Aseptic bone necrosis after renal transplantation

Osteonecrosis is a common complication of renal transplantation and is an obstacle to rehabilitation. While prednisone has long been implicated as causative, the sporadic nature of aseptic necrosis (ASN) is poorly understood. Four hundred forty-four patients received kidney transplants (TX) between January 1978 and December 1984. Fifty-two patients (16%) have developed ASN. This retrospective study was developed in an attempt to define potential etiologic factors. Age, sex, donor, source, primary renal disease, duration of dialysis, and pre-TX parathyroidectomy did not correlate with ASN. Prednisone administration and duration of use prior to transplantation was equally common in ASN and control patients. Black recipients had a twofold frequency of ASN, although this association did not quite reach significance (p = 0.07). Pretransplant x-ray evidence of either osteopenia or renal osteodystrophy was significant (p less than 0.01) and apparent in 23 of 52 patients (44%). ASN was associated with a history of early acute rejection (p less than 0.02), higher final serum creatinine (p = 0.07), and greater mean prednisone (p less than 0.0001). The mean linear trend of daily prednisone dose was also significant (p less than 0.03). This study suggests that ASN is three times more likely to occur if radiographic evidence is apparent before TX. Rejection and higher daily steroid dosage correlate with a greater incidence of ASN, and blacks appear to be at greater risk.     

Aseptic necrosis of the femoral head following renal transplantation

The occurrence of aseptic hip necrosis was investigated in 546 renal transplant patients (639 transplants) with graft survival for a minimum of 12 months. Aseptic hip necrosis developed in 39 hips in 29 patients (5.3%) from 3 to 121 months (mean 22 months) after the renal transplantation. There was no sex-related difference in incidence of hip necrosis. The complication was significantly more common among patients younger than 20 than among those older than 40 years. The development of hip necrosis did not correlate with type of renal disease, origin of graft (cadaver of living relative donor), side of transplant or length of dialysis treatment. The number of transplantations per patient did not influence the occurrence of hip necrosis. Analyses of serum concentrations of creatinine, calcium, phosphorus and parathormone before and at different periods after transplantation revealed no patterns predictive of hip necrosis. The pathogenesis of aseptic necrosis of the femoral head obviously is multifactorial.     

Pyelo-ureteral necrosis after renal transplantation

Because of the limited chance of receiving a kidney transplant (for several well-known reasons), a lot of desperate dialysis patients procure an unrelated donor kidney transplant against all medical advice. This type of renal paid transplantation is associated with many surgical complications and invasive opportunistic infections that increase the morbidity and mortality in this group of transplant recipients. In this report, we describe a case of a 22-year-old girl with a segmental infarction of the graft lower pole and a complete pyelo-ureteral necrosis as a consequence of some vascular damage, complicated by a pathohistological finding of an invasive candidiasis. Despite the successful surgical pyelovesical anastomosis and the good recovery of the patient and the kidney, long term prognosis remains poor. The lack of information from the transplanting center regarding both donor and recipient and the associated, unacceptable risks on the graft and patient survival in unrelated, paid transplant recipients reinforce the standpoint that this practice should be abandoned.     

Aseptic necrosis of bone following renal transplantation: relation with hyperparathyroidism

Bone status, calcium and phosphate metabolism were prospectively evaluated in 98 renal transplant recipients with stable renal function. Aseptic necrosis of bone was found in 30 patients, leading to arthroplasty in 12 patients. Plasma parathyroid hormone and nephrogenic cyclic adenosine monophosphate (cAMP) values were greater and the duration of pre-transplant chronic renal failure longer in patients with aseptic necrosis of bone than in those who were not affected. Cumulative oral corticosteroid doses and the number of acute rejection episodes treated by intravenous methylprednisolone pulses were similar in patients with or without aseptic necrosis of bone. Hyperparathyroidism was confirmed histologically in 14 patients, comprising 4 cases of adenoma and 10 of diffuse hyperplasia. Serum parathyroid hormone correlated positively with serum creatinine (r = 0.47; P less than 0.001) and with cumulative corticosteroid dose (r = 0.30; P less than 0.003). This study suggests that hyperparathyroidism is a factor in the pathogenesis of aseptic bone necrosis. The frequency and severity of bone necrosis may be decreased by early detection and treatment of post-transplant hyperparathyroidism.     

Avascular necrosis of bone after renal transplantation

Summary: Avascular necrosis (AVN) of bone is the most debilitating musculoskeletal complication that can follow renal transplantation, and has been reported in 3-41% of patients. In this unit 351 renal transplants have been done on 285 recipients. Five (1.8%) of these patients (mean age 41.6 years; range 22-57 years; four female; all cadaveric kidneys) developed AVN which affected both hip joints. the mean duration of renal failure before dialysis was 18.2 months (range 5-36). All five were on dialysis for a mean of 16.2 months (range 4-29) pre-transplant. No patient had radiological evidence of renal osteodystrophy prior to transplantation. the first 116 patients were immunosuppressed with prednisone/azathioprine and four (3.5%) developed AVN. the subsequent 169 patients were treated with prednisone/azathioprine/ cyclosporine and one (0.6%) developed AVN. Only two of the five patients needed treatment for acute rejection (methylprednisolone 3 g and 6 g). the mean time from transplantation to onset of joint pain was 45.4 months (range 6-108). Total hip replacement (THR) was undertaken on all 10 joints with the first side being operated on after a mean of 73.2 months (range 23-124) from transplantation and the contralateral side after 88.4 months (range 24–144). Total hip replacement resulted in relief of pain in all joints: three surgical revisions were required, two for dislocation and one for a fractured prosthesis. This study has shown a low prevalence of AVN after renal transplantation. Possible explanations include careful control of renal osteodystrophy while on dialysis and the use of low dose prednisone in the immunosuppressive regimen.     

肾移植后股骨头缺血性坏死行全髋关节置换的围手术期处理

目的探讨肾移植术后股骨头坏死（ANFH）行全髋关节置换（THA）术的围手术期处理。方法对4例肾移植术后ANFH患者（5髋）行THA治疗,分析手术时机、免疫抑制剂的使用和术中、术后相关治疗措施等。结果患者手术均获成功,术中、术后无并发症。4例均获随访,时间6~24个月。髋关节功能恢复较好,对移植肾无明显影响。结论肾移植术后ANFH行THA能有效解除髋部疼痛,只要围手术期处理得当,手术是安全可行的。     

肾移植术后人工全髋关节置换的护理体会

随着我国肾移植技术的不断发展,肾移植受者数量逐渐增多,由于长期使用免疫抑制剂导致的股骨头坏死、骨质疏松症等移植后骨病发生率也相应上升。国外有研究报道肾移植受者骨质减少和骨质疏松的椎体累及率达80％,股骨颈累及率达65％;     

Acute tubular necrosis after renal transplantation. Multifactoral analysis

Acute Tubular Necrosis (ATN) is a relatively common complication occurring after cadaver kidney transplant. In 64 human renal grafts performed in our center the influence of some factors on the incidence of ATN, related to donor and recipient, was evaluated. The total incidence of ATN was 26.5%. As far as factors related to donor are concerned, the donor's provenance (our medical center versus other centers) resulted statistically significant (p less than 0.01). The incidence of ATN was 17% when the donor came from our intensive care unit, compared with 52% of incidence observed when donor came from other medical centers. As far as factors related to recipients are concerned, the mean and systolic arterial pressure (both measured at the time of unclamping the renal vessels) resulted statistically significant (p less than 0.01 and 0.05 respectively). The influence of mean arterial pressure on the incidence of ATN suggests the administration of inotropic and vasopressant drugs in selected patients before and after organ reperfusion in order to maintain an adequate renal perfusion.     

Aseptic necrosis of the femoral head following renal transplantation: assessment of a 25-year experience]

From June 1963 to December 1988 aseptic necrosis of the femoral head has been treated surgically in 84 renal transplant recipients (150 surgical procedures). The long-term results of drilling of the neck and head of the femur (16), cup arthroplasty (32), cemented cup (1) and hemiarthroplasty (8) were unsatisfactory, as 23 of these 57 hips underwent a secondary procedure. Total hip arthroplasty progressively became the standard procedure for treatment of hip disease in transplanted patients. Since 1971, 63 renal transplant recipients underwent 92 cemented total hip replacement (THR) as a primary (73), secondary (16) or third (3) surgical procedure for severely symptomatic femoral head necrosis. Hospital stay averaged 22 days, and follow-up averaged 53 months. Two deaths related to the surgical procedure occurred in the first 4 years of our experience (one major local sepsis, one pulmonary infection). Other postoperative complications were urinary tract infection (12), pulmonary infection 1, transient sciatic nerve irritation (3), wound hematoma (6), reversible deterioration of renal function (3) and rejection of the graft (2). Thromboembolic complications did not occur. All operated hips showed a marked symptomatic improvement. Loosening of one or both components was definite in one, probable in two and possible in three of the 33 hips followed up more than 5 years. Other late complications included dislocation (6), painful class III heterotopic ossification (4), recurrence of previous sepsis (1) and late hematogenous sepsis. Late hip revision was required in 5 cases (recurrent dislocation, 1, ossification, 2, sepsis, 2). Two renal complications (one graft infarction and one reversible acute tubular necrosis) occurred after these revisions. The functional results of THR compare favourably with the results of other surgical procedures used in our early experience. We conclude that THR has become the treatment of choice for symptomatic established osteonecrosis of the femoral head in renal transplant patients. A relatively high rate of early and late complications is nevertheless to be expected.     

Hospitalized avascular necrosis after renal transplantation in the United States

BACKGROUND: The national incidence of and risk factors for hospitalized avascular necrosis (AVN) in renal transplant recipients has not been reported. METHODS: This historical cohort study consisted of 42,096 renal transplant recipients enrolled in the United States Renal Data System (USRDS) between 1 July 1994 and 30 June 1998. The data source was USRDS files through May 2000. Associations with hospitalizations for a primary diagnosis of AVN (ICD-9 codes 733.4x) within three years after renal transplant were assessed in an intention-to-treat design by Cox regression analysis. RESULTS: Recipients had a cumulative incidence of 7.1 episodes/1000 person-years from 1994 to 1998. The two-year incidence of AVN did not change significantly over time. Eighty-nine percent of the cases of AVN were due to AVN of the hip (733.42) and 60.2% of patients with AVN underwent total hip arthroplasty (THA); these percentages did not change significantly over time. In the Cox regression analysis, an earlier year of transplant, African American race [adjusted hazard ratio (AHR), 1.65, 95% confidence interval (CI) 1.33 to 2.03], allograft rejection (AHR 1.67, 95% CI 1.35 to 2.07), peritoneal dialysis (vs. hemodialysis; AHR 1.44, 95% CI 1.15 to 1.81), and diabetes (AHR 0.41, 95% CI 0.27 to 0.64) were the only factors independently associated with hospitalizations for AVN. CONCLUSIONS: The incidence of AVN did not decline significantly over time in the renal transplant population. Patients with allograft rejection, African American race, peritoneal dialysis and earlier date of transplant were at the highest risk of AVN, while diabetic recipients were at a decreased risk.