Do noninherited maternal antigens (NIMA) enhance renal graft survival?

To test the hypothesis that noninherited maternal antigens (NIMA) can modulate the alloreactivity of infant cells and provide protection for renal transplant recipients, a study of renal transplantations performed between 1980 and 1991 was undertaken. The survival rate of grafts with a mismatched antigen identical to the NIMA was compared to that of grafts in which the mismatched antigen was not identical to the NIMA. In the case of HLA-A mismatches, graft survival rates were significantly better for NIMA-mismatched transplants: 94 % and 83 % at 1 and 3 years, respectively, for single NIMA HLA-A mismatched transplants, and 83 % and 67 % when both HLA-A antigens were mismatched, compared to 76 % and 68 % (one non-NIMA HLA-A mismatch) and 67 % and 45 % (two non-NIMA HLA-A mismatches). Our results suggest that some class I NIMA-mismatched antigens are not harmful to renal transplant recipients. Received: 16 May 1997 Received after revision: 8 October 1997 Accepted: 19 November 1997     

Microsporidiosis in the graft of a renal transplant recipient

Microsporidia are intracellular protozoa that are emerging as significant opportunistic infections in AIDS patients. Although there are numerous published reports of intestinal and disseminated infections in patients with AIDS, there have been only two previous reports in transplantation medicine, both on intestinal microsporidiosis. We report here the first documented case of extra-intestinal microsporidiosis in a transplant recipient. A 39-year-old renal transplant recipient presented with a pyrexia and deteriorating graft function. Light microscopic examination of a renal allograft biopsy revealed numerous microsporidian spores within the renal tubular epithelium. Transmission electron microscopy confirmed the presence of an Encephalitozoon infection and was highly suggestive of Encephalitozoon intestinalis. Therapy with albendazole was extremely effective and resulted in recovery of renal function. Although a rare cause of renal allograft dysfunction, microsporidiosis is curable. It may be underdiagnosed, and should be considered in the differential diagnosis of transplant recipients presenting with opportunistic infections. Received: 18 May 2000 Accepted: 28 May 2001     

Is cytomegalovirus a cause of ureteral stricture in renal transplant recipients?

Cytomegalovirus (CMV) is regarded as a predominant infectious agent in solid organ transplants. CMV disease has highly protean clinical manifestations. Nevertheless, urinary tract involvement seems to be very rare during CMV infection. We report two cases of renal transplant recipients in whom ureteral stricture developed in the course of CMV disease. Histologic data were available for them and were consistent with CMV infection. We discuss previous case reports and propose physiopathologic mechanisms. Received: 3 October 1996 Received after revision: 13 February 1997 Accepted: 17 February 1997     

Renal-splenic shunt for infrahepatic caval occlusion after piggy-back liver transplantation

Inferior vena cava thrombosis after liver transplantation is uncommon. We describe a case of this unusual complication occurring after piggy-back (end-to-side) graft implantation. Renal failure, lower limb edema, and hemodynamic instability were the presenting symptoms requiring immediate surgical correction with a left renal-to-splenic vein shunt over a ringed 2.5-cm prosthesis. The decision to go ahead with the shunt was preceded by an intraoperative confirmation of a 10-cm H₂O pressure gradient between the caval and portal circulations. This gradient, unlike that observed in liver cirrhosis, ultimately turned a splenorenal shunt into a renal-splenic one. Six months after the procedure, the patient is alive and well with normal liver and renal function. The technique described may be useful in the management of other clinical conditions of acute infrahepatic caval hypertension. Received: 17 January 1997 Received after revision: 2 May 1997 Accepted: 13 May 1997     

Permanently reduced plasma ionized magnesium among renal transplant recipients on cyclosporine

Hypomagnesemia is common after kidney transplantation. Until recently, only the determination of total plasma magnesium was possible, whereas the assessment of ionized magnesium has since become practicable. One hundred and nine renal transplant patients on cyclosporine with allografts functioning stably for more than 6 months and plasma creatinine levels of less than 200 μmol/l entered the study. Total and ionized circulating magnesium were assessed among these 109 patients, as well as among 15 renal transplant patients not on cyclosporine and 21 healthy volunteers. Cyclosporine patients showed significantly lower total and ionized circulating magnesium values than the two control groups. Plasma total and ionized magnesium levels were also significantly lower among cyclosporine patients treated concurrently with insulin or oral hypoglycemic agents than among those who were not. No correlation was noted between time after transplantation and plasma magnesium with respect to patients on cyclosporine. In conclusion, the study demonstrates that a large subset of renal transplant patients treated with cyclosporine have permanent deficiencies of ionized and total magnesium. The tendency towards hypomagnesemia is also more pronounced among patients with diabetes mellitus. Received: 28 May 1998 Received after revision: 27 November 1998 Accepted: 18 December 1998     

Atypical mycobacterium infection with dermatological manifestation in a renal transplant recipient

In April 1997, a 58-year-old renal transplant recipient presented with abscess-like nodules in his left calf and on his right foot. Furuncular disease was suspected and the patient was treated with flucloxacillin. However, the lesions increased in size and became ulcerative. In the following 3 months, cultures of punctuated material, blood, and urine remained negative and gram stains did not reveal micro-organisms. In June 1997, acid-fast stains were positive. A diagnosis of a nontuberculous mycobacterium (NTM) infection was made and empirical antimycobacterial therapy was started. The combination of relatively minor symptoms with enlarged purulent lesions, causing severe morbidity, raises the possibility of NTM infection in the immunocompromised patient. Received: 24 March 1998 Received after revision: 28 July 1998 Accepted: 23 September 1998     

Long-term follow-up of renal transplant recipients treated with losartan for post-transplant erythrosis

Post-transplant erythrosis (PTE) develops in 9 %–22 % of all renal transplant recipients. Defined as a persistently elevated hematocrit (> 0.51), it occurs most commonly during the first 2 years post-transplantation in hypertensive males with excellent allograft function. Several studies have focused on a major role for angiotensin II in PTE pathogenesis, and some case reports have suggested that losartan is an effective treatment for PTE. Nevertheless, its long-term safety and efficiency have not been reported in renal transplant recipients suffering from PTE. We describe four patients successfully treated with losartan for PTE. Hematocrit remained normal for 21, 18, 15, and 15 months, respectively, after the beginning of losartan therapy. Mean erythropoietin concentration was not modified by treatment (17 ± 3.7 mU/ml vs 17 ± 3.8 mU/ml) and serum creatinine concentration remained stable. We conclude that losartan is a safe and effective long-term treatment for PTE. Received: 18 December 1997 Received after revision: 6 March 1998 Accepted: 16 March 1998     

Frequency of mucosal HPV DNA detection (types 6/11, 16/18, 31/35/51) in skin lesions of renal transplant patients

Human papillomaviruses (HPV) probably play a role in the development of skin cancer in renal transplant recipients. Since some mucosal HPV are strongly related to cervical cancer, we compared the frequency of HPV DNA detection (mucosal types 6/11, 16/18, and 31/33/51) in skin cancer of renal transplant recipients (21 lesions) with that in normal subjects without immunodeficiency (21 lesions) and studied the frequency of these same HPV in benign lesions of renal transplant recipients (34 lesions) and normal subjects (30 lesions). An in situ hybridization technique employing cold biotin probes was used. HPV DNA was not significantly (P = 0.095) more frequent in malignant skin cancer in renal transplant recipients (42.9 %) than in normal subjects (19.04 %), but was significantly more frequent in benign lesions in renal transplant recipients (32.4 %) than in controls (10 %; P < 0.05). These results on a limited number of skin lesions do not allow one to confirm the predominant role of mucosal HPV in the development of skin cancer in renal transplant recipients. HPV interaction with other factors related to the immunosuppressive state may play a role. Received: 21 May 1996 Received after revision: 6 September 1996 Accepted: 28 October 1996     

Reduced variability of Neoral pharmacokinetic studies in pediatric renal transplantation

In adult renal transplant recipients the Neoral area under the curve (AUC) displays less inter- and intra- individual variability than Sandimmune, and those renal transplant recipients with reduced intra-individual variability of the AUC have a lower risk for chronic rejection. As variability of Neoral pharmacokinetic (Pk) parameters has not been investigated in pediatric renal transplant recipients, we retrospectively analyzed 453 Pk profiles in 14 pediatric patients who were switched from Sandimmune to Neoral and compared the inter- and intra-individual variability of the Pk profiles on both formulations. After the switch, we observed less inter- and intra-individual variability of AUC, the 2-h concentration, and the oral clearance. As clearance with both formulations is supposedly equal, the significantly lower intra-individual variability of oral clearance is most likely an effect of less variable absorption. While the lower inter-individual variability of the Pk parameters suggests increased success in keeping cyclosporine concentrations on target, the lower intra-individual variability leads to the hypothesis that with Neoral, a lower incidence of chronic rejection might be achieved. Received: 8 February 2000 / Revised: 17 May 2000 / Accepted: 22 May 2000     

Ureteral urine leak presenting as a pleural effusion in a renal transplant recipient

We report a 15-year-old girl who developed a ureteral perforation soon after living-related donor renal transplantation. Her presentation was unusual in that a symptomatic pleural effusion accumulated as an extension of the perinephric urine collection. Recognition and surgical correction of the ureteral pathology led to resolution of respiratory symptomatology and full recovery of renal function. Received October 15, 1997; received in revised form February 17, 1998; accepted February 20, 1998     

Elective withdrawal of mycophenolate mofetil in renal transplant recipients treated with mycophenolate mofetil, cyclosporine, and prednisone

In a retrospective study we investigated the risk of acute rejection after the withdrawal of mycophenolate mofetil (MMF) in 39 adult patients treated with cyclosporine (CyA), prednisone, and MMF for at least 6 months following renal transplantation. After reaching a stable renal graft function, MMF was withdrawn and CyA and prednisone were continued. Preceding the withdrawal of MMF, four patients experienced an acute rejection. During a median follow-up of 38 months after discontinuing MMF, no acute rejection occurred. The mean serum creatinine level did not change during the first 6 months after withdrawal of MMF. We conclude that elective withdrawal of MMF in stable renal transplant recipients at 6 months after transplantation bears no important risk of an occurrence of acute rejection. Received: 24 November 1999 Revised: 11 May 2000 Accepted: 18 December 2000     

Two grams daily of oral acyclovir reduces the incidence of cytomegalovirus disease in CMV-seropositive liver transplant recipients

Our objective in this study was to determine the efficacy of 2 grams a day of oral acyclovir administered for 16 weeks after transplantation for the prevention of cytomegalovirus (CMV) infection and disease in CMV-seropositive liver transplant recipients. Seventy-three adult liver transplant recipients, seropositive for CMV, were randomized to receive either 2 grams a day of oral acyclovir for 16 weeks after transplantation or no prophylaxis. The incidence of CMV disease was significantly lower in the acyclovir group (5 %) than in the control group (27 %; P < 0.05). By log-rank analysis, the differences in the probability of presenting CMV disease over the first 16 weeks and over the 1st year were also significant (P < 0.05). We conclude that 2 grams a day of oral acyclovir provides effective prophylaxis against CMV disease in CMV-seropositive liver transplant recipients. Received: 14 March 1997 Received after revision: 30 May 1997 Accepted: 9 June 1997     

Successful endoluminal thrombo-aspiration of renal graft venous thrombosis

Renal transplant vein thrombosis is an unusual event occuring in 0.3–3 % of renal transplantations. Prognosis is uniformly poor with graft loss in nearly every case. We report here the first three cases of renal graft vein thrombosis successfully treated by percutaneous endoluminal thromboaspiration. After an initially uneventful course all recipients developed anuria and required hemodialysis. In two cases, an ultrasound examination suggested a diagnosis of venous thrombosis. Emergency arteriography and phlebography were performed, confirming the complete thrombosis of the graft veins. Thromboaspiration was carried out with full heparinization and led to renal function improvement in all cases. Grafts are still functioning 6 months after the procedure, with serum creatinine levels of 176 μmol/l, 120 μmol/l and 184 μmol/l, respectively. Thus, this procedure avoids surgical and anaesthetic risks and allows, if performed at an early stage, restoration of graft function. Great care must be taken to avoid vein wall damage, vascular suture line rupture, or pulmonary embolism. Received: 15 March 1999/Revised: 26 November 1999/Accepted: 30 November 1999     

肾移植手术中特殊供肾的处理

目的 总结特殊供肾的外科处理经验。方法 回顾性分析1996年1月-2001年6月间进行的868例尸体肾移植中326只特殊供肾的处理，并与542只普通供肾的移植效果进行比较。结果 326只特殊供肾均得到了利用，血管变异的供肾移植后1个月血肌酐水平，急性肾小管坏死（ATN）发生率及1年移植肾存活率与普通供肾均远见显著差异；其他特殊供肾均未发生与修整术有关的并发症。结论 畸形供肾或损伤供肾，通过合理手术整形，灵活运用等方法保肾，并不影响肾移植的效果。     

Impact of local donor and regionalization on a German transplantation center

Optimal allocation of donor organs is an ongoing matter of debate. We report on the impact of the foundation of UNI NRW, a close transplant collaboration of seven university centers with the intention of improving donor organ allocation, on the heart transplant program in Münster. All donor organs retrieved were offered first to the patients within this region before going into the Eurotransplant (ET) Foundation pool. The heart transplant program data were prospectively (for 1997) and retrospectively (for 1996) analyzed with regard to donor organ availability and allocation. There was a slight decrease in the number of donor hearts offered and accepted within the UNI NRW region in 1997 as compared to in 1996. However, due to the significantly lower organ export rate, the number of heart transplantations performed in UNI NRW rose from 47 to 72 procedures. In Münster, only six donor organs (16 %) were procured from outside UNI NRW in 1997, and these were, in part, due to special urgency requests. In conclusion, the institutionalization of UNI NRW within the framework of ET offers more flexibility, decreases total ischemic time, and may help to lower costs. Received: 26 May 1998 Received after revision: 22 September 1998 Accepted: 12 October 1998     

Do retrospective and prospective quality of life assessments differ for pancreas-kidney transplant recipients?

The literature indicates that chronically ill patients have a remarkable capacity to adapt to their illness. For example, they will generally report a better quality of life (QoL) than individuals in the general population who are asked to imagine themselves as chronically ill and to rate their QoL. The present study further explores this phenomenon in type I diabetic transplant recipients with end-stage renal disease. In a prospective, longitudinal study, we assessed the QoL in 22 patients, both before and after they received a combined pancreas-kidney transplant. After transplantation, the patients were also asked to assess their pretransplant QoL by rating it on a 10-point scale. What we found was that prior to transplantation, QoL was prospectively given a mean rating of 5.23; this score increased to 7 after a successful transplant procedure. During follow-up assessments 5, 12, and 18 months after successful transplantation, patients retrospectively scored their pretransplant QoL as 3.27, 3.14, and 3.05, respectively.We conclude that when type I diabetic patients with end-stage renal disease undergo a transplant procedure to improve their health status, they re-evaluate their pretransplant QoL, and this retrospective assessment is significantly lower than their prospective one when transplantation is successful. Received: 2 July 1997 Received after revision: 25 September 1997 Accepted: 10 October 1997     

The use of pamidronate in three children with renal disease

The successful use of pamidronate, a bisphosphonate, for the treatment of hypercalcemia and/or osteopenia is reported in three children with renal failure or following renal transplant. Patient 1 was an 11-year-old post renal transplant male who received a single dose of IV pamidronate (0.5 mg/kg) for the treatment of acute hypercalcemia associated with a pathological fracture and subsequent immobilization. Prompt resolution of the hypercalcemia was seen. He received a second course of pamidronate (0.5 mg/kg per day for 3 days) for the treatment of osteopenia and has had a subsequent 15% increase in lumbar spine bone mineral content (BMC). Patient 2, a 14-year-old male on peritoneal dialysis, presented with symptomatic hypercalcemia associated with tertiary hyperparathyroidism. A single dose of IV pamidronate (0.4 mg/kg) was given with prompt resolution and prolonged control of his hypercalcemia. The third patient was a 16-year-old female, also in renal failure on peritoneal dialysis. Her course had been complicated by marked osteopenia. IV pamidronate (0.5 mg/kg per dose) was given on 3 successive days before and after renal transplant in an attempt to stabilize her bone mineral density (BMD) around the time of renal transplantation, when additional glucocorticoid was necessary. Her total body BMC and BMD remained stable pre and post transplant. The treatment was effective and well tolerated in all three patients. Hence pamidronate is safe and effective for the management of hypercalcemia and osteopenia in children with renal failure and/or renal transplant. Received October 13, 1997; received in revised form May 13, 1998; accepted May 15, 1998     

Is obesity still a risk factor in renal transplantation?

At our center, since 1982, a body mass index (BMI) of less than 30 has been a prerequisite for placing a patient on the waiting list for renal transplantation. This decision was made because obese transplant recipients seemed to have a less than favorable post-transplant outcome. The aim of this study was to evaluate whether this requirement is still justified. Forty-six patients with a BMI above 30 underwent primary cadaveric renal transplantation between 1972 and 1993. For each of these obese patients, five consecutive non-obese (BMI 20–25) control patients were selected. Patient and graft survival, causes of graft loss, and acute rejection rate were evaluated for the two patient groups before and after the year 1982. Within the first 30 post-transplant days, one patient (2 %) and 11 grafts (24 %) were lost in the group of obese patients whereas seven patients (3 %) and 36 grafts (16 %) were lost in the control group. Among the obese patients, renal circulatory complications were a major cause of graft loss. In the period 1973–1981, the 1-year patient survival rate was 65 % among obese patients versus 75 % among controls from 1982 to 1993, this was 90 % versus 93 %. From 1973 to 1981, the 1-year graft survival rate was 25 % among obese patients versus 53 % among controls (P < 0.05); from 1982 to 1993, it was 68 % versus 84 % (P = NS). Multivariate analysis showed that the immunosuppressive regimen, age of the patient, BMI, and cold ischemia time of the graft had a significant influence on graft survival. The acute rejection rate within the first 30 days was 28 % among obese patients and 35 % among controls (P = NS). We conclude that a BMI below or equal to 30 is still justified as a prerequisite for placement on the waiting list for renal transplantation, for despite an overall improvement, the outcome of renal transplantation in obese patients remains worse than that in non-obese patients. Received: 3 February 1997 Received after revision: 4 April 1997 Accepted: 8 April 1997     

Campylobacter jejuni bacteremia and Guillain-Barré syndrome in a renal transplant recipient

In patients who have not undergone transplantation, Guillain-Barré syndrome (GBS) is typically preceded by an acute infection often sustained by Campylobacter jejuni. Thus far, in renal transplant recipients, only eight cases of GBS have been reported. In seven patients GBS was attributed to cytomegalovirus infection and in the eighth patient to cyclosporin A neurotoxicity. We report here the case of a GBS in a renal transplant recipient following C. jejuni bacteremia. The infection quickly disappeared after erythromycin and methronidazole therapy. GBS progressively evolved into a paraparesis within 1 week. After reaching a plateau phase, the clinical status improved and the patient was able to walk unassisted after 3 weeks. At his last check-up, 54 months later, the patient was doing well with a functioning graft and only minimal weakness of the lower limbs. Received: 17 February 1998 Received after revision: 7 July 1998 Accepted: 8 July 1998     

肾移植患者细菌谱的调查及耐药性的研究

目的：通过调查研究肾移植患者常见致病菌株分布特点及其对抗生素敏感性的规律，进一步提高临床治疗肾移植后感染患者的成功率。方法：1997年4月－2000年5月间，对拟诊为呼吸系和／或泌尿系细菌感染的肾移植患者进行，取其痰，咽拭子或中段尿标本进行细菌培养并作24种常用抗生素药敏试验，对结果进行统计学分析。结果：共有653份标本培养结果阳性，其中痰标本233份，咽拭子173份，中段尿247份，主要阳性菌株是铜绿假单胞菌，肺炎克雷伯杆菌，大肠杆菌和表皮葡萄球菌等。敏感率较高的抗生素有万古霉素，亚胺培南，阿米卡星和头孢他啶等，耐药率较高的有青霉素，氨苄西林，红霉素，苯唑西林和头孢唑林等。结论：（1）肾移植后感染的主要菌株种类与其他患者有所不同；（2）肾移植患者的感染菌株对抗生素敏感率最高的依次为万古霉素，亚胺培南，阿米卡星和头孢他啶，但耐药性也正在逐渐增强（3）肾移植患者的感染主要发生在呼吸和泌尿系统，其他部位的感染少见；（4）痰和咽拭子来源的细菌株对抗生素更敏感，中段尿来源的细菌则耐药株相对多见。