Renal transplantation of patients on chronic peritoneal dialysis

A retrospective review of patients transplanted from peritoneal dialysis was performed to assess the risk of this form of dialysis for patients awaiting renal transplantation. Eighteen transplants have been performed in 16 patients, ages 6 to 57 years, undergoing chronic peritoneal dialysis over the past 4 years. Sixteen were from cadaver donors, and two were from living related donors (LRD). The patients had been undergoing intermittent peritoneal dialysis or continuous ambulatory peritoneal dialysis (CAPD) using permanent silastic catheters, from five days to 4 years. No patient had clinical evidence for peritonitis at the time of transplantation. The peritoneal catheter was removed at the time of transplant in all cadaver donor recipients without complication. One recipient of a LRD kidney had the catheter removed two days prior to transplant. Cultures of the catheter were sterile in 16 cases. Two patients had positive peritoneal catheter cultures at the time of transplant but were treated with appropriate antibiotics and never developed clinical peritonitis. Fourteen transplants had postoperative fevers. No definite source was found in 13; one had fever in relation to acute graft rejection. The fevers resolved in all patients either spontaneously or subsequent to therapy. Other complications were similar to those seen in patients transplanted from hemodialysis. Hemodialysis was performed as needed pretransplant and posttransplant using a temporary femoral vein catheter or arteriovenous fistula without complication. Nine patients are alive with a functioning kidney 1 to 36 months posttransplant (mean 17 months). Six transplants rejected (five patients), and one failed secondary to renal vein thrombosis. Two patients died posttransplant, one after a cerebrovascular accident, and one due to an unknown cause 1 month postnephrectomy for rejection. In conclusion, patients undergoing chronic peritoneal dialysis can be successfully transplanted without a significant incidence of complications related to their peritoneal dialysis.     

Renal cell carcinoma in chronic renal failure without dialysis treatment

We report a case of renal cell carcinoma in chronic renal failure without dialysis treatment. The literature is reviewed, and the relationship between renal cell carcinoma and uraemia is discussed.     

未透析的尿毒症患者直接进行肾移植的临床可行性研究

目的 探讨未透析的尿毒症患者直接进行肾移植的临床可行性和优越性。方法 回顾性分析146例未透析直接行肾移植的尿毒症患者（未透析组）和同期653例透析后肾移植患者（透析组）的临床资料，并将两组资料进行统计学比较。结果 未透析组和透析组术前肝炎病毒感染率分别为5．48％和19．14％，差异有统计学意义（P〈0．05）。未透析组和透析组术后血肌酐恢复正常的时间及术后1个月的血红蛋白和白蛋白水平差异均无统计学意义（P〉0．05）。未透析组术后急性排斥反应、肾功能延迟恢复和肝功能损害的发生率分别为19．18％、6．16％和9．59％，透析组分别为33．54％、13．02％和25．57％，2组比较，差异均有统计学意义（P〈0．05）；2组患者术后高血压和感染的发生率比较，差异均无统计学意义（P〉0．05）。未透析组人／肾1年存活率均为98．63％，3年存活率均为95．95％。透析组人／肾1年存活率为97．24％／95．71％，3年存活率为94．37％／89．20％；2组比较，差异均无统计学意义（P〉0．05）。结论 未透析患者肾移植与透析后肾移植的临床治疗效果相当，并可避免透析的并发症和输血致敏，且术后急性排斥发生率低。因此，未透析的尿毒症患者直接行肾移植具有较明显的优势，临床上是完全可行的。     

Renal transplantation without steroids

Cyclosporin has been in use in our unit since 1982 to treat renal transplant recipients. In two controlled clinical trials cyclosporin monotherapy was compared with cyclosporin with steroids, and with cyclosporin with azathioprine. The addition of steroids did not improve graft survival but did increase the incidence of infection. The addition of azathioprine also had no effect upon graft outcome. We conclude that cyclosporin monotherapy provides very adequate immunosuppression in the majority of cases giving an 80% survival rate for cadaveric kidney transplants at 1 year. Triple therapy has been used successfully by other centres although graft survival rates are no different from our own. Such treatment does, however, provide more powerful immunosuppression and is appropriate for previously sensitised patients and for children. Under this regimen steroids can be withdrawn at a later date. Sequential therapy with four agents is highly immunosuppressive. The long-term results are uncertain at the present time, and this expensive treatment needs careful evaluation. In our experience it is perfectly possible to undertake cadaveric renal transplantation without having to prescribe regular steroid therapy for the majority of patients. We have been impressed by the lack of serious side effects with this treatment and would still regard cyclosporin monotherapy as the treatment of choice for unsensitised renal transplant patients.     

Renal replacement therapy options from an Indian perspective: dialysis versus transplantation

In developing countries such as India, the management of end-stage renal disease (ESRD) is largely guided by economic considerations. In the absence of health insurance plans, fewer than 10% of all patients receive renal replacement therapy (RRT). Hemodialysis (HD) is mainly a short-term measure to support ESRD patients prior to transplant. Infections are common in dialysis patients. The majority of patients starting HD die or are forced to abandon treatment because of cost constraints within the first 3 months. The cost of peritoneal dialysis (PD) is two times higher than that of HD, fewer than 2% of patients are started on PD. Among the three RRT options available, renal transplant is the preferred mode, as it is most cost-effective and provides a better quality of life. But due to financial constraints and nonavailability of organs, only about 5% of ESRD patients undergo transplant surgery. Though the removal of organs from brain-dead patients has been legalized, the concept of donation of organs from deceased donors has not received adequate social sanction. Only 2% of all transplants are performed from deceased donors. Due to limited access to RRT, the ideal approach should be to reduce the incidence of ESRD and attempt preventive measures. Preemptive transplant, reducing the duration of dialysis prior to transplant, use of immunosuppression for only up to 1 year, and availability of more deceased donor organs may be helpful to make RRT options within the reach of the common man.     

Kidney transplantation in patients with long-term (more than 15 years) prior dialysis therapy

Objective

The number of kidney transplantations (KTx) among patients on long-term hemodialysis (HD) is increasing due to the donor shortage in Japan. We investigated the outcomes of KTx among long-term (more than 15 years) patients on HD.

Methods

We performed 103 KTx between April 2003 and April 2010 including seven patients (one living and six deceased donor grafts), who had been treated with HD for more than 15 years (group 1) compared with 96 patients (94 living and two deceased donor grafts) treated for less than 15 years (group 2) before KTx. We examined the differences in patient and graft survivals and complication rates between the groups.

Results

Acute rejection episodes (ARE) occurred in 2 (29%) group 1 and 22 (22%) group 2 subjects. Urinary tract infections were diagnosed in 1 (14%) group 1 versus 8 (8%) group 2 cases. The incidence of perioperative complications, such as delayed graft function, cytomegalovirus infection, and surgical complications was higher among group 1. The serum creatinine at 1 year after KTx was the same (1.3 mg/dL). The patient/graft survivals were 100%/100% at 1 and 3 years in group 1 versus 100%/100% at 1 and 99%/98% at 3 years in group 2.

Conclusion

The outcomes of KTx among long-term dialysis patients were similar to those in short-term dialysis patients.     

Renal transplantation after prolonged dwell peritoneal dialysis in children

Thirty-three children received a total of 38 renal transplants (18 living related donor, and 20 cadaveric) after being on CAPD and/or CCPD (PDPD). Ten patients (12 transplants) were converted to hemodialysis pre-transplant in order to be free of the risk of peritonitis and off antibiotics, whereas 23 patients (26 transplants) were on PDPD at the time of transplant. The latter group of patients are described in greater detail. Within this group there was one episode of catheter colonization with Flavobacterium, and only three patients developed ascites post-transplant. Of the 26 transplants, catheters were removed at the time of transplant in the 13 LRD allografts but left in situ for a mean of 3.8 weeks in the 13 cadaveric transplant recipients. Peritoneal dialysis was required post-transplant in seven patients (two LRD recipients requiring a new catheter placement) without complications. Our policy of removing PD catheters at the time of transplant in LRD recipients and prior to hospital discharge in cadaveric transplant recipients has resulted in the avoidance of additional hospitalizations in 19 of the 26 transplants and avoided extra surgery in 11 of the 13 LRD transplants. We conclude that children who have been on PDPD are suitable candidates for renal transplantation and that the early removal of PD catheters, including removal at the time of transplantation in LRD recipients, is associated with a significant reduction in operative procedures for the patients.     

Pregnancy in chronic dialysis and after renal transplantation

A female patient gave birth to a child while receiving hemodialysis, six years later, she gave birth to another child after cadavatic renal transplantation. Both children showed normal growth without any congenital defects. During the term of pregnancy after renal transplantation, there was no significant rejection episode, and graft function was stable. It seems rare for a patient to bear children during dialysis and after renal transplantation.     

Successful pancreas-renal transplantation without induction therapy

Most pancreas transplant centers initially use immunosuppression with antilymphocyte induction because the pancreas appears to be a highly immunogeneic organ. Although the addition of an antilymphocyte agent provides enhanced immunosuppression in the early posttransplant period, it is associated with added costs and adverse reactions. In this study we evaluated the safety and efficacy of tacrolimus (Tac), mycophenolate mofetil (MMF), and steroid immunosuppression without induction after simultaneous kidney-pancreas transplantation (SKPT). Six patients (30%) displayed rejection episodes with a mean follow-up of 12 months (range = 4 to 18 months). No graft was lost due to rejection. The results of this series suggest that SKPT can be safely performed without induction therapy.