

Methods: A retrospective database review of 10 cases of abdominal panniculectomies performed in patients with ESRD prior to kidney transplantation was conducted.

Results: The median body mass index was 35.2 kg/m2 (range 28.5-53.0 kg/m2) at first transplant-assessment versus 31.0 kg/m2 (range 28.0-34.4 kg/m2) at panniculectomy, and 31.6 kg/m2 (range 30.3-32.4 kg/m2) at kidney transplantation. We observed no major postoperative complications following panniculectomy and minor wound-healing complications in 2 patients. All aside from 1 patient became active transplant candidates 6 weeks after panniculectomy. No posttransplant wound complications occurred in the transplanted patients.

Conclusion: Abdominal panniculectomy is feasible in patients suffering ESRD with no major postoperative complications, thus converting previously ineligible patients into kidney transplant candidates. An interdisciplinary approach is advisable in this selective patient cohort.
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http://dx.doi.org/10.1159/000516678DOI Listing
June 2021

Significance of Glomerular Immune Reactivity in Time Zero Biopsies for Allograft Survival Beyond IgA.

Front Med (Lausanne) 2021 6;8:656840. Epub 2021 Apr 6.

Department of Nephropathology, Institute of Pathology, Friedrich-Alexander-University Erlangen-Nuremberg and University Hospital, Erlangen, Germany.

The quality of a renal transplant can influence the clinical course after transplantation. Glomerular immune reactivity in renal transplants has previously been described, focusing particularly on IgA, and has been shown to disappear in most cases without affecting the outcome. Here, we describe a cohort of time zero biopsies with regard to glomerular immune reactivity and implications for histomorphology and follow-up. 204 Time zero biopsies were analyzed by immunohistochemistry for glomerular immune reactivity. Time zero and 1-year biopsies were evaluated for histomorphological changes, which, together with clinical and follow-up data, were assessed for associations with glomerular immune profiles. Nearly half of the analyzed time zero biopsies showed glomerular immune reactivity with mesangial C3 being the most common (32.9%), followed by IgA (13.7%) and fullhouse patterns (6.9%). Strong C3 deposits (C3high) were only observed in deceased transplants. In the majority of cases immune reactivity was undetectable in follow-up biopsies and had no adverse effect on transplant function in follow-up of 5 years. In kidney pairs transplanted to different recipients a strong concordance of immune profiles in both kidneys was observed. Moreover, an association of male donor sex and deceased donor transplantation with the presence of immune reactivity was observed. In conclusion, glomerular immune reactivity is a very frequent finding in time zero biopsies, which seems to be determined by donor parameters including male sex and deceased donor transplants. It had no adverse impact on transplant function in 5-year follow-up. Glomerular immune reactivity in time zero biopsies, therefore, does not appear to indicate an inferior quality of the transplant.
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http://dx.doi.org/10.3389/fmed.2021.656840DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8057301PMC
April 2021

Quantitative Assessment of Intraoperative Laser Fluorescence Angiography with Indocyanine Green Predicts Early Graft Function after Kidney Transplantation.

Ann Surg 2020 Dec 30;Publish Ahead of Print. Epub 2020 Dec 30.

Department of Surgery, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, D-68167 Mannheim, Germany Department of Surgery, RoMed Hospital Rosenheim, Pettenkoferstraße 10, D-83022 Rosenheim, Germany Department of Vascular Surgery, Friedrich Alexander University Erlangen-Nuremberg, Krankenhausstraße 12, D-91054 Erlangen, Germany Department of Biometry and Statistics, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, D-68167 Mannheim, Germany Department of Medicine V, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, D-68167, Mannheim, Germany Department of Nephrology, Friedrich Alexander University Erlangen-Nuremberg, Ulmenweg 18, D-91054 Erlangen, Germany Department of Urology and Pediatric Urology, Friedrich Alexander University Erlangen-Nuremberg, Krankenhausstrasse 12, D-91054 Erlangen, Germany.

Objective: This study was designed to demonstrate the predictive ability of quantitative indocyanine green (ICG) fluorescence angiography for the short-term postoperative outcome, the occurrence of delayed graft function (DGF), and long-term graft survival.

Summary Background Data: DGF is a relevant problem after kidney transplantation; sufficient microperfusion of the allograft is crucial for postoperative organ function. Fluorescence angiography with ICG can serve as an intraoperative quality control of microperfusion.

Methods: This prospective diagnostic study, conducted in two German transplantation centers from November 2015 to October 2018, included 128 consecutive kidney transplantations. Intraoperative assessment of the allograft microperfusion was performed by near-infrared fluorescence angiography with ICG; a software was used for quantitative analysis. The associations between perfusion parameters (e.g. ICG Ingress) and donor, recipient, periprocedural, and postoperative characteristics were evaluated.

Results: DGF occurred in 23 (24%) kidney recipients from deceased donors. ICG Ingress (p = 0.0027), donor age (p = 0.0452), recipient age (p = 0.0139) and recipient body mass index (p = 0.0017) were associated with DGF. ICG Ingress correlated significantly with recipient age (r = -0.27662, p = 0.0016), cold and warm ischemia time (r = -0.25204, p = 0.0082; r = -0.19778, p = 0.0283), operating time (r = -0.32208, p = 0.0002), eGFR on postoperative days 1 (r = +0.22674, p = 0.0104) and 7 (r = +0.33189, p = 0.0001). The cutoff value for ICG Ingress was 106.23 AU with sensitivity of 78.3% and specificity of 80.8% (p < 0.0001) for the prediction of DGF.

Conclusion: Fluorescence angiography with ICG allows intraoperative quantitative assessment of microperfusion during kidney transplantation. The parameter ICG Ingress reflects recipient and procedure characteristics and is able to predict the incidence of DGF.

Trial Registration: Clinicaltrials.gov: NCT-02775838.
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http://dx.doi.org/10.1097/SLA.0000000000004529DOI Listing
December 2020

Kidney Autotransplantation in a 78-Year-Old Man with Proximal Ureteral Urothelial Carcinoma after Living Donor Nephrectomy.

Urol Int 2020 30;104(11-12):994-996. Epub 2020 Jul 30.

Department of Urology, University Erlangen-Nürnberg, Erlangen, Germany.

Six years after living donor nephrectomy to his daughter, the 78-year-old donor presented to the emergency room with anuria for approximately 12 h. Only arterial hypertension, mildly reduced kidney function (eGFR 54 mL/min), and benign prostatic hyperplasia were known as preexisting medical conditions. In sonography, hydronephrosis III° was visible in the right single kidney. Ureterorenoscopy revealed an occlusive tumor in the right proximal ureter, which was treated via double J stent. Biopsy showed focal invasive papillary urothelial carcinoma of G2 high grade. Preoperative staging did not show any signs of lymph node or distant metastases. For therapeutic options, nephroureterectomy with consecutive need for dialysis was discussed versus partial ureteral resection with in situ ureteral reconstruction versus nephroureterectomy with partial ureteral resection and kidney autotransplantation. Eventually, laparoscopic right nephroureterectomy was performed with back-table preparation and tumor resection, followed by ipsilateral autotransplantation. The patient developed postsurgical acute kidney failure due to ischemia/reperfusion with a maximum serum Cr of 5.66 mg/dL (eGFR 10 mL/min), which quickly resolved. The papillary invasive urothelial carcinoma was graded pT1 pTis G2 high grade R0. Regular follow-ups showed no sign for cancer recurrence in computer tomography or cystoscopy; serum Cr was at 1.87 mg/dL (eGFR 53) 12 months after surgery.
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http://dx.doi.org/10.1159/000509445DOI Listing
June 2021

Variant morphology and random chromosomal integration of BK polyomavirus in posttransplant urothelial carcinomas.

Mod Pathol 2020 07 11;33(7):1433-1442. Epub 2020 Feb 11.

Institute of Clinical and Molecular Virology, University Hospital Erlangen, Friedrich-Alexander Universität Erlangen-Nürnberg, 91054, Erlangen, Germany.

BK polyomavirus (BKPyV) causes major complications in solid organ transplant recipients but little is known about its role in the development of urothelial carcinoma (UC) during immunosuppression. Immunohistochemistry (IHC) screening for polyomavirus large T antigen (LTag) was performed in 94 micropapillary UC (MPUC), 480 unselected UC, 199 muscle invasive UC (including 83 UC with variant differentiation), 76 cases of plasmocytoid, nested and large nested UC and 15 posttransplant UC. LTag expressing UC were reevaluated regarding their histomorphological features and characterized by IHC for p53 and HER2, chromogenic in situ hybridization for HER2 and SNaPshot analysis of the TERT promoter and HRAS. Real-time PCR and next generation sequencing (NGS) were performed to search for BKPyV-DNA and for variants in the tumor and viral genomes. We detected five LTag expressing UC which were diagnosed between 2 and 18 years after kidney (n = 4) or heart (n = 1) transplantation. 89 MPUC without history of organ transplantation and overall 755 UC (including cases with variant histology) were LTag negative. Of the five LTag expressing UC, three were MPUC, one showed extensive divergent differentiation with Mullerian type clear cell carcinoma, and one displayed focal villoglandular differentiation. All five tumors had aberrant nuclear p53 expression, 2/5 were HER2-amplified, and 3/5 had TERT promoter mutations. Within the 50 most common cancer related genes altered in UC we detected very few alterations and no TP53 mutations. BKPyV-DNA was present in 5/5 UC, chromosomal integration of the BKPyV genome was detectable in 4/5 UC. Two UC with BKPyV integration showed small deletions in the BKPyV noncoding control region (NCCR). The only UC without detectable BKPyV integration had a high viral load of human herpesvirus 6 (HHV-6). Our results suggest that LTag expression of integrated BKPyV genomes and resulting p53 inactivation lead to aggressive high-grade UC with unusual, often micropapillary morphology.
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http://dx.doi.org/10.1038/s41379-020-0489-0DOI Listing
July 2020

Development and Usability Analysis of a Multimedia eConsent Solution.

Stud Health Technol Inform 2019 Sep;267:297-303

Friedrich-Alexander-Universität Erlangen-Nürnberg.

Background: More and more medical data is being stored digitally in routine care. The secondary use of patient data is only possible to a limited extent for data protection reasons. In order to enable a long-term and far-reaching use of secondary data, a possible approach is to obtain "broad consent" from patients, e.g. on research projects whose purpose is still unknown at the time of consent.

Objective: To develop and evaluate an interactive eConsent prototype that presents the extensive contents of the "broad consent" in multimedia form for the purpose of a successful and resource-efficient information and consent process.

Methods: The eConsent prototype was designed on basis of a literature review and in accordance with the goals of the German medical informatics initiative. User tests and subsequent questionnaire surveys using the System Usability Scale (SUS) were carried out with patients from a university hospital to assess the prototype's usability. The study was conducted in a quasi-experimental, one-group posttest-only design.

Results: The created interactive prototype can present the contents acoustically and visually and offers the possibility to retrieve additional information. With a SUS score of 84,1/100 the results indicate a very good usability of the prototype.

Conclusion: The next steps will include further refinements of the prototype based on the feedback received and a subsequent study with a broader user group aimed at introducing an eConsent tool as part of a patient portal.
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http://dx.doi.org/10.3233/SHTI190841DOI Listing
September 2019

Dosing of indocyanine green for intraoperative laser fluorescence angiography in kidney transplantation.

Microcirculation 2017 11;24(8)

Department of Surgery, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.

Objective: Sufficient blood supply is a crucial factor determining postoperative allograft function in kidney transplantation. Therefore, besides the surgeon's individual impression, a method for evaluating the quality of the organ's microperfusion is required. Laser fluorescence angiography with indocyanine green (ICG) is an emerging tool for this purpose. However, no reproducible quantification of ICG fluorescence has been performed in transplantation so far.

Methods: This retrospective two-center study was designed to evaluate the dosing of ICG for intraoperative laser fluorescence angiography in kidney transplantation. The Spy Elite system (NOVADAQ, Canada) was employed for quantitative assessment of allograft microperfusion. ICG was administered systemically 5 minutes after reperfusion applying doses between 0.25 and 0.01 mg ICG per kg body weight. Quantitative assessment was performed with the implemented SPY-Q Software.

Results: A total of 57 kidney recipients were included in two centers. The generated curves showing ICG IN and EgR were not evaluable due to oversensing when doses exceeded 0.02 mg per kg body weight.

Conclusions: Fluorescence angiography with ICG is an emerging tool for the intraoperative quality control and evaluation of microperfusion in kidney transplantation. A dose of 0.02 mg ICG per kg body weight is recommended to ensure the quantitative assessment with SPY-Q.
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http://dx.doi.org/10.1111/micc.12392DOI Listing
November 2017

Deceased Donor Kidney Transplantation in the Eurotransplant Senior Program (ESP): A Single-Center Experience from 2008 to 2013.

Ann Transplant 2016 Feb 11;21:94-104. Epub 2016 Feb 11.

Department of Nephropathology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany.

Background: The aim of this study was to evaluate the outcome after transplantation of deceased allografts in donor/recipient pairs aged ≥65 years enrolled in the Eurotransplant Senior Program (ESP).

Material And Methods: In this retrospective cohort study we evaluated data from 89 patients transplanted under the ESP protocol from 2008 to 2013. Outcome parameters included graft and patient survival, rate of biopsy-proven acute rejections (BPAR), peri- and post-operative complications, tumor development, development of donor-specific antibodies (DSA), and the prognostic role of preimplantation biopsies.

Results: One-year patient and allograft survival rates were 92.1% and 84.3%, respectively. During follow-up, 23 (26%) patients died; the major cause of death was sepsis, followed by cardiovascular events and malignancies. BPAR episodes were frequent within the first year (~33%) and overall were less common in patients treated with tacrolimus. Post-transplant malignancies were seen in 15 (17%) patients. During follow-up, 16 (18%) patients developed DSA; patients with delayed graft function (DGF) were more likely to develop DSA (p=0.029). A higher preimplantation biopsy score was associated with DGF but did not predict later graft outcome.

Conclusions: The results highlight increased risks in ESP transplant candidates and the importance of careful surveillance of this patient group.
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http://dx.doi.org/10.12659/aot.895731DOI Listing
February 2016

Results of Renal Transplantation on Alloplastic Arterial Grafts.

Urol Int 2016 13;96(2):157-63. Epub 2016 Jan 13.

Department of Vascular Surgery, Friedrich Alexander University Erlangen, Erlangen, Germany.

Background: The aim of this retrospective study was to report results of a consecutive series of kidney transplant patients in whom the renal artery was implanted on a prosthetic vascular graft (PVG).

Methods: Between January 2011 and December 2014, 208 deceased donor renal transplantations (68 female, 140 male, mean age 52, SD 16 years) were performed. Medical charts and outpatient clinical records of patients who had undergone renal artery implantation on a PVG were reviewed. Extensive literature research added to our 4 patients further 170 published cases during 1989 and 2015 and was compared with regular transplanted patients. Data on patient characteristics, prior vascular procedures, postoperative and long-term outcome were collected.

Results: Patients with transplant renal artery anastomosis on a PVG were 4 years older than the control group. Function of the graft was similar in these patients compared to regular renal transplant patients. Resistance indices assessed in our clinic over the entire follow-up period showed also no significant difference between the 2 groups. Thirty-day mortality was 6% (none in our group), which occurred mostly in combination when renal transplantation and PVG replacement was performed simultaneously.

Conclusion: Grafting of the renal artery to a PVG is feasible and yields good results, despite the technical difficulties involved.
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http://dx.doi.org/10.1159/000443213DOI Listing
December 2016

Isolated testicular pain mimicking ruptured abdominal aortic aneurysm in a nonagenarian.

Am J Emerg Med 2015 Aug 31;33(8):1117.e1-2. Epub 2015 Jan 31.

Department of Vascular Surgery, University Hospital, Erlangen, Germany.

Ruptured abdominal aortic aneurysm commonly presents as acute abdominal or lower back pain and hemodynamic instability. We discuss the case of a 90-year-old patient who presented to the emergency unit with a 3-day history of left testicular pain. Ultrasound scan demonstrated and a computed tomography scan confirmed a 6 cm in diameter ruptured abdominal aortic aneurysm with enlargement and hematoma of the left psoas muscle causing the symptoms. This atypical presentation highlights the need for clinical vigilance and emergency physician–performed ultrasound scan in the older patients with seemingly benign testicular symptoms.
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http://dx.doi.org/10.1016/j.ajem.2015.01.038DOI Listing
August 2015

Treatment of a chronic vesicocutaneous fistula and abdominal wall defect after resection of a soft tissue sarcoma using a bipedicled latissimus dorsi and serratus anterior free flap.

Int J Urol 2014 Nov 8;21(11):1178-80. Epub 2014 Jul 8.

Department of Plastic and Hand Surgery, Friedrich-Alexander-University of Erlangen-Nuernberg, Erlangen, Germany.

We present a surgical treatment for bladder reconstruction in a case of chronic vesicocutaneous radiation-induced fistula and reconstruction of the abdominal wall after resection of a liposarcoma in the rectus abdominis muscle. Fistulas are sequelae after radiotherapy. To regain bladder function and reconstitute abdominal wall stability, a microsurgical flap approach should be considered. A male patient underwent resection of a liposarcoma in the rectus abdominis muscle with adjuvant radiotherapy, suffering from a chronic vesicocutaneous fistula. A bipedicled combined latissimus dorsi and serratus anterior flap was carried out after resection of the fistula for reconstruction of the urine bladder and the abdominal wall. Ascending urethrography 4 weeks postoperatively showed no leakage. In the 4-month follow-up period, no signs of recurrence of the fistula or herniation occurred. A bipedicled flap allowed reconstruction of the urine bladder and the abdominal wall. Using non-irradiated, well-perfused intra-abdominal muscle tissue over the urine bladder prevented recurrence of the fistula.
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http://dx.doi.org/10.1111/iju.12545DOI Listing
November 2014

De novo malignancies in renal transplant recipients: experience at a single center with 1882 transplant patients over 39 yr.

Clin Transplant 2013 Jan-Feb;27(1):E30-6. Epub 2012 Dec 27.

Department of Urology, University Hospital Erlangen, Friedrich Alexander University, Erlangen-Nuremberg, Germany.

Purpose: Cancers complicating organ allografts are a major cause of morbidity and mortality after renal transplantation. Different registries have described an overall three to eightfold increase in cancer risk compared with the general population. This retrospective study investigated the incidence and outcome of de novo malignancies following kidney transplantation in a single German kidney transplantation center.

Materials And Methods: Between 1966 and 2005, 1882 patients underwent kidney transplantation at the Erlangen-Nuremberg kidney transplantation center. The incidence and types of post-transplant malignancies were retrospectively analyzed according to the patients' records and the database of the local cancer registry.

Results: We identified 257 malignancies in 231 patients, an overall incidence of 13.7%. The mean follow-up time was 9.9 yr (range, 0.4-25.5 yr). The observed incidence data corresponded to a 12.1-fold increase in the overall risk of developing a malignant nonskin tumor compared with the nontransplanted population. Urinary tract malignancies represented the most frequent malignancies among the nonskin tumors (32.1%), followed by gastrointestinal tract (30.7%) and gynecological (14%) cancers. When we considered the duration from renal transplantation to tumor detection and tumor-specific survival, there was no difference between patients treated with or without a cyclosporine A-based regimen.

Conclusions: In our study, the overall risk of developing a post-transplant nonskin malignancy was 12.1-fold higher compared with the age-matched general population. Development of solid organ malignancies is one of the most frequent causes of morbidity and mortality in renal transplant recipients; thus, close tumor screening in patients after kidney transplantations is warranted.
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http://dx.doi.org/10.1111/ctr.12050DOI Listing
July 2013
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