Living-unrelated (paid) renal transplantation--ten years later

Due to the increase of organ shortage and still inadequate development of cadaver transplantation, many end-stage patients from the Balkan region travel mostly to India to buy a kidney. Despite all the ethical dilemmas and discussions, organ sales is present nowdays in Third-World countries. Sixteen patients (13 from Macedonia and 3 from Kosovo, SCG) were observed clinically during a period of 10 years. Recipients of mean age 36.5 years (range 10 to 58) displayed the following underlying diseases: chronic glomerulonephritis (n = 5), urethral valves with reflux (n = 2), ADPKD (n = 1), hypertensive nephropathy (n = 4), lithiasis (n = 1), and unknown cause of ESRD (n = 3). The donor population was young (22 to 29 years). Most patient records did not include data on HLA, cross-match, MLC, kind of surgery, or usual pretransplant workup. The immunosuppressive protocol included CyA, PRED, and AZA or MMF. All transplanted patients were followed on an outpatient basis in our department; patients with complications were hospitalized. The 1, 3, 5, and 10 year Kaplan Meier graft survival rates were 78.6%, 50.2%, 33.3%, and 18.8%, respectively. Seven patients were lost (43.7%), two during the first month after transplantation, two at the end of the first year, and three at 5, 6, and 8 years thereafter. The main reasons for death were severe pulmonary infections with sepsis, hepatitis B with liver cirrhosis, Kala Azar, CMV, and cancer of the colon. Five grafts were lost due to repeated rejection episodes and chronic graft nephropathy. The last three cases remained with good renal function and actual serum creatinine values of 135 +/- 9. In view of this experience, the authors cannot recommend this type of transplantation, not only from the ethical point of view, but also from frequent medical and surgical complications which are sometimes life threatening.     

Ultrasound in renal transplantation.

Because of important differences in prognosis and treatment, prompt and accurate diagnosis of fever, decreasing function, and pain and tenderness around a renal allograft is crucial for differentiation between acute rejection and other post-operative conditions which may give a similar picture. Ultrasound examinations within 24 hours have been performed on all transplant recipients exhibiting symtoms compatible on all transplant recipients exhibiting symptoms compatible with an episode of acute rejection between September 1973 and June 1976 at the Peter Bent Brigham Hospital. The patients were separated into four groups dependent upon diagnosis by ultrasound; Group I(73 patients); allograft enlargment consistent with acute rejection; Group II (14 patients); dilitation of the collecting system; Group III (14 patients); perinephric fluid collections; Group IV (6 patients); miscellaneous conditions. The accuracy of the ultrasound technique was compared within each group to the results from intravenous pyelography, retrograde pyelography, serial renograms, kidney biopsy and/or surgical exploration. This convenient, non-invasive and reproducible method has been extremely effective in the differential diagnosis of rejection in clinical transplantation.     

Hyperreninemia during renal transplantation.

18 patients undergoing renal transplantation were studied prospectively to determine the incidence and mechanism of blood pressure elevations which sometimes occur after release of vascular clamps from the grafts. No patients became as severely hypertensive as noted in previous reports. A weak, but statistically significant (r=0.56, p less than 0.05) positive correlation was found between changes in plasma renin activity and small incremental changes in blood pressure. 2 patients in whom the greatest change in renin occurred showed little or no increase in blood pressure. In view of the small blood pressure changes seen in the face of significant changes in plasma renin activity, it appears unlikely that acute hyperreninemia alone is sufficient explanation for postdeclamping hypertension which is sometimes observed during renal transplantation.     

Proteinuria following renal transplantation.

Proteinuria was studied in ten renal allograft recipients; it was defined as: (a) glomerular--characterized by predominant albumin excretion; (b) tubular--significant excretion of both albumin and low molecular weight (LMW) proteins; and (c) glomerulo-tubular or mixed type, a combination of the two. LMW protein and albumin were quantitated by polyacrylamide gel electrophoresis with sodium dodecyl sulfate. In the immediate posttransplant period, LMW protein and albumin excretion, expressed as a percentage of creatinine clearance, were high, revealing a mixed pattern, and excretion of both protein classes was higher than during both acute tubular necrosis and acute rejection crisis. Tubular proteinuria was observed in acute tubular necrosis; a glomerulo-tubular or mixed pattern of protein excretion in acute rejection crises.     

Coccidioidomycosis and renal transplantation.

Two cases of coccidioidomycosis detected in a group of more than 750 renal transplants are presented. The first patient died from unsuspected disseminated coccidioidomycosis 4 1/2 years after primary transplantation and 6 days after retransplantation. In the second patient pulmonary coccidioidomycosis was recognized and treated by lobectomy and amphotericin B before transplantation; subsequent transplantation has provided good renal function without recurrence of infection for 5 years. Experience with six other reported cases of coccidioidomycosis illustrates the high risk of exacerbation and dissemination of preexisting coccidioidal infection in immuno-suppressed transplanted recipients. Nevertheless, this risk can be made acceptable if active coccidioidomycosis is treated vigorously before immunosuppression is started and if the possibility of exacerbation of infection after transplantation is carefully monitored.     

Toxoplasmosis after renal transplantation.

Infection is the main cause of death following renal transplantation. In the literature 7 fatal cases of toxoplasmosis following renal transplantation have been described. In the present papers a case of reactivated toxoplasmosis is presented where the patient survived. Fortuitous withdrawal of therapy and transplant nephrectomy may have been responsible for the patient's survival. The problems of diagnosis of toxoplasmosis following renal transplantation are discussed. Early diagnosis is vitally important as successful treatment of toxoplasmosis with pyrimethamine and sulfonamides in patients receiving immunosuppressive therapy has been reported. It is emphasised that reaction of toxoplasmosis should always be considered in patients with fever of unknown origin and cerebral symptoms.     

Cancer following renal transplantation.

Ninety-nine (21%) of 471 patients who survived with functioning grafts for at least six months following renal transplantation developed cancer. Of these 76 (77%) had skin malignancy, 29 (29%) had malignancy affecting other organs, and six had cancer of both skin and other organs. In patients with skin cancer squamous cell carcinoma (SCC) was three times as frequent as basal cell carcinoma (BCC). SCC tended to be multiple, recurrent and aggressive. Seven (12%) patients with SCC developed metastases of whom five died. Cancers other than skin included reticulum cell sarcoma (9), acute leukaemia (2) and cancers involving the gastrointestinal (5), genitourinary (11) and respiratory (2) systems. Incidence of cancer in patients surviving beyond one, five and nine years after operation was 98/428 (23%), 70/179 (39%) and 20/45 (44%) respectively. In 31 patients who died more than five years after transplantation cancer was the major cause in eight (26%). For the types of cancers recorded estimates show allograft recipients to be at increased risk when compared with the age-matched Australian population by factors which varied from 300 times for reticulum cell sarcoma to 1.8 times for invasive carcinoma of the cervix. The full extent of the threat of cancer in immune suppressed transplant recipients remains to be determined.     

Age-matching in renal transplantation.

BACKGROUND: So far, the combined influence of donor age and recipient age on renal allograft survival has not been investigated sufficiently. In this retrospective single-centre study we analysed whether the influence of donor age and recipient age on renal allograft survival are dependent on each other. METHODS: Data from 1269 cadaveric renal allograft transplantations were evaluated. Paediatric donors (<15 years) and paediatric recipients (<15 years) were excluded. Donors and recipients were divided by age: young donors (yd, 55 years, n=176), young recipients (yr, 55 years, n=211). Functional and actual long-term graft survival (8 years) within the four resulting groups was determined: yd/yr (n=926), yd/or (n=167), od/yr (n=132), and od/or (n=44). RESULTS: Univariate analysis showed that long-term graft survival of both, kidneys from young donors (functional, 66.1 vs 52.2%, P=0.004; actual, 53.3 vs 46.2%, P=0.065) and kidneys from old donors (functional, 68.7 vs 22.5%, P=0.07; actual, 57.1 vs 20.8%, P=0.15) was better in old recipients as compared to young recipients. Multivariate regression analysis revealed that actual graft survival of kidneys from old donors was significantly reduced in young recipients (od/yr) as compared to all other groups (P=0.001; RR, 1. 97; 95% CI, 1.32-2.94). In this group of patients, graft loss was mainly due to acute (33.7%) and chronic (24.0%) rejection. CONCLUSION: Transplantation of kidneys from 'old' donors into 'young' recipients should be avoided, and these kidneys should be given to age-matched recipients.     

Pericarditis following renal transplantation.

We analyzed data on renal allograft recipients over a 27-year period in order to investigate the frequency, etiology, and outcome of pericarditis developing during the first two months following renal transplantation. Of the 1497 patients receiving renal transplants between 1963 and 1990, 34 patients developed 36 episodes of pericarditis and/or pericardial effusions, for an overall incidence of 2.4%. Pericarditis was attributed to uremia in 14 episodes, cytomegalovirus infection in three, both uremia and CMV infection in four, nonspecific bacterial infection in three, and tuberculosis and minoxidil therapy in one episode each. No etiologic diagnosis could be established in 10 episodes. No statistically significant differences were found between pericarditis and case-matched control patients considering demographic features, the number of immediately functioning grafts, the duration of posttransplant acute renal failure, the number of supportive dialysis days, pre- and postoperative CMV status of the patients, and pretransplant BUN and serum creatinine levels. There were more uremic-related complications (pulmonary edema, gastrointestinal bleeding, central nervous system symptoms) in the pericarditis group. Five allografts in the pericarditis group never functioned, versus only one in the control group. Three patients with pericarditis developed pericardial tamponade. Early diagnosis, close follow-up, and in the case of cardiac tamponade early invasive treatment, should improve the prognosis of this potentially life-threatening complication.     

Lymphocele after renal transplantation.

Lymphoceles occurred in 25 of 115 patients after renal transplantation in the Oxford Unit. Signs of obstruction or pressure were produced in 16 of these 25 patients (15%), while nine were detected on a routine ultrasound scan. The 16 symptomatic lymphoceles were treated successfully by aspiration or surgical fenestration into the peritoneal cavity . Of the possible causes examined, diathermy and division of iliac lymphatics seemed to be the most likely reason for this high incidence. Since a technique of ligating or clipping the iliac lymphatics has been adopted, no lymphoceles have occurred in the subsequent 70 transplants.     

Reversible renal artery stenosis in renal transplantation.

Spontaneous regression of an arterial stenosis in a renal transplant recipient is documented. Implications of this observation and possible pathogenic mechanisms are discussed.     

Morbidity of pancreas transplantation during cadaveric renal transplantation.

Simultaneous transplantation of the pancreas is an option for diabetic patients undergoing kidney transplantation to attempt to halt progression of diabetic complications, but the additional risk imposed by the procedure is unclear. Our aim was to determine the morbidity attributable to pancreas transplantation during simultaneous pancreas and kidney transplantation. We compared the first posttransplant year of 18 consecutive recipients of combined pancreas and kidney transplantation to 18 consecutive recipients of kidney transplantation alone. All patients received cadaver donor allografts between 1986 and 1989, and had type I diabetes mellitus with chronic renal failure. There were no differences in patient survival (94% both groups) or satisfactory renal allograft function (89% pancreas/kidney group, 83% kidney group) up to 18 months after transplantation. Eighty-eight percent of pancreas allografts were functioning satisfactorily at 18 months. There was a mean (+/- SD) of 1.5 +/- 1.0 acute rejection episodes per patient for the pancreas/kidney group compared to 0.8 +/- 6 for the kidney-only group (P less than 0.02). Cytomegalovirus infection and wound complications were each encountered more often after pancreas/kidney transplantation than kidney transplantation alone, and together with rejection accounted for a difference in days of hospitalization during the first year (71 +/- 34 vs. 27 +/- 13, P less than 0.001). We conclude that simultaneous pancreas transplantation during cadaver donor kidney transplantation accounted for more frequent rejection episodes, CMV infections, and wound complications. These complications resulted in more hospitalization for patients undergoing simultaneous pancreas/kidney transplantation than kidney transplantation alone.